The role of decompressive craniectomy in ischaemic stroke
Klinika Neurochirurgii i Onkologii Układu Nerwowego, Uniwersytet Medyczny w Łodzi, Uniwersytecki Szpital Kliniczny nr 1 im. N. Barlickiego. Kierownik Kliniki: prof. dr hab. n. med. Dariusz J. Jaskólski
Adres do korespondencji: Prof. dr hab. n. med. Dariusz J. Jaskólski, Klinika Neurochirurgii i Onkologii Układu Nerwowego, Uniwersytet Medyczny w Łodzi, Uniwersytecki Szpital Kliniczny nr 1 im. N. Barlickiego, ul. Kopcińskiego 22, 92-153 Łódź, e-mail: dariusz.jaskolski@umed.lodz.pl
Aktualn Neurol 2014, 14 (4), p. 235–244
DOI: 10.15557/AN.2014.0027
ABSTRACT

Malignant ischaemic stroke i.e. one accompanied by extensive oedema bringing about raised intracranial pressure, carries a significant mortality risk as well as a substantial likelihood of permanent neurological deficits. This paper reviews the history of decompressive craniectomy in the management of ischaemic stroke and presents the current views on its usefulness in both supra- and infratentorial infarctions. The surgical technique was looked over along with common complications of surgery. The results of prospective randomised clinical trials: DECIMAL, HAMLET and DESTINY I and II were presented. They have confirmed the role of decompressive surgery in the cases of infarction in the MCA territory. In patients who deteriorate neurologically despite the best medical therapy, decompressive craniectomy, particularly if carried out within the first 48 hours from the onset, yet before the decline of the neurological condition, considerably improves the outcome. Nonetheless, various issues require further studies. The most important ones are: to define the age limit beyond which the patients would not benefit from surgery, to list clearly clinical and radiological indications for decompression, including the cases in which thrombolysis or mechanical revascularisation have been attempted, and finally, to work out the standards of an informed consent for the procedure. To date, no prospective randomised trials assessing the role of surgery in infratentorial infarctions have been conducted. However, on the basis of retrospective studies, suboccipital decompressive craniectomy is strongly recommended in patients with cerebellar ischaemic stroke and decreased level of consciousness, in whom medical treatment failed. The outcome improves along with the better clinical condition at surgery. Ventricular drainage as a single means of decompression does not seem to be indicated whereas its use before suboccipital craniectomy is still a matter of debate.

Keywords: ischaemic stroke, malignant MCA infarction, cerebellar infarction, decompressive craniectomy, suboccipital craniectomy