Post-traumatic cerebral infarction : outcome after decompressive hemicraniectomy for the treatment of traumatic brain injury

Abstract

Objective: Posttraumatic cerebral infarction (PTCI), an infarction in well-defined arterial distributions after head trauma, is a known complication in patients with severe head trauma. The primary aims of this study were to evaluate the clinical and radiographic characteristics of PTCI, and to assess the effect on outcome of decompressive hemicraniectomy (DHC) in patients with PTCI.

Methods: We present a retrospective analysis of 20 patients with PTCI who were treated between January 2003 and August 2005. Twelve patients among them showed malignant PTCI, which is defined as PTCI including the territory of Middle Cerebral Artery (MCA). Medical records and radiologic imaging studies of patients were reviewed.

Results: Infarction of posterior cerebral artery distribution was the most common site of PTCI. Fourteen patients underwent DHC an average of 16 hours after trauma. The overall mortality rate was 75%. Glasgow outcome scale (GOS) of survivors showed that one patient was remained in a persistent vegetative state, two patients were severely disabled and only two patients were moderately disabled at the time of discharge. Despite aggressive treatments, all patients with malignant PTCI had died. Malignant PTCI was the indicator of poor clinical outcome. Furthermore, Glasgow coma scale (GCS) at the admission was the most valuable prognostic factor. Significant correlation was observed between a GCS less than 5 on admission and high mortality (p<0.05).

Conclusion: In patients who developed non-malignant PTCI and GCS higher than 5 after head injury, early DHC and duroplasty should be considered, before occurrence of irreversible ischemic brain damage. High mortality rate was observed in patients with malignant PTCI or PTCI with a GCS of 3-5 at the admission. A large prospective randomized controlled study will be required to justify for aggressive treatments including DHC and medical treatment in these patients.

Keywords: Brain trauma; Cerebral infarction; Decompressive craniectomy.

Fig. 1

Computerized tomography showing a post-traumatic cerebral infarction on the left posterior cerebral artery distribution.

Fig. 2

A : Computerized tomography (CT) showing an acute subdural hematoma with a milti-territory infarction including middle cerebral artery distribution (malignant post-traumatic cerebral infarction), B : CT angiography showing the vascular distortions of both anterior cerebral arteries and compression of the right middle cerebral artery (arrow) caused by a mass effect.

Fig. 3

Computerized tomography showing a traumatic intracerebral hematoma with a post-traumatic cerebral infarction on the right posterior cerebral artery distribution.

Fig. 4

A : Computerized tomography (CT) showing an acute epidural hematoma with a midline shift, B : postoperative CT showing a multi-territory infarction including middle cerebral artery distribution.

Fig. 5

A : Computerized tomography (CT) reveals right sided acute subdural hematoma with a midline shift, B : The following CT performed after craniectomy and evacuation of blood shows PTCI in the posterior cerebral artery territory.