Hemicraniectomy After a Stroke

brain surgery, neurosurgery
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Brain swelling, referred to as edema, is one of the immediate short term dangers of stroke.

Large strokes, in particular, may cause significant swelling that can rapidly worsen, leading to serious consequences, including severe brain damage, a permanent state of unresponsiveness or even death.

How Does a Stroke Cause Brain Edema?

When a stroke occurs, the interruption of blood flow to the brain causes a series of events that lead to brain injury.

Among the effects of brain injury, a temporary period of swelling in an around the stroke may last for hours to days.

The larger the stroke, the more significant the associated edema.

For example, when a  large vessel stroke affects the blood flow through the main middle cerebral artery, almost an entire side of the brain may be deprived of blood, causing the rapid death and swelling of nearly half of the brain.

Because the brain is encased by the rigid walls of the protective bony skull, this swelling leads to an increase in pressure, described as an increase in intracranial pressure (ICP.) ​Increased ICP results in an enlarged area of brain damage. In addition to exerting physical pressure on the brain, the increased ICP also interferes with blood flow.

The increased ICP leads to additional damage beyond the initial damage caused by a stroke. If the swelling causes injury to large areas of the brain, it can result in a rapid progression to brain death.

Sometimes, the best way to relieve the dangerously increased ICP is through a life-saving surgery called a hemicraniectomy.

What is a hemicraniectomy?

A hemicraniectomy is one of the most effective ways of relieving massive brain swelling. This surgical procedure, which is performed in the operating room under anesthesia, consists of temporarily removing a portion of the skull (sometimes up to one-half or more) in order to allow the swollen brain to expand beyond the confines of the skull bone, without causing further elevations in brain pressure.

The part of the skull bone that is removed is typically preserved until the edema resolves, at which point it can be sutured back onto its original position to protect the brain.

Should every large stroke be treated with a hemicraniectomy?

Although many physicians advocate for hemicraniectomy in cases of severe brain swelling, others feel that in spite of the proven benefits of this procedure in terms of survival, hemicraniectomy does not guarantee a meaningful restoration of quality of life for every stroke survivor.

There are other treatments for brain edema, although none are as definitive as hemicraniectomy. If your loved one has had a large stroke with severe edema, the decision about whether to proceed with hemicraneictomy to relive the pressure is based on a number of factors, including how stable your loved one is, and whether your loved one's health is able to tolerate the risks of surgery.

Who decides whether my loved one will get a hemicraniectomy?

Sometimes, a hemicraniectomy is an emergency procedure, in which case there may be little time to deliberate about the pros and cons of the procedure.

Often, a stroke survivor who needs a hemicraniectomy is not alert enough to be able to discuss the plan of action with the stroke team.

Unless a hemicraniectomy is performed emergently, the family's opinion about whether or not the procedure should be performed is taken into great consideration. The decision about whether a stroke survivor should undergo hemicraniectomy is usually reached after the risks and benefits of the surgery have been thoroughly communicated to the family, and after the family agrees to go ahead with the procedure.

Should I agree to a hemicraniectomy for my loved one?

If you are faced with the need to provide medical consent for a hemicraniectomy for someone you know, it might be helpful to ask the medical team about the following issues to help make your decision:

  • What is the likelihood that your loved one will recover meaningful brain function if a hemicraniectomy is performed?
  • If the surgery is performed and your loved one survives the stroke, is there a meaningful chance that he/she will be able to eat or breath on his/her own? If not, did he/she ever express his/her feelings about being completely dependent on tube feedings and/or mechanical ventilation?
  • Does my loved one have a living will that explains what interventions he/she would be willing to tolerate under the present circumstances?

A Word From Verywell

A  stroke can cause short term consequences that require urgent medical intervention. Many stroke survivors experience significant recovery after a hemicraniectomy is performed to reduce edema. Recovery after a hemicraniectomy takes time and patience. Rehabilitation may be prolonged, so it is important that you get as much information as you can about the recovery process so that you can help your loved one through the healing phase after a stroke.

Sources:

Infarct volume predicts outcome after decompressive hemicraniectomy for malignant hemispheric stroke.Hecht N, Neugebauer H, Fiss I, Pinczolits A, Vajkoczy P, Jüttler E, Woitzik J, J Cereb Blood Flow Metab. 2017 Jan 1:271678X17718693

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