Decompressive Hemicraniectomy

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Decompressive hemicraniectomy is primarily intended to treat the high intracranial pressure associated with massive MCA infarction and subsequent swelling (Fig. 6.3). Focal areas of ischemia may result when intracranial pressure is greater than 20 mmHg, and global ischemia can occur when intracranial pressure exceeds 50mmHg.33 Therefore, removal of a large part of the calvarium, theoretically reducing intracranial hypertension, ongoing ischemia, and preventing swollen tissue from displacing healthier neighboring tissue, may benefit some patients following large territory MCA infarction.

The procedure typically involves a wide bone removal of the cranial vault, measuring roughly 13 cm in antero-posterior dimensions and from the floor of the middle cranial fossa to at least 9 cm superiorly. After opening of the dura, an anterior temporal lobectomy is usually performed, with or without resection of any necrotic avas-cular tissue.34 This is followed by loose closure of the dura with allograft or pericranium. The bone flap can be either stored in the preperitoneal fat, or refrigerated in antibiotic solution and replaced after the edema has subsided. Decompressive hemicraniectomy is usually done with the patient being treated in the ICU setting and in conjunction with other aggressive medical therapies. Success of the procedure

Decompressive Hemicraniectomy

FIGURE 6.3 (a) Thirty-eight-year-old male presenting with new onset headache, hand numbness, and visual changes, deteriorating to aphasia and right hemiparesis over 3 hours. This CT demonstrates a large left MCA infarct with hypoattenuation in the MCA territory, loss of normal gray-white matter differentiation, partial effacement of the frontal horn of the left lateral ventricle, and sulcal effacement within the left frontal and parietal lobes. (b) Postoperative CT after decompressive hemicraniectomy and left anterior temporal lobectomy.

FIGURE 6.3 (a) Thirty-eight-year-old male presenting with new onset headache, hand numbness, and visual changes, deteriorating to aphasia and right hemiparesis over 3 hours. This CT demonstrates a large left MCA infarct with hypoattenuation in the MCA territory, loss of normal gray-white matter differentiation, partial effacement of the frontal horn of the left lateral ventricle, and sulcal effacement within the left frontal and parietal lobes. (b) Postoperative CT after decompressive hemicraniectomy and left anterior temporal lobectomy.

depends on the degree of decompression achieved, and a repeat operation may be necessary for clinical and/or radiographic evidence of persistent herniation.

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