Decompressive craniectomy for intractable cerebral edema

Experience of a single center

Wendy C. Ziai, John D. Port, Jhon A. Cowan, Ira M. Garonzik, Anish Bhardwaj, Daniele Rigamonti

Research output: Contribution to journalArticle

65 Citations (Scopus)

Abstract

Several case reports and small clinical series have reported benefits of decompressive hemicraniectomy in patients with intractable cerebral edema and early clinical herniation. Specific indications and timing for this intervention remain unclear. We present our experience with this procedure in a subset of 18 patients with massive cerebral edema refractory to medical management, treated with decompressive craniectomy over a 3-year period (1997 to 2000). Computerized tomography (CT) scans were independently analyzed by a neuroradiologist blinded to clinical outcome. Eleven male and seven female patients, ages 20 to 69 years (mean ± SEM, 46 ± 14 years), underwent hemicraniectomy for the following diagnoses: 12 hemispheric infarcts, 3 traumatic intracerebral hemorrhages/contusions, 2 nontraumatic intraparenchymal hemorrhages (ICH), and 1 subdural empyema. This population included four patients with aneurysmal subarachnoid hemorrhage (SAH). Patients were followed for a mean of 10 months. Clinical factors including age, side of lesion, preoperative herniation signs, and early surgery (<12 or <24 hours) were not significantly associated with mortality or Glasgow outcome score (GOS). Preoperative CT evidence of transtentorial herniation (present in 5/17 patients) was associated with mortality (P = 0.04), while preoperative uncal herniation (8/17 patients) was associated with poor outcome (GOS > 1) (P = 0.01). Favorable outcome (GOS > 3) occurred in six patients, three with spontaneous or traumatic focal hematomas. Of four patients with SAH, one died while the others were severely disabled (GOS 3). Seven of nine patients with malignant MCA infarctions unrelated to SAH had poor outcomes. The overall mortality was 4/18 (22%). Patients with refractory cerebral swelling secondary to focal hematomas may have better outcomes following decompressive craniectomy. Patients with preexisting SAH seem to have poor outcomes, possibly related to other neurologic comorbidities. Hemicraniectomy requires definition of proper timing. Preoperative CT findings, especially transtentorial and uncal herniation may be useful in defining when decompressive surgery should not be performed.

Original languageEnglish (US)
Pages (from-to)25-32
Number of pages8
JournalJournal of Neurosurgical Anesthesiology
Volume15
Issue number1
DOIs
StatePublished - Jan 2003
Externally publishedYes

Fingerprint

Decompressive Craniectomy
Brain Edema
Subarachnoid Hemorrhage
Hematoma
Traumatic Cerebral Hemorrhage
Subdural Empyema
Tomography
Contusions
Age Factors
Middle Cerebral Artery Infarction
Nervous System
Comorbidity

Keywords

  • Brain edema
  • Cerebral infarction
  • Decompressive craniectomy
  • Intracerebral hemorrhage

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine
  • Clinical Neurology

Cite this

Decompressive craniectomy for intractable cerebral edema : Experience of a single center. / Ziai, Wendy C.; Port, John D.; Cowan, Jhon A.; Garonzik, Ira M.; Bhardwaj, Anish; Rigamonti, Daniele.

In: Journal of Neurosurgical Anesthesiology, Vol. 15, No. 1, 01.2003, p. 25-32.

Research output: Contribution to journalArticle

Ziai, Wendy C. ; Port, John D. ; Cowan, Jhon A. ; Garonzik, Ira M. ; Bhardwaj, Anish ; Rigamonti, Daniele. / Decompressive craniectomy for intractable cerebral edema : Experience of a single center. In: Journal of Neurosurgical Anesthesiology. 2003 ; Vol. 15, No. 1. pp. 25-32.
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