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. 2022 Dec 16:13:580.
doi: 10.25259/SNI_895_2022. eCollection 2022.

Decompressive craniectomy index: Does the size of decompressive craniectomy matter in malignant middle cerebral artery infarction?

Thiago Pereira Rodrigues  1 , Mariana Athaniel Silva Rodrigues  2 , Leonardo Favi Bocca  1 , Feres Eduardo Chaddad-Neto  1 , Sergio Cavalheiro  1 , Edson Amaro Junior  2 , Gisele Sampaio Silva  3 , Italo Capraro Suriano  1 , Ricardo Silva Centeno  1
Affiliations

Decompressive craniectomy index: Does the size of decompressive craniectomy matter in malignant middle cerebral artery infarction?

Thiago Pereira Rodrigues et al. Surg Neurol Int. .

Abstract

Background: Malignant middle cerebral artery (MCA) infarction is associated with high mortality, mainly due to intracranial hypertension. This malignant course develops when two-thirds or more of MCA territory is infarcted. Randomized clinical trials demonstrated that in patients with malignant MCA infarction, decompressive craniectomy (DC) is associated with better prognosis. In these patients, some prognostic predictors are already known, including age and time between stroke and DC. The size of bone flap was not associated with long-term prognosis in the previous studies. Therefore, this paper aims to further expand the analysis of the bone removal toward a more precise quantification and verify the prognosis implication of the bone flap area/whole supratentorial hemicranium relation in patients treated with DC for malignant middle cerebral infarcts.

Methods: This study included 45 patients operated between 2015 and 2020. All patients had been diagnosed with a malignant MCA infarction and were submitted to DC to treat the ischemic event. The primary endpoint was dichotomized modified Rankin scale (mRS) 1 year after surgery (mRS≤4 or mRS>4).

Results: Patients with bad prognosis (mRS 5-6) were on average: older and with a smaller decompressive craniectomy index (DCI). In multivariate analysis, with adjustments for "age" and "time" from symptoms onset to DC, the association between DCI and prognosis remained.

Conclusion: In our series, the relation between bone flap size and theoretical maximum supratentorial hemicranium area (DCI) in patients with malignant MCA infarction was associated with prognosis. Further studies are necessary to confirm these findings.

Keywords: Cerebral volumetry; Decompressive craniectomy; Intracranial pressure; Malignant middle cerebral artery infarction.

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Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1:
Figure 1:
Bone segmentation of preoperative C.T. examination. (a) All cranial bone segmented. (b) The red-dotted line represents a cut passing through external occipital protuberance, sagittal suture, and internasal suture. (c) A left-sided hemicranium with the red-dotted line representing a cut that passes through internal occipital protuberance, groove for transverse sinus, intersection between the middle fossa floor and the lateral wall, and the intersection between anterior cranial fossa floor and lateral/anterior wall. (d) The maximum theoretical hemispheric hemicranium bone flap.
Figure 2:
Figure 2:
Bone flap area calculation. (a) Coregistration of preoperative and postoperative C.T. examinations. (b) Subtracting postoperative C.T. examination from preoperative C.T. examination obtained exactly the bone flap defect.
Figure 3:
Figure 3:
Correlation between decompressive craniectomy index and maximum craniectomy diameter. AP: Anteroposterior
Figure 4:
Figure 4:
Dichotomized outcomes according to decompressive craniectomy index cutoffs.
See this image and copyright information in PMC

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