“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