Decompressive Craniectomy-Surgical and Nursing Management

Good morning. Today’s video presentation we will discuss on decompressive craniectomy, mainly for large, cerebral infarct. And we’ll focus mainly on both the surgical and nursing management. The presenter is Dr. Vincent Ng. He’s a consultant from Neurosurgery from NNI. And the core presenter Ms. Lee Kah Keow. She’s a nurse clinician also from the Department of Surgery from NNI. In the lecture outlined today, we will talk about the purpose of decompressive craniectomy in stroke management. The focus really is– will be on the large malignant MCA infarct or medial cerebral artery infarct. We will discuss the various criteria for early decompressive craniectomy. Subsequently, Ms. Lee will then discuss about the various nursing care issues that concern with decompressive craniectomy. What is malignant cerebral infarction? When patients develop large vessel occlusion, usually from atrial fibrillation, the middle cerebral artery can be infarcted from embolic clot from the heart or develop vasodissection mainly affecting the middle cerebral artery territory. It can happen on both right and left sides. When such a major artery is affected during ischemic stroke, there will be a large cerebral volume that is affected. On top of the ongoing cerebral ischemia and infarction that lead to a decrease in neurological deficit, subsequent swelling also may predispose the patient to herniation. As such, this condition traditionally has very high mortality at about 80%. If the patient did not undergo thrombectomy or failed RTPV treatment to open up the middle cerebral artery, then the patient may sustain a large cerebral infarct. The current literature is that perhaps doing a large decompressive craniectomy, to open up the skull may allow the cerebrum to have space to swell and to decrease the risk of herniation. Herniation itself is life threatening and can also lead to early demise of the patient on top of the large territory infarct. As such, by opening the skull, you allow outward herniation of the cerebral volume out of the skull rather than towards the brain stem and, therefore, causing foramen magnum herniation or transtentorial herniation. When we look at the evidence, there was a discussion previously whether this group of patients who has now sustained a large cerebral infarct whether they will be suitable to go for a fairly moderate neurosurgical procedure such as decompressive craniectomy. The literature. Now knows and proves that early decompressive craniectomy usually within 48 hours may be beneficial to the patient. If you look at the video slide in front of you, there is a meta analysis of three randomized controlled trial, the DECIMAL trial, the DESTINY trial, the HAMLET trial with a total number of patients of 93 reach the age ranging between 80 to 60 with a large left MCA single-territory function. Decompressive craniectomy was performed within 48 hours of stroke, and evidence shows that there is definitely a reduction in mortality, although there may be– it does not show that there is an increase in the number of severely-disabled survivors. And, therefore, the number of intention to treat is 2 for per patient if mRS less than 4. In the updated meta-analysis of DESTINY, DECIMAL, and HAMLET trial with the total number at n equals to 108, there was also a non-significant benefit of decompressive craniectomy with favorable outcome defined as mRS less than 3. Of course, not all patients with large cerebral infarct area in the middle cerebral artery may benefit from the early decompressive craniectomy. It is important, therefore, to also look at inclusion and exclusion criteria for this group of patients. In general, patients with abysmal prognosis such as when their pupils are fixed and dilated with serious comorbidity that increases their risk or decompressive craniectomy. When a Glasgow coma scale at presentation is very low at less than 6, or the overall life expectancy is less than 3. they may be unsuitable to consider for early prophylactic decompressive craniectomy. For patients less than 48 hours or presentational stroke, where the MCA territory is significant, i.e., that it is more than half of the MCA territory on imaging. And patients who have premorbid good functional status on the NIHSS scale is 1a, then we should consider early decompressive craniectomy. Based on the evidence, this inclusion and screening criteria are for patients with a single MCA-territory infarction. For patients with two territory infarcts, that means the combination of MCA and intercerebral artery infection, they are not in the protocol. However, it will be a case-by-case basis on discussion between the neurosurgeons, the neurologist, and family members, whether they would prefer to proceed on with the decompressive craniectomy. It is important to inform family members regarding the complications that can occur potentially during an prophylactic early decompressive craniectomy. Complications usually would include, for example, worsening of post-op hemorrhage, infection of the wound, or intracranial infection due to the surgery itself. There is a possibility of a CSF leakage. We also perhaps also can consider the additional surgery that will be required after the patient recovers from the decompressive craniectomy and the MCA territory stroke, where we then have to call in the complications or the indications associated with two cranioplasty operations later. In general, 1 in 10 patients undergoing decompressive craniectomy may suffer a complication necessitating additional medical or neurosurgical intervention. As in any brain surgery, vital signs and neurological status monitoring are critical to detect complication. Perform one care per the hospital protocol, monitor early signs of wound infection, hair washing is possible, especially when the stitches and staples are removed. Pay particular attention at the edge of the groove. That is where poor hair hygiene always happens, and that can actually increase the risk of infection when the patient is due for cranioplasty. Educate patient and family members what is normal and abnormal. Depending on the patient preferences, religious or [INAUDIBLE], on the disposal and collection of skull bone if the bone is not put back into the body. It is normal for the skull bones to sink when the brain relaxes. Avoid pressure on the bone [INAUDIBLE]. You may consider a no-pressure dressing over it to alert the health care worker. If the brain budges out like this, it is abnormal, and you should report it to the doctor. The take–home whole message is, early decompressive craniectomy has been shown to reduce mortality in malignant MCA infarction. However, efficacy of decompressive craniectomy on functional outcome remains inconclusive. Thank you.

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