Timing of Hemicraniectomy

Animal and clinical studies have provided evidence for benefit from early surgery. In animal MCA occlusion models, early hemicraniectomy at one hour versus 24 hours reduced infarct volume significantly (15). A 1998 analysis of the influence on functional outcome and mortality of early hemicraniectomy (<24 hours after symptom onset) versus late surgery (>24 hours after first reversible signs of herniation), based on clinical status at admission and initial CT findings showed that, out of 31 patients who underwent early hemicraniectomy, mortality was 16%, and 84% had a Barthel index >60 at 3-month follow-up (31). Early hemicraniectomy led to a significant reduction in ICU admission (7.4 vs. 13.3 days, p < 0.05). On the other hand, late intervention has been shown to affect neither outcome nor recovery. Early decompressive surgery should be performed to prevent irreversible damage to adjacent brain tissues. Several other case reports and retrospective studies have revealed the same results (24,26). Analysis of pooled published reports suggests that signs of herniation have no impact on the timing of surgery and outcomes (30). Randomized, controlled trials are necessary to determine the optimal timing for hemicraniectomy. Current ongoing clinical trials randomize patients who present between 12 and 96 hours from symptom onset (Table 1).

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