Hemicraniectomy Research Articles

Decompressive Hemi Craniectomy in Malignant Middle Cerebral Artery Infarction: Adding Years of Quality Life or Mere Existence?

In spite of advancements in treatment options for MCA infarct, there is a definite role of decompressive hemicraniectomy. When compared with best medical management, it decreases mortality and improves functional outcome. But does surgery improve quality of life in terms of independence, cognition or it merely leads to increased survival? Outcome of 43 consecutive patients of MMCAI who underwent DHC was studied. Functional outcome was evaluated based on mRS and GOS in addition to survival advantage. The patient's proficiency in performing ADL was evaluated. MMSE and MOCA were performed to evaluate the neuropsychological outcome. In-hospital mortality was 18.6%, and by 3 months, 67.5% of patients survived. During follow-up, nearly 60% of patients showed improvement in functional outcome when evaluated based on mRS and GOS. No patient could reach to the level of independent existence. Only eight patients could perform MMSE and five had good score (>24). All were young and had a right-sided lesion. None of the patients could perform well in MOCA. DHC improves survival and functional outcome. Cognition remains poor in the majority of the patients. These patients, though survive the stroke, remain dependent on care givers.

Decompressive Craniectomy in Traumatic Brain Injuries. Indications and Limits

Background: Decompressive craniectomy is a surgical technique proposed in the treatment of intracranial hypertension refractory to medical treatment and engaging the vital prognosis of patients.
 Materials and methods: We conducted a retrospective study about 41 cases of decompressive flap in the neurosurgery department of CHU ibn Rochd of Casablanca between 2015 and 2018.
 Aim: This study aims to discuss the management of intractable ICH in adults, focusing on the role of DC in patients with traumatic brain and identify the different indications, contraindications and complications.
 Results: The results show a clear male predominance with an average age of 40 years. The initial GCS >7 was in 63%, and <7 in 36% of cases, anisocoria was present in 65%. The most frequent indication for craniectomy is a neurological worsening. The type of craniectomy performed in the majority of cases is a hemi craniectomy in 92% of cases. Concerning the prognosis, we observed 32% of deaths and 68% of survivors of which 39% of patients without sequelae GOS 5 and 32% with a moderate disability GOS 4. The moderate disability GOS 3 was found in 21% and one case in vegetative state GOS 2. Regarding immediate complications after craniectomy: 33% of patients presented convulsions, 12% a new homolateral hematoma, 49% a nosocomial pneumopathy and 10% a postoperative meningitis.
 Conclusion: Decisions to recommend DC must always be made not only in the context of its clinical indications but also after consideration of an individual patient's preferences and quality of life expectations.

Abstract WMP94: Temporal Trends in Racial, Age, and Sex-Specific Utilization of Decompressive Hemicraniectomy Among Acute Ischemic Stroke Patients in the United States

Background: The aim of this study is to evaluate current trends in racial, age, and sex-specific utilization of decompressive hemicraniectomy (HC) in acute ischemic stroke (AIS) patients in the United States over the last decade. Methods: All adult patients with a diagnosis of AIS were identified from the 2004-2015 Nationwide Inpatient Sample (weighted N=4,792,428) using International Classification of Diseases Ninth revision (ICD-9) codes. Proportion of patients undergoing HC in various age, race, and sex groups were ascertained using ICD-9 procedural codes. Temporal trends were mapped by year in order to track changes in utilization over time. Analysis of utilization disparities and trends within age, sex, and race subgroups was conducted via multivariate logistic regression. Results: Of all eligible AIS patients from 2004-2015, 0.25% underwent HC (.08 in 2004 to .46 in 2015). Increased utilization over time was seen in both men (.13 to .57) and women (.08 to .54), with women showing comparable odds of utilization to men [OR: 0.95 (95% CI: .87-1.04, p=0.27)]. Similarly, increased utilization trends were seen in all age groups (Figure 1) with the highest rates in the 18-39 subgroup (1.41%). Compared to trends in this younger subgroup (.43 to 2.12), patients aged 60-79 experienced a similar overall increase but at lower utilization rates (.06 to .37). Compared to white patients in multivariate models, blacks did not show significant differences in odds of HC [1.09 (.96-1.24, p=0.20)], while patients from Hispanic [1.25 (1.03-1.51, p=0.02)] and other [1.26 (1.04-1.52, p=0.02)] race-ethnic groups showed increased odds. Conclusions: From 2004-2015, hemicraniectomy rates have seen substantial increases in all age, sex, and race groups. The increasing rates of hemicraniectomies among those over age 60 suggest that there has been at least partial acceptance of DESTINY 2 study results.

Abstract WP117: Therapeutic Hypothermia in Patients With Malignant Ischemic Stroke and Hemicraniectomy: A Systematic Review and Meta-Analysis

Introduction: Numerous animal models have demonstrated the efficacy of mild to moderate therapeutic hypothermia (TH) in reducing cerebral edema and conferring protection after ischemic injury. We investigated whether TH had a beneficial effect in stroke patients after hemicraniectomy (HC). Methods: A MEDLINE systematic review was performed. Inclusion criteria included: ≥10 patients with acute malignant ischemic stroke having undergone HC, studies published in full in the English language, and studies reporting on clinical outcome and complications. Results: Thirty-four studies met our search criteria. Six studies with 302 patients with malignant ischemic stroke (TH: n=146, HC alone: n=156) were included. Age, and initial median NIHSS were comparable between the two groups. All studies used systemic TH; four utilized combined TH (venous endovascular and surface cooling), while one study used systemic surface and one used systemic venous endovascular TH. TH was initiated within 37.2 hours (range 24-42 hours) from onset for a median target temperature of TH was 33.6°C (range 33-35°C) and maintained for a median of 72 hours (range 48-96 hours). Target temperature was achieved within 4.5 hours (range 2-36 hours). All studies used rewarming (3 active rewarming). Clinical outcomes at follow-up were not different (follow-up modified Rankin’s 0-2; RR 1.04, 95% CI 0.60-1.80, p=0.9; Figure 1). Cardiac complications were greater in TH (RR 1.79, 95% CI 1.16-2.76, p<0.01). A suggestion of greater mortality was seen with TH (RR 1.43, 95% CI 0.97-2.10, p=0.07), and was significantly greater in studies that did not actively rewarm patients (RR 1.65, 95% CI 1.04-2.60, p<0.05). Conclusions: Clinical and functional outcomes were comparable between patients undergoing systemic TH vs. normothermia following HC despite higher complications associated with TH.

Therapeutic effect of early directional catheterization on malignant middle cerebral artery infarction

Objective To investigate the efficacy and safety of cuboid stereotactic aspiration of necrotic brain tissue for treating malignant middle cerebral artery infarction in the elderly patients. Methods Sixteen elderly patients with malignant middle cerebral artery infarction were selected from June 2017 to January 2019 in our hospital. Patients were followed up for 6 months to evaluate the efficacy of stereotactic aspiration of necrotic brain tissue using the modified Rankin Scale (mRS). Results The 30-day mortality was 18.75%. Among the 16 elderly patients, 6 (37.5%) had an mRS score of 3 (defined as moderate disability), 6 (37.5%) had an mRS score of 4 (defined as moderate to severe disability), 1 (6.25%) had an mRS score of 5 (defined as severe disability), and 3 (18.75%) had an mRS score of 6. The probability of 6-month favorable outcome, defined as an mRS score of ≤3, was 37.5%, and the 6-month mortality was 18.75%. Conclusions It is a simple, minimally invasive, effective and safe method to treat malignant middle cerebral artery infarction in the elderly patients with cuboid stereotactic aspiration of necrotic brain tissue, which needs to be confirmed by further randomized controlled studies. Key words: Malignant middle cerebral artery infarction; Large hemisphere infarction; Decompressive hemicraniectomy; Cuboid stereotactic technique; Brain tissue; the aged; Soft channel; Minimally invasive puncture; mRS

Abstract TP542: EEG Detection of Secondary Worsening of Neuronal Function in Malignant MCA Infarction: Development of a Tool to Identify Patients for Decompressive Hemicraniectomy

Hemicraniectomy (HC) improves mortality in Malignant Middle cerebral artery Infarctions (MMI), but patient selection and optimal timing for HC remains unclear. A continuous method to monitor for the risk and development of herniation from infarction would allow a better selection of patients for HC We hypothesized that certain EEG features reflective of worsening mass effect will be easier to detect on quantitative EEG (qEEG) analysis trends We studied qEEG trends before, during clinical deterioration (drop in GCS by at least 3 points) and after administration of osmotherapy. qEEG trends included rhythmicity spectra 0-25 Hz (scale 0- 2uV/Hz), Color Density Power Spectra (CSA) 0-20Hz (scale 0-2uV/Hz), amplitude integrated EEG (aEEG): 0-100uV and VsRhythmicity spectrogram 1 - 25 Hz (-3-3 Zscore) Trends demonstrated bilateral loss of power on beta and alpha frequencies and increase in theta preceded clinical deterioration by approximately 1 hour (left > right). Patient2 subsequently had a robust theta power increase (+z score, red) in left > right hemisphere which coincide with clinical deterioration on vsRhythmmicity Spectrogram. Also, there was a decreased of fast and slow frequencies bands on rhythmicity spectrogram and CSA with a diffuse attenuation outlined by aEEG (Left > right). Following osmotherapy gradual improvement in all frequencies is seen but with an incomplete recovery in patient1 with lower alpha and theta power on right posterior and anterior quadrants suggested ongoing uncal and sub-falcine herniation, later confirmed on imaging Changes on qEEG reflecting impaired perfusion during acute herniation can manifest as decreased power in all frequency bands of varying severity prior to clinical deterioration. These changes can be completely or partially reversed with osmotherapy. Partial EEG response to osmotherapy may represent a potential sign of patients who will fail medical management and need DC. qEEG may be a helpful tool in HC patient selection

Hemicraniectomy for Malignant Middle Cerebral Artery Syndrome: A Review of Functional Outcomes in Two High-Volume Stroke Centers

Despite recent landmark randomized controlled trials showing significant benefits for hemicraniectomy (HCT) compared with medical therapy (MT) in patients with malignant middle cerebral artery infarction (MMCAI), HCT rates have not substantially increased in the United States. We sought to evaluate early outcomes in patients with MMCAI who were treated with HCT (cases) in comparison to patients treated with MT due to the perception of procedural futility by families (controls). We retrospectively evaluated consecutive patients with acute MMCAI treated in 2 tertiary care centers during a 7-year period. Pretreatment National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 3 months were documented. Functional independence (FI) and survival without severe disability (SWSD) were defined as mRS of 0-2 and 0-4, respectively. A total of 66 patients (37 cases and 29 controls) fulfilled the study inclusion criteria (mean age 59 ± 15 years, 52% men, median admission NIHSS score: 19 points [interquartile range {IQR}: 16-22]). Cases were younger (51 ± 11 versus 68 ± 13 years; P < .001) and tended to have lower median admission NIHSS than controls (18 [IQR:16-20] versus 20 [IQR:18-23]; P = .072). The rates of FI and SWSD at 3 months were higher in cases than controls (16% versus 0% [P = .031] and 62% versus 0% [P < .001]), while 3-month mortality was lower (24% versus 77%; P < .001). Multivariable Cox regression analyses adjusting for potential confounders identified HCT as the most important predictor of lower risk of 3-month mortality (hazard ratio: .02, 95% confidence interval: .01-0.10; P < .001). HCT is a critical and effective therapy for patients with MMCAI but cannot provide a guarantee of functional recovery.

Applied anatomy of large unilateral frontotemporoparietal decompressive craniectomy

Objective To study the anatomy of unilateral frontotemporoparietal structures of the Chinese people and to provide the anatomical basis for approach design in large craniectomy. Methods Large unilateral frontotemporoparietal decompressive craniectomy were performed on 15 corpse skulls. Through dissection layer by layer, anatomical landmarks were identified and relevant data were documented. Results The vertical distance between the distal point of posterior edge of parietal eminence and the external auditory canal was 79.90±4.06 mm. The distance from the midpoint between nasal root and external occipital protuberance to the midpoint of zygomatic arch was 144.60±4.73 mm. The distance between the eyebrow arch and the parietal eminence was 163.50±4.75 mm. Within the bone window, the longest distance between arachnoid granulation in the superior sagittal and midline was 19.62±3.98 mm. The vertical distance between the superior margin of zygomatic arch and the point where the Sylvian vein drains into sphenoparietal sinus was 25.26±3.77 mm. Conclusions In order to achieve adequate decompression, the vertical distance from the farthest point of skin incision around parietal eminence to the external auditory canal should not be less than 8 cm, the bone window could be 2 cm from the midline, and the lower margin of the bone could be located at the upper margin of zygomatic arch. Key words: Craniology; Anatomy; Decompressive hemicraniectomy

Umfragestudie zur Behandlung des malignen Mediainfarkts an deutschen Kliniken

There are a variety of intensive care therapies in the treatment of malignant middle cerebral artery infarction (MMI) besides hemicraniectomy (HC), the only treatment with proven efficacy. It is, however, not known how HC and conservative treatments are utilized in German hospitals, Furthermore, data on the care-situation of patients with MMI in Germany is scarce. An anonymous questionnaire was sent to 297 neurological and 133 neurosurgical hospitals in Germany. The Response rate was 24,7%. Most respondents indicated personal experience in the treatment of MMI (83,3%). HC is usually performed early on site (83,3%). Indication to HC is confirmed on a high level of hierarchy and profession using clinical and radiological criteria in 78,2% of hospitals. Inherent standardized treatment protocols are established in 70,8% of hospitals. Patients are treated on an intensive care unit in 74,5% of hospitals after DHC and in 42,5% of hospitals under non-surgical treatment. Intracranial pressure monitoring is not performed on a regular basis. Differing opinions were observed concerning diagnosis and treatment of MMI without recognizable consensus. Basically, structural requirements for the treatment of MMI exist in the participating hospitals. Heterogeneity in the treatment of MMI is striking. The implementation of treatment protocols and adherence to guidelines are desirable steps to optimize treatment.

Study of external cerebral herniation at different times in traumatic brain injury patients after decompressive craniectomy

Objective To explore external cerebral herniation at different times in traumatic brain injury patients after decompressive craniectomy. Methods Clinical data of 90 patients with traumatic brain injury routine hemicraniectomy were analyzed, brain incisional hernia incidence and severity in early(less than a week after surgery), medium(after 7d- 30d)and late(after 1 month- June), and compare GCS score and GOS score of different periods were observed. Results Brain incisional hernia incidence in early, middle and late was 42.22%,21.11%, 12.12% with significant difference(χ2= 4.312,P< 0.05;χ2= 4.523,P< 0.05;χ2= 4.543,P< 0.05),and the severity in early was the most(P< 0.01);GCS scores in early,mid and late was(3.22±0.41)points,(6.53±0.37) points,(12.05±0.84) points with significant difference(t= 5.215,P< 0.05;t= 6.312,P< 0.05;t= 6.312, P<0.05);T test showed that the difference was existed between different period of patients. Conclusion Traumatic brain injury incidence and serivity in 1 week was the most; brain hernia occurs sooner in GCS score lower patients; prognosis was worse in later external cerebral herniation patients, so GCS score and incisional hernia occurrence time is important for improving prognosis of traumatic brain injur patients. Key words: Traumatic brain injury; Decompressive craniectomy; External cerebral herniation

Decompressive hemicraniectomy with or without clot evacuation for large spontaneous supratentorial intracerebral hemorrhages

ObjectiveThe management of patients with supra-tentorial intracerebral hemorrhage (ICH) remains controversial. Here we critically evaluate the safety, feasibility, and outcomes following decompressive hemicraniectomy (HC) with or without clot evacuation in the management of patients with large ICHs. MethodsWe analyzed data from 73 consecutive patients managed with a HC for a spontaneous ICH. All relevant patient variables at initial presentation and management were compiled. Variables were modeled as independent regressors against the three-month Glasgow Outcome Score using a multivariate logistic regression model. ResultsOver 7 years, HC was performed in 73 patients with clot evacuation in 86% and HC alone in 14%. The average ICH volume was 81cc and the median HC surface area was 105cm2. 26 patients were comatose at initial presentation. Three-month functional outcomes were favorable in 29%, unfavorable in 44% and 27% of patients expired. Admission Glasgow Coma Scale (p=0.003), dominant hemisphere ICH location (p=0.01) and hematoma volume (p=0.002) contributed significantly to the outcome, as estimated by a multivariate analysis. Eight surgical complications occurred. ConclusionsEarly HC with or without clot evacuation is feasible and safe for managing spontaneous ICH. Our experience in this uncontrolled retrospective series, the largest such series in the modern era, suggests that it may be of particular benefit in patients with large non-dominant hemisphere ICH who are not moribund at presentation. Our findings suggest that a prospective randomized trial of HC vs. craniotomy for ICH be conducted.

Hemicraniectomy in Older Stroke Patients

Middle cerebral artery (MCA) territory infarcts with life-threatening edema — previously termed “malignant” MCA infarcts — carry a mortality rate as high as 80%. Hemicraniectomy (HC) is a surgical treatment option that allows pressure gradients to be directed outward instead of toward the brainstem, thereby potentially preventing brain herniation. In patients younger than 60, HC substantially reduces mortality without increasing the rate of severe disability. To evaluate whether older patients would also benefit from HC, investigators randomized …

Abstract WP285: Hemicraniectomy Outcomes in Patients with Malignant Middle Cerebral Artery Infarctions Plus

Hemicraniectomy (HC) is a proven treatment to reduce mortality and improve outcomes in patients with malignant middle cerebral artery (MCA) infarction. The benefit of HC in patients with MCA strokes plus infarctions in other vascular territories has not been well defined. We hypothesized that there would be no difference in outcomes in patients with MCA strokes compared to those with MCA Plus infarctions. We retrospectively reviewed our registry from 07/2003 to 12/2011, and identified consecutive patients diagnosed with an ischemic stroke that underwent HC. Outcome measures included mRS at discharge, mRS at day 90 and death at one year. A good outcome was defined as mRS 0-4. The vascular territory of infarction was established by a vascular neurologist who reviewed the nearest CT scan prior to the procedure and compared it with the official interpretation of a neuroradiologist. The MCA Plus infarctions included MCA + anterior cerebral artery (ACA), MCA + posterior cerebral artery (PCA) and MCA + ACA + PCA. Ninety seven patients had a HC. Sixty four were MCA and 33 were MCA Plus. The mean MCA and MCA plus ages were 51.9 (± 14.2) and 51.3 (± 12.8) years respectively. Median NIHSS was 12.5 (IQR 10.0-15.0) in MCA vs. 12.2 (IQR 9.5-14.0) in MCA Plus. MCA group had a good outcome at discharge in 25% of subjects vs. 21% in the MCA Plus cohort, OR 0.72 (95% CI: 0.24-2.15). For patients with available data, 40% of MCA was dead at 90 days and 50% in MCA Plus, and for those who survived, 33% of MCA had a good outcome compared to 15% of the MCA Plus, OR 2.4 (95% CI: 0.45-7.61). Forty eight percent of MCA patients were dead at one year vs. 76% of the MCA Plus patients. We found no difference in good outcomes at discharge and 90 days in our cohort of patients who received a HC with MCA or MCA plus infarctions. Limitations include a high rate of missing data at day 90 and at one year, and poor standardization of HC timing. Further prospective studies are necessary to evaluate the clinical implications of HC in MCA Plus syndromes.

Increased Blood–Brain Barrier Permeability on Perfusion CT Might Predict Malignant Middle Cerebral Artery Infarction

Perfusion CT has been used to assess the extent of blood-brain barrier breakdown. The purpose of this study was to determine the predictive value of blood-brain barrier permeability measured using perfusion CT for development of malignant middle cerebral artery infarction requiring hemicraniectomy (HC). We retrospectively identified patients from our stroke registry who had middle cerebral artery infarction and were evaluated with admission perfusion CT. Blood-brain barrier permeability and cerebral blood volume maps were generated and infarct volumes calculated. Clinical and radiographic characteristics were compared between those who underwent HC versus those who did not undergo HC. One hundred twenty-two patients (12 HC, 110 no HC) were identified. Twelve patients who underwent HC had developed edema, midline shift, or infarct expansion. Infarct permeability area, infarct cerebral blood volume area, and infarct volumes were significantly different (P < 0.018, P < 0.0211, P < 0.0001, P < 0.0014) between HC and no HC groups. Age (P = 0.03) and admission National Institutes of Health Stroke Scale (P = 0.0029) were found to be independent predictors for HC. Using logistic regression modeling, there was an association between increased infarct permeability area and HC. The OR for HC based on a 5-, 10-, 15-, or 20-cm² increase in infarct permeability area were 1.179, 1.390, 1.638, or 1.932, respectively (95% CI, 1.035 to 1.343, 1.071 to 1.804, 1.108 to 2.423, 1.146 to 3.255, respectively). Increased infarct permeability area is associated with an increased likelihood for undergoing HC. Because early HC for malignant middle cerebral artery infarction has been associated with better outcomes, the infarct permeability area on admission perfusion CT might be a useful tool to predict malignant middle cerebral artery infarction and need for HC.

Anesthesia Considerations for the Patient With Acute Ischemic Stroke

Stroke is the leading cause of long-term disability in the United States. Hence immediate diagnosis must be made by CT or MRI and therapy instituted rapidly. Anesthesiologists must be aware of the concept of "penumbra" and maintain collateral flow. Blood pressure management is crucial. American Stroke Council recommends blood pressure reduction if systolic >220 mm Hg and diastolic >120 mm Hg. However if thrombolytic therapy is being used, blood pressure must be reduced to systolic <180 mmHg and diastolic < 105 mm Hg. Cerebral autoregulation may be dysfunctional in ischemic brain. Anesthesia management requires control of the airway to prevent aspiration, maintain adequate oxygenation and ventilation, and management of raised intra cranial pressure. Complications of intra-arterial thrombolysis include intracerebral hemorrhage. Frequent neurological exams are warranted. Extensive cerebral swelling may require hemi craniectomy. "Time is Brain" hence urgent thrombolysis is the key to a good outcome.

Decompressive (hemi)craniectomy for refractory intracranial hypertension after traumatic brain injury

Sedation, administration of mannitol or hypertonic saline, mild hyperventilation, moderate hypothermia and high-dose barbiturate therapy are all strategies in the treatment of intracranial hypertension in traumatic brain injury (TBI). Intracranial pressure (ICP) >20 mmHg not responding to conservative strategies caries a bad prognosis, mortality exceeding 80%. A final option in refractory intracranial hypertension might be decompressive (hemi)craniectomy.

Extracellular markers of impending malignant brain edema in large hemispheric stroke

117 Background: The development of malignant brain edema is a life-threatening complication of large hemispheric stroke. Hemicraniectomy and hypothermia are two invasive therapeutic options aiming to reduce mortality and to improve outcome in space-occupying MCA-infarction. The earlier such interventions are initiated the better is the chance of favourable outcome. However, therapeutic decision making is quite arbitrary as clinical observation, imaging or ICP measurement do not yield reliable prognostic criteria. Objective: To assess potential predictors of evolution of malignant brain edema in large MCA-infarction by microdialysis. Subjects and Methods: Following an ongoing prospective clinical trial invasive monitoring was performed in eight patients with large MCA-infarction. 18–36 hours after stroke onset a microdialysis probe was inserted in the parenchyma of the ipsilateral frontal lobe together with an ICP measuring device. Extracellular concentrations of glutamate, lactate, pyruvate, glycerol and various aminoacids were measured continuously for five days. CCT scans were performed on admission, after 6–12 h and at day 5. Scans were scrutinized for presence of mass-effect and size of infarction. Neurological deficit was assessed using the National Institutes of Health Stroke Scale (NIHSS). Results: Median NIHSS at baseline was 18 pts. (range 15–29 pts.). All patients suffered from a large stroke covering more than two thirds of the MCA-territory. In 4/8 patients an infarction of the entire territory of the MCA developed, in 3 of them with fatal space-occupying brain edema. The dynamics of the different substances varied in accordance with the clinical course, size of infarction and local brain edema: in patients with a massive edema in CCT an increase in glutamate concentrations and lactate/pyruvate-ratio was found, whereas patients without mass-effect demonstrated generally low and stable concentrations of these substances. Conclusion: In patients with large hemispheric infarction, bedside monitoring with microdialysis is feasible and may be valuable to predict impending malignant brain edema.

Decompressive Hemicraniectomy for Massive Cerebral Hemorrhage

P103 Background: Hemicraniectomy and durotomy has been shown to be a promising treatment for malignant MCA infarction, but has not been evaluated for cerebral hemorrhage. Methods: We analyzed the clinical course and outcome of 15 patients treated with decompressive surgery for space-occupying cerebral hematomas between 9/98 and 6/00. All patients were treated with duroplasty and either hemicraniectomy (n=13) or a “floating” bone flap (n=2); in some patients, hematoma (n=5) and subdural clot (n=2) evacuation was also performed. Outcomes were assessed by telephone interview using the modified Rankin scale (mRS). Results: Mean age was 49 years (range 33–66); 8 were women; the lesion was left-sided in 7. Hematoma formation was related to spontaneous aneurysmal rupture (n=7), intra-operative aneurysmal rupture (n=3), hypertensive intracerebral hemorrhage (n= 3), and hemorrhagic infarction (n=2). Surgery was peformed Conclusion: Duroplasty and hemicraniectomy, with or without concurrent hematoma evacuation, may improve survival and recovery in comatose patients with large aneurysmal, hypertensive, or infarct-related cerebral hemorrhages.

The Role of Repeat CT for Predicting Fatal Outcome Following Massive Middle Cerebral Artery Territory Infarction

P233 Background Large MCA ischemic stroke when associated with extensive mass effect can result in brain herniation and death. As yet there are no guidelines to aid the selection of patients for decompressive therapies, such as hemicraniectomy. Methods This was a multicentre retrospective study of large MCA infarction requiring neurocritical care. The repeat CT scans performed within 120 hours of stroke onset were assessed for horizontal displacement of septum pellucidum and pineal gland, the size of MCA infarction, involvement of other vascular territories and hydrocephalus. The primary outcome measure was death within 30 days. Results A total of 251 patients fulfilled entry criteria into the study of which 201 received conventional medical therapy alone. Univariate analysis identified the following predictors of early death: NIHSS >16 (P 7 mm (P 3 mm (P 7 mm had sensitivity 53%, specificity 93%, positive predictive value (PPV) 88%, negative predictive value (NPV) 69% for neurological death. Pineal shift dichotomised Conclusions We identified the role of follow-up CT in predicting early death following massive MCA infarction. Anteroseptal shift >7 mm and pineal shift >3 mm if present were strongly predictive of fatal outcome. These follow-up CT parameters require validation before they impact the decision to perform surgical intervention.

Hemi-Craniectomy for Epilepsy

Hemi-Craniectomy for Epilepsy