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Semin Neurol 2023; 43(03): 370-387
DOI: 10.1055/s-0043-1771208
Review Article

Surgery for Malignant Acute Ischemic Stroke: A Narrative Review of the Knowns and Unknowns

Kailash Krishnan   *
1   Stroke Unit, Department of Acute Medicine Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
2   Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
,
Milo Hollingworth   *
3   Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
,
Thanh N. Nguyen
4   Department of Neurology, Neurosurgery and Radiology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
,
Ashwin Kumaria
3   Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
,
Matthew A. Kirkman
3   Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
,
Surajit Basu
3   Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
,
Christos Tolias
5   Department of Neurosurgery, King's College Hospitals NHS Foundation Trust, London, United Kingdom
,
Philip M. Bath
1   Stroke Unit, Department of Acute Medicine Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
2   Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
,
Nikola Sprigg
1   Stroke Unit, Department of Acute Medicine Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
2   Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
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Abstract

Malignant acute ischemic stroke (AIS) is characterized by acute neurological deterioration caused by progressive space-occupying brain edema, often occurring in the first hours to days after symptom onset. Without any treatment, the result is often fatal. Despite advances in treatment for AIS, up to 80% of patients with a large hemispheric stroke or cerebellar stroke are at risk of poor outcome. Decompressive surgery can be life-saving in a subgroup of patients with malignant AIS, but uncertainties exist on patient selection, predictors of malignant infarction, perioperative management, and timing of intervention. Although survivors are left disabled, most agree with the original decision to undergo surgery and would make the same decision again. In this narrative review, we focus on the clinical and radiological predictors of malignant infarction in AIS and outline the technical aspects of decompressive surgery as well as duraplasty and cranioplasty. We discuss the current evidence and recommendations for surgery in AIS, highlighting gaps in knowledge, and suggest directions for future studies.

Key Points

  • Acute ischemic stroke from occlusion of a proximal intracranial artery can progress quickly to malignant edema, which can be fatal in 80% of patients despite medical management.

  • Decompression surgery is life-saving within 48 hours of stroke onset, but the benefits beyond this time and in the elderly are unknown.

  • Decompressive surgery is associated with high morbidity, particularly in the elderly. The decision to operate must be made after considering the individual's preference and expectations of quality of life in the context of the clinical condition.

  • Further studies are needed to refine surgical technique including value of duraplasty and understand the role monitoring intracranial pressure during and after decompressive surgery.

  • More studies are needed on the pathophysiology of malignant cerebral edema, prediction models including imaging and biomarkers to identify which subgroup of patients will benefit from decompressive surgery.

  • More research is needed on factors associated with morbidity and mortality after cranioplasty, safety and efficacy of implants, and comparisons between them.

  • Further studies are needed to assess the long-term effects of physical disability and quality of life of survivors after surgery, particularly those with severe neurological deficits.

Keywords

decompressive hemicraniectomy - ventriculostomy - suboccipital craniectomy - acute stroke - morbidity - mortality - indication for surgery - surgical decompression

* Authors contributed equally to this manuscript.




Publication History

Article published online:
18 August 2023

© 2023. Thieme. All rights reserved.

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