Time course of hemispheric cerebral volume after decompressive craniectomy in malignant middle cerebral artery stroke

Abstract

Background Brain edema is the leading cause of death in patients with malignant middle cerebral artery (MCA) infarction. Midline shift (MLS) has been used as a monohemispheric brain edema marker in several studies; however, it does not precisely measure brain edema. It is now possible to directly measure hemisphere brain volume. Knowledge about the time course of brain edema after malignant middle cerebral artery infarction may contribute to the condition's management.

Objective Therefore, our goal was to evaluate the course of brain edema in patients with malignant MCA infarction treated with decompressive craniectomy (DC) using hemispheric volumetric measurements.

Methods Patients were selected consecutively from a single tertiary hospital between 2013 and 2019. All patients were diagnosed with malignant middle cerebral artery infarction and underwent a decompressive craniectomy (DC) to treat the ischemic event. All computed tomography (CT) exams performed during the clinical care of these patients were analyzed, and the whole ischemic hemisphere volume was calculated for each CT scan.

Results We analyzed 43 patients (197 CT exams). Patients' mean age at DC was 51.72 [range: 42–68] years. The mean time between the ischemic ictus and DC was 41.88 (range: 6–77) hours. The mean time between the ischemic event and the peak of hemisphere volume was 168.84 (95% confidence interval [142.08, 195.59]) hours.

Conclusion In conclusion, the peak of cerebral edema in malignant MCA infarction after DC occurred on the 7th day (168.84 h) after stroke symptoms onset. Further studies evaluating therapies for brain edema even after DC should be investigated.

Resumo

Antecedentes O edema cerebral é a principal causa de morte em pacientes com infarto maligno de artéria cerebral média. O desvio da linha média tem sido utilizado como marcador de edema cerebral mono-hemisférico em alguns estudos; porém, ele não mede de forma precisa o edema cerebral. Atualmente é possível mensurar diretamente o volume do hemisfério cerebral. O conhecimento sobre a evolução temporal do edema cerebral após infartos malignos da artéria cerebral média pode contribuir para o cuidado clínico desta condição.

Objetivo Nosso objetivo é avaliar o edema hemisférico ao longo do tempo, em pacientes com infarto maligno da artéria cerebral média, tratados com craniectomia descompressiva.

Métodos Os pacientes foram selecionados de forma consecutiva, em um hospital terciário, entre 2013 e 2019. Todos os pacientes apresentavam diagnóstico de infarto maligno de artéria cerebral média e foram submetidos a craniectomia descompressiva. Todas as tomografias computadorizadas de crânio destes pacientes foram analizadas, e o volume do hemisfério cerebral infartado foi mensurado.

Resultados Analisamos 43 pacientes (197 tomografias de crânio). A idade média dos pacientes na craniectomia descompressiva foi 51,72 (42–68) anos. O tempo médio entre o ictus e a craniectomia descompressiva foi 41,88 (6–77) horas. O tempo médio entre o ictus e o pico do volume hemisférico foi 168,84 (142,08–195,59) horas.

Conclusão O pico do volume cerebral em pacientes com infarto maligno de artéria cerebral média submetidos a craniectomia descompressiva ocorreu no 7o dia (168,84 horas) após o infarto. Mais estudos avaliando terapêuticas direcionadas ao edema cerebral seriam úteis neste contexto.

Keywords

Decompressive Craniectomy - Infarction, Middle Cerebral Artery - Intracranial Pressure

Palavras-chave

Craniectomia Descompressiva - Infarto de Artéria Cerebral Média - Pressão Intracraniana

Authors' Contributions

LFB: final revision; TPR, MASR: first draft and final revision; TPR, FECN, SC, EAJ, GSS, ICS, RSC: concept and discussion.

Support

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.

Publikationsverlauf

Eingereicht: 17. Mai 2022

Angenommen: 11. September 2022

Artikel online veröffentlicht:
09. Mai 2023

• References

• 1 Schwab S, Steiner T, Aschoff A. et al. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 1998; 29 (09) 1888-1893
• 2 Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R. ‘Malignant’ middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol 1996; 53 (04) 309-315
• 3 Dohmen C, Galldiks N, Bosche B, Kracht L, Graf R. The severity of ischemia determines and predicts malignant brain edema in patients with large middle cerebral artery infarction. Cerebrovasc Dis 2012; 33 (01) 1-7
• 4 Silver FL, Norris JW, Lewis AJ, Hachinski VC. Early mortality following stroke: a prospective review. Stroke 1984; 15 (03) 492-496
• 5 Shaw CM, Alvord Jr EC, Berry RG. Swelling of the brain following ischemic infarction with arterial occlusion. Arch Neurol 1959; 1: 161-177
• 6 Chen X, Huang Q, Deng Q. et al. A prediction model of brain edema after endovascular treatment in patients with acute ischemic stroke. J Neurol Sci 2019; 407: 116507
• 7 Schur S, Martel P, Marcoux J. Optimal Bone Flap Size for Decompressive Craniectomy for Refractory Increased Intracranial Pressure in Traumatic Brain Injury: Taking the Patient's Head Size into Account. World Neurosurg 2020; 137: e430-e436
• 8 Dhar R, Yuan K, Kulik T. et al. CSF Volumetric Analysis for Quantification of Cerebral Edema After Hemispheric Infarction. Neurocrit Care 2016; 24 (03) 420-427
• 9 Dhar R, Chen Y, Hamzehloo A. et al. Reduction in Cerebrospinal Fluid Volume as an Early Quantitative Biomarker of Cerebral Edema After Ischemic Stroke. Stroke 2020; 51 (02) 462-467
• 10 Poca MA, Benejam B, Sahuquillo J. et al. Monitoring intracranial pressure in patients with malignant middle cerebral artery infarction: is it useful?. J Neurosurg 2010; 112 (03) 648-657
• 11 Harkey T, Baker D, Hagen J, Scott H, Palys V. Practical methods for segmentation and calculation of brain volume and intracranial volume: a guide and comparison. Quant Imaging Med Surg 2022; 12 (07) 3748-3761
• 12 Fedorov A, Beichel R, Kalpathy-Cramer J. et al. 3D Slicer as an image computing platform for the Quantitative Imaging Network. Magn Reson Imaging 2012; 30 (09) 1323-1341
• 13 Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet 2000; 355 (9216): 1670-1674
• 14 Funchal BF, Alves MM, Suriano ÍC, Chaddad-Neto FE, Ferraz MEMR, Silva GS. Intracranial pressure following decompressive hemicraniectomy for malignant cerebral infarction: clinical and treatment correlations. Arq Neuropsiquiatr 2018; 76 (12) 812-815
• 15 Paldor I, Rosenthal G, Cohen JE. et al. Intracranial pressure monitoring following decompressive hemicraniectomy for malignant cerebral infarction. J Clin Neurosci 2015; 22 (01) 79-82
• 16 Brott T, Marler JR, Olinger CP. et al. Measurements of acute cerebral infarction: lesion size by computed tomography. Stroke 1989; 20 (07) 871-875
• 17 Freyschlag CF, Boehme C, Bauer M. et al. The Volume of Ischemic Brain Predicts Poor Outcome in Patients with Surgically Treated Malignant Stroke. World Neurosurg 2019; 123: e515 –e519