Seeking Clarity Around Craniotomy

Andrew N. Wilner, MD; Christopher D. Streib, MD, MS


August 03, 2017

Andrew N. Wilner, MD: I am Dr Andrew Wilner, and I am here with Dr Christopher Streib, director of stroke operations at the University of Minnesota in Minneapolis. Today we are going to be speaking about the treatment of malignant cerebral infarction (MCI).

Dr Streib, thanks for speaking with Medscape today.

Christopher D. Streib, MD, MS: My pleasure. Thank you for having me.

Dr Wilner: What is MCI?

Dr Streib: MCI is generally defined as a large, acute ischemic stroke, typically within the middle cerebral artery territory, complicated by life-threatening cerebral edema within the closed compartment of the skull. As edema increases, it may lead to coma, brain herniation, respiratory arrest, and death. The mortality of medically managed MCI is between 70% and 80%.

Dr Wilner: You recently published a meta-analysis of decompressive craniectomy treatment for MCI in the journal Neurology Clinical Practice.[1] What were your findings?

Dr Streib: This was a project I undertook with Dr Brad Molyneaux, a neurointensivist at the University of Pittsburgh Medical Center. Six randomized clinical trials of decompressive craniectomy for MCI have been conducted previously. However, the topic is controversial because, despite positive trials, there remains significant skepticism about decompressive craniectomy for the MCI patient population.

Each of the six trials showed that decompressive craniectomy improves survival and functional outcomes. Many believe, however, that despite the improvement in functional outcome, the functional outcomes attained still do not represent a quality of life worth living. Rather than restate known data, our meta-analysis attempted to ask and answer questions in a way that could provide clinical clarity.

Our first question was: Does decompressive craniectomy for patients with MCI improve the likelihood of attaining functional outcomes with a consensus that the quality of life is worth living? And the answer was clearly yes. Significantly more patients are either independent, or nearly independent, with the ability to ambulate 1 year after undergoing decompressive craniectomy.

The second question was: Does decompressive craniectomy for patients with MCI increase the likelihood of survival with a quality of life that is not worth living? And the answer is, it might. The outcome depends upon the valuation of different outcome strata by the patient and the family.

Rather than make a case that there is a right or wrong answer regarding decompressive craniectomy for MCI, we put our findings into a clinical decision algorithm to help frame the question for treating physicians and families, based on the likelihood of attaining a 'good" or "poor” quality of life as it relates to the individual family and patient's perception of those outcomes.

Dr Wilner: What are the indications for decompressive craniectomy?

Dr Streib: With the caveat that the expected outcomes after decompressive craniectomy are in line with the treatment goals of the patient and family, the indications for decompressive craniectomy are typically major middle cerebral artery stroke with subsequent cerebral edema, leading to decreased level of consciousness and the expectation of further progression of edema and neurologic deterioration.

Dr Wilner: In your experience, how effective is decompressive craniectomy?

Dr Streib: Obviously, it varies widely. I have multiple patients who have returned to work full-time and are completely independent after decompressive craniectomy. With the appropriate family support, most patients will return home. Very few are totally bedbound and dependent, which is the outcome everyone wants to avoid.

Dr Wilner: Who are the best candidates for decompressive craniectomy?

Dr Streib: As you might expect, the best candidates are young, healthy people. The original trials were limited to patients under 60 years of age, although more recent trials have included older patients. There is clearly a major difference in outcome between these age groups, and it is an important treatment consideration. These differences in outcomes are highlighted in our paper.

Dr Wilner: Is the timing important?

Dr Streib: Extremely important. MCI is not malignant because of the initial stroke; it is the secondary injury from brain edema, increased intracranial pressure, and poor cerebral perfusion that perpetuates itself if untreated. Decompressive surgery stops this cycle. In fact, in our paper we excluded trials that did not perform the decompression within 48 hours of presentation, because the morbidity benefit is not seen in patients who are treated later. Also, patients who are already herniating tend to have bad outcomes despite decompression. Essentially, the patient should be treated as quickly as possible, but that enthusiasm must be balanced to avoid performing craniectomy on patients who will not develop MCI.

Dr Wilner: Does it matter if the patient was treated with tissue plasminogen activator (tPA)?

Dr Streib: Typically, no. The development of brain edema is generally slow enough that the tPA-induced coagulopathy will have resolved by the time of surgery. However, that is not always the case, and coagulation studies should be checked. If necessary, the effect of tPA can be reversed.

Dr Wilner: Does it matter whether the stroke is hemorrhagic or ischemic?

Dr Streib: That question is not yet definitively answered. Our study only looked at ischemic stroke. Previous studies of craniotomy for intracerebral hemorrhage (ICH) did not show improved mortality or morbidity. The current American Heart Association guidelines suggest that surgery may be considered for ICH in the setting of deterioration or as a life-saving measure. In addition, trials of minimally invasive hematoma evacuation are ongoing, and we hope that those trials will demonstrate a positive treatment effect.

Dr Wilner: What is the practice regarding MCI at the University of Minnesota?

Dr Streib: We begin by determining the goals of care for the patients and their families. For younger, healthier patients, we are typically aggressive because we see good long-term outcomes fairly consistently. The decision is more difficult in older patients or in those with significant medical comorbidities. We consider each patient on a case-by-case basis. The decision is rarely straightforward or easy.

I should also note that this debate only applies to supratentorial infarcts. It is well known that patients with ischemic or hemorrhagic stroke who develop mass effect in the posterior fossa do benefit markedly from surgical decompression. There is really no debate that nearly all of these patients should undergo surgical decompression.

Dr Wilner: Dr Streib, thank you very much for sharing your insights and experience regarding decompressive craniectomy for MCI with Medscape.


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