Acute Supratentorial Ischemic Stroke: When
Surgery Is Mandatory-A small review
Amit Kumar Ghosh*
Department of Neurosurgeon, National Neuroscience Institute, India
Submission: September 24, 2018; Published: October 11, 2018
*Corresponding author: Amit Kumar Ghosh, Department of Neurosurgeon, National Neuroscience Institute, India, Email: [email protected]
How to cite this article: Amit K G. Acute Supratentorial Ischemic Stroke: When Surgery Is Mandatory-A small review. Open Access J Neurol
Neurosurg. 2018; 9(2): 555760. DOI: 10.19080/OAJNN.2018.09.555760.
Massive supratentorial infarct due to large vessel occlusion results death which can be prevented by early decompressive craniectomy rather than delayed. This is a short review of those clues to decide which cases will need early surgery.
Massive brain swelling may occur in 10% of cerebral ischemic strokes. In these patients the clinical presentation usually starts with focal signs (motor weakness, speech disturbances, and hemianopsia) and progresses with a decline of consciousness (drowsiness, stupor). Despite optimal medical management this condition may lead to death in 70-80% of cases Because of the grim prognosis, this condition has been termed “malignant” cerebral infarction. The etiology is the occlusion of a large vessel, primarily the Internal Carotid (ICA) or the Middle Cerebral Artery (MCA).
Decompressive surgery seems to be more effective if performed earlier rather than later. That is why, there is great interest in identifying clinical, laboratory, and imaging findings which is able to predict which patients are going to develop a malignant infarction.
Clues to detect ischemic patients at higher risk for a malignant supratentorial (MCA) infarction who will require surgery .
Signs of raised intracranial pressure specifically progressive deterioration of consciousness. But, decrease in consciousness level may be due to shift of the ischemic tissue rather than raised Intracranial Pressure (ICP). So, clinical data must be correlated with Imaging findings.
Ischemic area > 145 mL, even at early stages. Moreover, DWI ischemic volumes larger than 210 mL were found related to a 100% mortality in patients without surgical treatment Laboratory data  (Figures 1&2).
Serum astroglial protein S100B protein >1.03 mcg/L (Has
94% sensitivity and 83% specificity to predict massive cerebral
edema) Unfortunately at this stage, this tool is not available in
The role of ICP monitoring in patients with large cerebral
infarctions is controversial. There is no absolute recommendation
for a routine use of intracranial pressure monitoring. And it is not
considered a risk-free procedure. Uncal herniation and anisocoria
sometimes occur without an overall increase of ICP. In patients
with a malignant MCA infarction, pupillary abnormalities and
severe brainstem compression may be present despite normal ICP
values. Therefore, continuous ICP monitoring cannot substitute
for close clinical and radiological follow-up in the management of
these patients. Other facts [2,3].
The side of the stroke does not seem to affect the vital
status after surgical decompression, so it should not influence
the choice to operate Patients older than 60 years are not ideal
candidates for surgical decompression as they possess a lower
neuronal plasticity and also frequently have more risk factors and
comorbidities. However, older patients with a good antecedent
condition hemicraniectomy seems somehow to improve the
prognosis Surgery can be safely performed even after intravenous
tissue plasminogen activator administration for thrombolysis.
The craniotomy should include the frontal, parietal, and
temporal bones and its antero-posterior length should not be
inferior to 12 cm larger openings up to 14 cm or more are thought
to allow an even better pressure relieve. Particular attention
has to be paid to decompression of the basal temporal area, as
it represents a critical compartment with close relationship
with the brainstem. In order to gain additional room, the dura
mater is commonly opened as well. It can then be enlarged with
a biological or synthetic substitute or left patent, just covered by
hemostatic material for a faster closure the cerebral tissue itself
should be completely preserved at surgery for recovery of the not
deadly damaged areas, which may be not distinguishable from the
infarction itself (Figure 3).