Cranial decompression for the treatment of malignant intracranial hypertension after ischemic cerebral infarction: decompressive craniectomy and hinge craniotomy

Clinical article

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Object

Recent randomized trials have demonstrated a positive role (improved survival) in patients treated with cranial decompression for malignant cerebral infarction. However, many variables regarding operative decompression in this setting remain to be determined. Hinge craniotomy is an alternative to decompressive craniectomy, but its role in space-occupying cerebral infarctions has not been delineated. The objective of this study was to compare the authors' experiences with these 2 procedures in the management of space-occupying cerebral infarctions to determine the efficacy of each.

Methods

The authors conducted a retrospective review of 28 cases involving patients who underwent cranial decompression (hinge craniotomy in 9 cases, decompressive craniectomy in 19) for treatment of malignant intracranial hypertension after ischemic cerebral infarction.

Results

No significant differences were identified in baseline demographics, neurological examination, or Rotterdam score between the hinge craniotomy and decompressive craniectomy groups. Both treatments resulted in adequate control of intracranial pressure (ICP). The need for reoperation for persistent intracranial hypertension and duration of mechanical ventilation and intensive care unit stay were similar. Hospital survival was significantly higher in the decompressive craniectomy group (89% vs 56%), whereas long-term functional outcome was better in the hinge craniotomy group. Cranial defect size was comparable in the 2 groups. Postoperative imaging revealed a higher rate of subarachnoid hemorrhage, contusion/hematoma progression, and subdural effusions/hygromas after decompressive craniectomy. The requirement for cranial revision in survivors was higher for patients undergoing decompressive craniectomy (100%) than those undergoing hinge craniotomy (20%).

Conclusions

Hinge craniotomy appears to be at least as good as decompressive craniectomy in providing postoperative ICP control at a similar therapeutic index. Although the in-hospital mortality was higher in patients treated with hinge craniotomy, that procedure resulted in superior long-term functional outcomes and may help limit postoperative complications.

Abbreviations used in this paper:BMI = body-mass index; CCI = Charlson Comorbidity Index; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; ICU = intensive care unit; IVH = intraventricular hemorrhage; mRS = modified Rankin Scale; NIHSS = National Institutes of Health Stroke Scale; SAH = subarachnoid hemorrhage.

Article Information

Address correspondence to: Tyler J. Kenning, M.D., Department of Neurosurgery, Thomas Jefferson University Hospital, 909 Walnut Street, 2nd Floor, Philadelphia, Pennsylvania 19107. email: tyler.kenning@jeffersonhospital.org.

Please include this information when citing this paper: published online March 30, 2012; DOI: 10.3171/2012.2.JNS111772.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Computed tomography morphometrics. A demonstration of the measurements taken from the first postoperative CT scan for decompressive craniectomy (DC; upper left) and hinge craniotomy (HC; lower left). The measurements included maximum hemicraniectomy diameter (A), maximum anteroposterior skull diameter (B), magnitude of external cerebral herniation (C), horizontal brain diameter (D), brain width on the side of hemicraniectomy (E), and brain width on the contralateral side (F). At the same approximate level on the last preoperative CT scan (right), the maximum horizontal brain diameter preoperatively was obtained (D2). Reprinted with permission from Kenning et al.: Neurosurg Focus 26(6):E6, 2009.

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    A: Average daily ICP recording for each of the patients in the hinge craniotomy group who underwent ICP monitoring during the first 5 postoperative days. The solid line represents the overall average for the group. B: Average daily ICP therapeutic intensity index for each of the patients in the hinge craniotomy group who underwent ICP monitoring during the first 5 postoperative days. The solid line represents the overall average for the group.

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    A: Average daily ICP recording for each of the patients in the decompressive craniectomy group who underwent ICP monitoring during the first 5 postoperative days. The solid line represents the overall average for the group. B: Average daily ICP therapeutic intensity index for each of the patients in the decompressive craniectomy group who underwent ICP monitoring during the first 5 postoperative days. The solid line represents the overall average for the group.

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    Boxplots demonstrating the trend in postoperative mRS (A) and GOS (B) scores. Results for the hinge craniotomy group are shown in light gray and those for the decompressive craniectomy group in dark gray. The horizontal bars within the boxes represent median values.

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    A and B: Preoperative (A) and postoperative (B) cranial CT images obtained in the patient in the decompressive craniectomy cohort with the smallest area of infarction. C and D: Preoperative (C) and postoperative (D) cranial CT images obtained in the patient in the decompressive craniectomy cohort with the largest area of infarction.

  • View in gallery

    A and B: Preoperative (A) and postoperative (B) cranial CT images of the patient in the hinge craniotomy cohort with the smallest area of infarction. C and D: Preoperative (C) and postoperative (D) cranial CT images of the patient in the hinge craniotomy cohort with the largest area of infarction.

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