Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
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Proper Indication of Decompressive Craniectomy for the Patients with Massive Brain Edema after Intra-arterial Thrombectomy

  • Sang-Hyuk Im (Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea) ;
  • Do-Sung Yoo (Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea) ;
  • Hae-Kwan Park (Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea)
  • Received : 2023.06.21
  • Accepted : 2023.08.21
  • Published : 2024.03.01
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Abstract

Objective : Numerous studies have indicated that early decompressive craniectomy (DC) for patients with major infarction can be life-saving and enhance neurological outcomes. However, most of these studies were conducted by neurologists before the advent of intra-arterial thrombectomy (IA-Tx). This study aims to determine whether neurological status significantly impacts the final clinical outcome of patients who underwent DC following IA-Tx in major infarction. Methods : This analysis included 67 patients with major anterior circulation major infarction who underwent DC after IA-Tx, with or without intravenous tissue plasminogen activator. We retrospectively reviewed the medical records, radiological findings, and compared the neurological outcomes based on the "surgical time window" and neurological status at the time of surgery. Results : For patients treated with DC following IA-Tx, a Glasgow coma scale (GCS) score of 7 was the lowest score correlated with a favorable outcome (p=0.013). Favorable outcomes were significantly associated with successful recanalization after IA-Tx (p=0.001) and perfusion/diffusion (P/D)-mismatch evident on magnetic resonance imaging performed immediately prior to IA-Tx (p=0.007). However, the surgical time window (within 36 hours, p=0.389; within 48 hours, p=0.283) did not correlate with neurological outcomes. Conclusion : To date, early DC surgery after major infarction is crucial for patient outcomes. However, this study suggests that the indication for DC following IA-Tx should include neurological status (GCS ≤7), as some patients treated with early DC without considering the neurological status may undergo unnecessary surgery. Recanalization of the occluded vessel and P/D-mismatch are important for long-term neurological outcomes.

Keywords

Acknowledgement

This work was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science (NRF2022R1F1A1076411) and The Catholic University of Korea, Eunpyeong St. Mary's Hospital, Research Institute of Medical Science in program year 2021, 2022. Authors appreciate the help of neurosurgical nurse specialist Hye-Seon Jeong R.N. for collecting the data by and the grammatical review of our manuscript by Ann C. Rice, PhD of J. Sargeant Reynolds Community College, Richmond, VA, USA.

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