Suboptimum hemicraniectomy as a cause of additional cerebral lesions in patients with malignant infarction of the middle cerebral artery

Simone WagnerDepartments of Neurology and Neurosurgery, University of Heidelberg, Germany; and Department of Molecular and Experimental Medicine, Division of Biomathematics, Scripps Research Institute, La Jolla, California

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Holger SchnipperingDepartments of Neurology and Neurosurgery, University of Heidelberg, Germany; and Department of Molecular and Experimental Medicine, Division of Biomathematics, Scripps Research Institute, La Jolla, California

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Alfred AschoffDepartments of Neurology and Neurosurgery, University of Heidelberg, Germany; and Department of Molecular and Experimental Medicine, Division of Biomathematics, Scripps Research Institute, La Jolla, California

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James A. KoziolDepartments of Neurology and Neurosurgery, University of Heidelberg, Germany; and Department of Molecular and Experimental Medicine, Division of Biomathematics, Scripps Research Institute, La Jolla, California

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Stefan SchwabDepartments of Neurology and Neurosurgery, University of Heidelberg, Germany; and Department of Molecular and Experimental Medicine, Division of Biomathematics, Scripps Research Institute, La Jolla, California

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Thorsten SteinerDepartments of Neurology and Neurosurgery, University of Heidelberg, Germany; and Department of Molecular and Experimental Medicine, Division of Biomathematics, Scripps Research Institute, La Jolla, California

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Object. The goal of this study was to determine the frequency of hemicraniectomy-associated lesions and their potential effect on the risk of mortality in patients suffering from malignant infarction of the middle cerebral artery (MCA).

Methods. The authors evaluated serial computerized tomography scans obtained in 60 patients with complete infarction of the right MCA who were treated using hemicraniectomy. The maximum diameter of the hemicraniectomy was determined and the hemicraniectomy-associated lesions were classified as ischemic lesions or hemorrhages. The category of hemorrhages was composed of parenchymal, subdural, or epidural/subgaleal hematomas.

Parenchymal hemorrhages and infarcts associated with hemicraniectomy occurred with frequency rates of 41.6% and 28.4%, respectively. The occurrence of hemicraniectomy-associated bleeding was related to the size of the hemicraniectomy performed; that is, the smaller the hemicraniectomy, the more often lesions occurred (p < 0.05). Hemicraniectomy-associated bleeding was also related to an increased risk of mortality.

Conclusions. Hemicraniectomy is an effective therapy in patients with malignant infarction of the MCA. However, a hemicraniectomy that is too small in diameter may cause the formation of additional lesions and adversely affect the risk of mortality and the quality of survival. In addition, the size and shape of the edges of the bone defect are important factors relating to its efficacy.

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