ESO Guidelines 2021

1. ROLE OF DECOMPRESSIVE CRANIECTOMY IN
ISCHEMIC STROKE
YOGYAKARTA, 27 OKTOBER 2022

2. Introduction
2019 2021

3. INTRODUCTION
Ischemic stroke is on of the leading causes for death and disability worldwide
Especially in patients with malignant middle cerebral artery infarction, brain swelling secondary to vessel
occlusion is associated with high mortality
Several studies have shown that DC reduces the mortality rate in patients with malignant cerebral
infarction
Two principal groups of stroke who may benefit from craniectomy : first, patients with large infarction of
the middle cerebral artery territory, second is patients with space occupying cerebellar infarction
ESO provide guidelines on the management of space occupying brain infarction based on a systematic
review and on the Grading of Recommendations, Assesment, Develpoment and Evaluation (GRADE)

4. Malignant Middle Cerebral Artery
Infarction
Malignant MCA infarction’ is the term used to describe rapid
neurological deterioration due to the effects of space occupying
cerebral oedema following middle cerebral artery (MCA) territory
stroke.
Clinical: hemiparesis or hemiplegia, loss of visual field, gaze
deviation, neglect or aphasia, impaired level of consciousness,
nausea, vomiting, pupillary changes and papilledema
NIHSS Score typically have scores > 15 (non dominant hemisphere)
and > 20 points if dominant hemisphere

5. Yang MH, Lin HY, Fu J, et al.
Decompressive hemi- craniectomy in
patients with malignant middle
cerebral artery infarction: a
systematic review and meta-analysis.
Surgeon J R Coll Surgeons
Edinburgh Ireland 2015; 13: 230–
240.

6. Patophysiology

7. Cerebral Arteries Territory

8. Inclusion Criteria Diagnosis MMCI
DECIMAL
• Imaging Criteria:
• > 50% ischemic MCA
territory; MRI-DWI
Infarct vol > 145 cc
• Clinical Criteria:
• NIHSS > 15
DESTINY II
• Imaging Criteria:
• > 2/3 MCA Territory with
basal ganglia
• Clinical Criteria:
• NIHSS > 14 (Non
dominant) or >19
(dominant), reduced LOC
on NIHSS
HAMLET
• Imaging Criteria:
• >= 2/3 MCA territory;
formation of space
occupying edema
• Clinical Criteria:
• NIHSS >=16 (right) or
>=21 (left); NIHSS 1a>=1;
GCS < 13 (right sided) or
GCS (E and M score) < 9
(left sided)

9. Overview of the RCTs

10. Overview of the RCTs

11. Role of Imaging for Malignant Cerebral Infarct

12. Role of Imaging for Malignant Cerebral Infarct

13. Role of Decra for Malignant Cerebral Infarct

14. Proposed Management Algorithm for MHI

15. ESO Guidelines on The Management of Space-Occupying
Brain Infarction 2021
ESO Guidelines
Recommendations
2021
Evidence Based
recommendation
Expert Consensus
statement
Systematic review
based on 13 PICOs
Questions

16. PICOs Questions
1. DC vs Conservative in age 18-60
within 48 hr reduce the risk of death
or poor outcome?
2. DC vs Conservative in age 18-60 >
48 hr reduce the risk of death or
poor outcome?
3. DC vs Conservative in age >60
within 48 hr reduce the risk of death
or poor outcome?
4. DC vs Conservative in space
occupying cerebellar infarction reduce
the risk of death or poor outcome?
5. CSF drainage reduce mortality or
improve functional outcome in space
occupying cerebellar infarction?
6. ICP monitoring in space occupying
hemispheric infarction reduce the
risk of death or a poor outcome?

17. PICOs Questions
7. Does admission to an ICU reduce the
risk of death or a poor outcome in space
occupying hemispheric infarction?
8. Does sedation reduce the risk of death
or a poor outcome in space occupying
hemispheric infarction?
9. Does Osmotic therapy reduce the risk of
death or a poor outcome in space
occupying hemispheric infarction?
10. Do Corticosteroids reduce the risk of
death or a poor outcome in space
occupying hemispheric infarction?
11. Does Hyperventilation reduce the risk
of death or a poor outcome in space
occupying hemispheric infarction?
12. Does Hypothermia reduce the risk of
death or a poor outcome in space
occupying hemispheric infarction?
13. Does Glyburide reduce the risk of
death or a poor outcome in space
occupying hemispheric infarction?

18. 1. DC vs Conservative in age 18-60 within 48 hr reduce
the risk of death or poor outcome?

19. 2. DC vs Conservative in age 18-60 > 48 hr reduce the risk of
death or poor outcome?

20. 3. DC vs Conservative in age >60 within 48 hr reduce the risk
of death or poor outcome?

21. 4. DC vs Conservative in space occupying cerebellar
infarction reduce the risk of death or poor outcome?

22. 5. CSF drainage reduce mortality or improve functional
outcome in space occupying cerebellar infarction?

23. 6. ICP monitoring in space occupying hemispheric
infarction reduce the risk of death or a poor outcome?

24. 7. Does admission to an ICU reduce the risk of death or a
poor outcome in space occupying hemispheric infarction?

25. 8. Does sedation reduce the risk of death or a poor
outcome in space occupying hemispheric infarction?

26. 9. Does Osmotic therapy reduce the risk of death or a
poor outcome in space occupying hemispheric infarction?

27. 10. Do Corticosteroids reduce the risk of death or a poor
outcome in space occupying hemispheric infarction?

28. 11. Does Hyperventilation reduce the risk of death or a
poor outcome in space occupying hemispheric infarction?

29. 12. Does Hypothermia reduce the risk of death or a poor
outcome in space occupying hemispheric infarction?

30. 13. Does Glyburide reduce the risk of death or a poor
outcome in space occupying hemispheric infarction?

32. Conclusion
Malignant cerebral infarction is a life threatening condition with a mortality rate of 80 %
if treated conservatively
Decompressive craniectomy is the only thereapeutic approach that is based on data
of large RCT
Other treatment options like osmotherapy may be used in an individual risk-benefit, but
evidence is scarce
Recommend careful assessment of the patient’s will

33. References
H Bart van der Worp, Hofmeijer J, Juttler E, et al. 2021. European Stroke Organisation Guideline
on the management of space occupying brain infarction.: European Stroke Journal
Barlinn K, Puetz V., 2019. Role of Decompressive Craniectomy in Ischemic Stroke: Frontiers.
Lin J, A. Frontera J., 2021. Decompressive Hemicraniectomy for large hemispheric strokes. AHA
journals
Godoy D, Pinero G, Cruz Flores S, Alcala Cerra G, Rabinstein A., 2013. Malignant hemispheric
infarction of the middle cerebral artery, diagnostic consideration and treatment options.
Neurolgia; 31;332-343.

34. Terima kasih