Abstract
Adult patients with space-occupying hemispheric infarctions have a poor prognosis, with an associated fatality rate of 80 %. Decompressive hemicraniectomy (DH) has been studied as a treatment option for patients with malignant cerebral infarction refractory to maximal medical therapy, with reasonable outcomes demonstrated in the adult population if the patient is decompressed within 48 h. However, there are no randomized controlled trials in the pediatric literature to make the same claims. In this study, we evaluated the current literature in regards to DH following malignant stroke in the pediatric population. We found that excellent recovery, with an acceptable quality of life, is possible, particularly in the pediatric patient. Our cohort suggests that pediatric intervention beyond the 48-h time interval may still lead to positive outcomes, unlike adult patients. Regardless, randomized controlled trials are needed to determine optimal timing of intervention following symptom onset, as well as to identify predictors for positive outcome in the pediatric population.
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George A Alexiou, Ioannina, Greece
Decompressive craniectomy has improved the survival in selected cases of traumatic brain injury, cerebral infarction, and subarachnoid hemorrhage in adults. In the case of an ischemic stroke, decompressive craniectomy is usually performed when the intracranial pressure cannot be controlled by conservative treatment methods, ideally within 48 h of symptom onset. Although decompressive craniectomy has been shown to reduce mortality, it has been associated with high morbidity rates in adults. In children, the use of decompressive craniectomy has not been extensively evaluated and only small series and case reports are available. In the current study, the authors performed a nice review of the current literature on the value of decompressive craniectomy in children with malignant cerebral edema following stroke. Analysis of the available studies revealed that decompressive craniectomy is a life-saving and effective treatment option in children with malignant cerebral infarction. The majority of children had satisfactory outcomes. Although a limited experience, the important message from this study is that decompressive craniectomy might be warranted for malignant stroke in children.
Divaldo Camara Junior, Recife, Brazil
The authors have done a good work with the paper “Decompressive Hemicraniectomy for Ischemic Stroke in the Pediatric Population.” Although an extensive review of the literature did not find a huge amount of cases, the authors could collect and properly analyze a small, yet important sample of patients. The favorable outcome encountered sheds light on the beneficial role of surgery, urging the necessity of well-designed trials to establish the impact of DHC on mortality and functional outcome. By doing so, we would be even more confident on the benefit of surgery as a tool to be offered to such young patients. However, due to the wide different conditions leading to stroke at this group age, it may be difficult to access a homogeneous group.
Hamit Selim Karabekir, Izmir, Turkey
Malignant cerebral infarction (MCI), especially middle cerebral, results in significant mortality and morbidity in adults that is characterized by space-occupying edema, intracranial hypertension, and herniation. Medical treatment results in approximately 80 % mortality, and survivors generally remain moderately to severely disabled. An earlier review of adult literature revealed that younger patients under 50 years old had good prognostic factor, although the application of decompressive craniectomy (DC) in children with MCI has not been evaluated adequately. Smith et al. reviewed cases of MCI from five pediatric tertiary care centers retrospectively in 2010. Medical management included controlled mechanical ventilation in all patients and intravenous mannitol and/or 3 % saline in all but one individual. The mean Glasgow Coma Scale (GCS) was 6; the range of it is 3 to 9. Three of the children were monitored for following intracranial pressure (ICP) and did not undergo DC. They died from transtentorial herniation. The other seven children, who had GCS <8, underwent DC at a median time of 54 h after symptom onset (the range was 18 to 291 h). All of those children survived. Follow-up of outcome was 5 years and 4 months (range, 1 year and 8 months to 7 years and 2 months). Two of them had mild weakness, four had moderate hemiparesis, and one had hemidystonia. All of the patients were walking independently and were speaking fluently at their last follow-up visit despite residual impairment. In the meta-analysis of randomized controlled trials in adults by Vahedi et al. (Lancet Neurology, 2007), stroke size is similar to the study of Smith et al., although the patients in the study underwent surgery within 48 h of stroke onset. In the literature, surgical decompression appears to benefit deeply comatose children or adults with traumatic head injury. At the studies of Omay et al. and Smith et al., they demonstrated that survival with moderately good outcome may be achieved in deeply unconscious children with stroke; this procedure should be considered for children even with GCS = 7 or less or deteriorating level of consciousness. Both of the authors' studies are important for the readers to understand DC and the cases of MCI. There must be other studies which reveal the benefit of this surgical procedure, but as a conclusion, monitoring of ICP may delay the DC and is unlikely to be beneficial in the initial treatment of MCI. Therefore, this life-saving DC should be considered in children with MCI.
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Omay, S.B., Carrión-Grant, G.M., Kuzmik, G.A. et al. Decompressive hemicraniectomy for ischemic stroke in the pediatric population. Neurosurg Rev 36, 21–25 (2013). https://doi.org/10.1007/s10143-012-0411-4
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DOI: https://doi.org/10.1007/s10143-012-0411-4