“KEYHOLE” CRANIOTOMY

EARLIER

MORE EXTENSIVE

Ultrasound Guided Aspiration +/- Thrombolytic Agent

DECOMPRESSIVE CRANIECTOMY FOR ICH

Decompressive Craniectomy +/- evacuation of ICHImprove ICP, hemodynamics and

metabolic parameters Murthy et al: Neurocrit. Care 2005

12 pxs, GCS 5-8, 92% survived54.5% good outcomeSchaller et al; Brain Res 2003

May be better with evacuation of ICH? Dierssen et al ACTA Neurochirg 1983

Decompressive Craniectomy

Most minimally invasive?

OCCLUSIVE STROKE

Intracranial StenosisIntraarterial ThrombolysisAngioplasty with stentingEC-IC Bypass for chronic ischemia

Predicted to increase in numbersNeed to retrain the neurosurgeons

Indications Skills

62/f Neurologist

INTRAARTERIAL THROMBOLYSIS (rTPA)on the 6th hour

L MCA Occlusion

10th hour 30th hour

Angioplasty with IC Stent

IMPLICATION OF INTRAVASCULAR FOREIGN BODIES?

MALIGNANT MCA INFARCTION

DECOMPRESSIVE CRANIECTOMY

DECOMPRESSIVE HEMICRANIECTOMY

EFFECT ON ICP AND PtiO2

ICPPtiO2

Decompressive Craniectomy

Increasing in acceptance and usagePGH: Site of RCT

Only one ongoing as of nowFactors to increase good outcome

Younger (55 y)Earlier (<48 hrs)Non fulminant course /Dilemna of doing it

too early or too late

Decompressive Craniectomy

HeMMI: Hemicraniectomy for Malignant Middle Cerebral Artery Infarcts. Jamora,R, Chua, A., Collantes, E., Manila/Philippines

Year started 2004Study size actual26 (12 Medical)Study size planned 56Age 15-65Timing of surgery <72 hrs

Decompressive Craniectomy

RCT s in HemicraniectomyImproved survivalIs this enough?

For most families it is