Saudi Stroke Standards

Decompressive Hemi Craniectomy for acute ischemic stroke Purpose To treat brain swelling and mass effect secondary to a middle cerebral artery (MCA) territory infarction by decompressive hemicraniectomy. Rationale 11 https://www.strokeassociation.org/idc/groups/stroke- public/@wcm/@hcm/@sta/documents/downloadable/ucm_499252.pdf  In patients <60 years of age with unilateral MCA infarctions that deteriorate neurologically within 48 hours despite maximal medical therapy, decompressive craniectomy with dural expansion is effective.12  Although the optimal trigger for decompressive craniectomy is unknown, it is reasonable to use a decrease in level of consciousness and its attribution to brain swelling as selection criteria.  The efficacy of decompressive craniectomy in patients older than 60 years of age and the optimal timing of surgery are uncertain.  Clinicians may discuss with family members that a third of the patients with massive hemispheric infarctions, even after decompressive craniectomy, are severely disabled and fully dependent on care.13  Decompressive craniectomy reduces mortality from avoiding the progression to brain death. Standards 1. Identification of patients with or at high risk for infarction and swelling should be made using clinical data, including vessel occlusion status. 2. Patients with large MCA infarcts and potential herniation should be referred for neurosurgery urgently. 3. Patients with middle cerebral artery infarction who meet all of the criteria below should be considered for decompressive hemicraniectomy.  Patients aged 60 years or under.  Clinical deficits suggestive of infarction in the territory of the middle cerebral artery, with a score on the NIHSS of above 15.  Decrease in the level of consciousness to give a score of 1 or more on item 1a of the NIHSS.  Signs on CT of an infarct of at least 50% of the middle cerebral artery territory, with or without additional infarction in the territory of the anterior or posterior cerebral artery on the same side, or infarct volume greater than 145 cm3 as shown on diffusion-weighted MRI. 4. Patients who are referred for decompressive hemicraniectomy should be monitored by appropriately trained professionals skilled in neurological assessment. QM