Postoperative management following decompressive hemicraniectomy for malignant middle cerebral artery infarction-AGerman nationwide survey study

Abstract

Malignant middle cerebral artery infarction is apotentially life-threatening disease. Decompressive hemicraniectomy constitutes an evidence-based treatment practice, especially in patients under 60years of age; however, recommendations with respect to postoperative management and particularly duration of postoperative sedation lack standardization. This survey study aimed to analyze the current situation of patients with malignant middle cerebral artery infarction following hemicraniectomy in the neurointensive care setting. From 20 September 2021 to 31 October 2021, 43members of the initiative of German neurointensive trial engagement (IGNITE) network were invited to participate in astandardized anonymous online survey. Descriptive data analysis was performed. Out of 43centers 29 (67.4%) participated in the survey, including 24university hospitals. Of the hospitals 21 have their own neurological intensive care unit. While 23.1% favored astandardized approach regarding postoperative sedation, the majority utilized individual criteria (e.g., intracranial pressure increase, weaning parameters, complications) to assess the need and duration. The timing of targeted extubation varied widely between hospitals (≤ 24 h 19.2%, ≤ 3days in 30.8%, ≤ 5days in 19.2%, > 5days in 15.4%). Early tracheotomy (≤ 7days) is performed in 19.2% and 80.8% of the centers aim for tracheotomy within 14days. Hyperosmolar treatment is used on aregular basis in 53.9% and 22 centers (84.6%) agreed to participate in aclinical trial addressing the duration of postoperative sedation and ventilation. The results of this nationwide survey among neurointensive care units in Germany reflect aremarkable heterogeneity in the treatment practices of patients with malignant middle cerebral artery infarction undergoing hemicraniectomy, especially with respect to the duration of postoperative sedation and ventilation. Arandomized trial in this matter seems warranted.