A 42-year-old male presented with a stroke. He was admitted to a general ward with a right- sided hemiplegia, neglect and speech deficits. He was not thrombolysed.
A day post admission, you are called by your registrar from a MET call because the patient has just become drowsy, although wakes to follow commands.
His CT scan at the time of the MET call is as below.
NB: original college image was removed from this question.
It is impossible to guess what the original image was, even approximately. I guess some sort of midline shift and oedema would have been found. That CT above is actually from a case report of some sort of horrific CNS vasculitis (Caneppa-Raggio et al, 2016) which presented as an MCA stroke. The issue of decompressive craniectomy in MMCAS has become the topic of Question 2 from the second paper of 2014, and is discussed at length elsewhere.
Anyway, the findings are:
The implications are:
From the three belowmentioned European trials, "malignantness" was determined by the presence of the following features:
A pooled analysis of the first three studies, including 93 patient cases, came to a fairly positive conclusion:
"...after decompressive surgery the probability of survival increases from 28% to nearly 80% and the probability of survival with an mRS of ≤3 doubles."
(mRS here being the score of the modified Rankin scale, equating to a disability where one requires some help, some of the time, with some things - but is otherwise able to walk unassisted).
In summary:
The complications of decompressive craniectomy are well summarised in an article by Margules and Jallo. I will present them as a list:
Disclaimer: the viva stem above may be an original CICM stem, acquired from their publicly available past papers. Or, perhaps it is a slightly altered version of the original CICM stem. Or, it is a completely original viva stem, concocted by the monstrously amoral author of Deranged Physiology for nothing more than his own personal amusement. In either case, because the college do not make the main viva text or marking criteria available, almost everything here has been confabulated. It might sound like a plausible viva and it could be used for the purpose of practice, but all should be aware that it does not represent the "true" canonical CICM viva station.
C. Canepa-Raggio, Makkuni D (2016) Primary Angiitis of the Central Nervous System a Riddle, Wrapped in a Mystery, inside an Enigma. J Case Rep Stud 4(1): 107. doi: 10.15744/2348-9820.4.107
Chapter 51 (pp. 568) Acute cerebrovascular complications by Bernard Riley and Thearina de Beer
Torbey, Michel T., et al. "Evidence-Based Guidelines for the Management of Large Hemispheric Infarction." Neurocritical care (2015): 1-19.
Wartenberg, Katja E. "Malignant middle cerebral artery infarction." Current opinion in critical care 18.2 (2012): 152-163.
Yang, Ming-Hao, et al. "Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: A systematic review and meta-analysis." The Surgeon (2015).
Jüttler, Eric, et al. "Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY) a randomized, controlled trial." Stroke 38.9 (2007): 2518-2525.
Jüttler, Eric, et al. "DESTINY II: DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY II." International Journal of Stroke 6.1 (2011): 79-86.
Vahedi, Katayoun, et al. "Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial)." Stroke 38.9 (2007): 2506-2517.
Hofmeijer, Jeannette, et al. "Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial." The Lancet Neurology 8.4 (2009): 326-333.
Vahedi, Katayoun, et al. "Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials." The Lancet Neurology 6.3 (2007): 215-222.
Slotty, Philipp Jörg, et al. "The influence of decompressive craniectomy for major stroke on early cerebral perfusion." Journal of neurosurgery (2015): 1-6.
Barroso, Bruno. "Decompressive craniectomy for stroke after intravenous thrombolytic therapy." International Journal of Stroke 9.8 (2014): E40-E40.
Wijdicks, Eelco FM, et al. "Recommendations for the Management of Cerebral and Cerebellar Infarction With Swelling A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association." Stroke 45.4 (2014): 1222-1238.
Jüttler, Eric, et al. "Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke." New England Journal of Medicine 370.12 (2014): 1091-1100.
Margules, Andrew, and Jack Jallo. "Complications of decompressive craniectomy." JHN Journal 5.1 (2010): 4.