Malignant Cerebral Venous Infarction: Decompressive Craniectomy versus Medical Treatment.

BACKGROUND: Cerebral venous thrombosis (CVT) is a common type of stroke in young adults and associated with 8% mortality. High intracranial pressure (ICP) and brain herniation are the most common causes of death in these patients. In contrast with malignant arterial middle cerebral infarction, there are few studies reporting the efficacy of decompressive craniectomy (DC) for treatment of high ICP in patients with CVT. In this study, we assess the clinical outcome of patients with CVT with impending brain herniation treated with DC versus medical management. METHODS: In this retrospective study, medical records of all patients with CVT admitted to our hospital were reviewed. Patients with the following inclusion criteria were entered into the study: 1) CVT proven by contrast-enhanced magnetic resonance venogram and/or computed tomography venogram, 2) malignant CVT (impending brain herniation according to imaging and clinical finding), and 3) age between 16 and 80 years. Patients with deep venous system thrombosis, Glasgow Coma Scale (GCS) score of 3, and bilateral nonreactive midposition pupils or mydriasis on admission were excluded. Patients were classified into 2 groups: surgical group (DC group) including patients who received medical treatment and DC and medical group (MG) including patients who received only medical treatment. Outcomes and complications were assessed and compared between the 2 groups. RESULTS: Of 357 patients with CVT hospitalized in our center, 48 patients entered into the study. Twenty-three patients were managed medically, and 25 patients were managed surgically. There was no significant difference between the groups concerning age, sex, presenting symptoms, transient and permanent risk factors of CVT, GCS score on admission, and pupils' reactivity on admission. All patients in the MG died during hospitalization in comparison with 8 patients in the DC group (100% vs. 32%, P < 0.001). Favorable outcome (modified Rankin scale score 0-2) was achieved in 52% of the DC group and 0% of the MG group (P < 0.001). CONCLUSIONS: The results of our study confirmed that in contrast with DC, medical treatment could not prevent transtentorial herniation. DC is not only lifesaving for patients with CVT with impending brain herniation but also results in favorable outcome in most patients.

Cognitive function, depression, and quality of life in patients with ruptured cerebral aneurysms.

Background: Neuropsychiatric dysfunction is one of the most common complications after aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to evaluate cognitive function, depression, and quality of life (QOL) in patients with aSAH. Methods: In this study, we prospectively enrolled patients with SAH due to rupture of anterior circulation aneurysms who referred to Ghaem hospital, Mashhad, Iran, and who had good function outcome [modified Rankin scale (mRS) > 2]. They underwent microsurgery or endovascular treatment. Cognitive function, depression, and QOL were evaluated 6 months after surgery with standard psychiatric examinations, including Mini-Mental State Examination (MMSE) for cognitive function, Hospital Anxiety and Depression Scale (HADS) for depression, and 36-Item Short Form Health Survey (SF-36) for QOL. Risk factors for cognitive dysfunction were assessed. Results: Fifty-three patients were entered the study. The mean of age was 50.9 ± 13.6 years. QOL and its components were affected in most patients. Fifty-five percent of patients suffered from depression. Cognitive impairment was found in 57% of patients. Older patients experienced more cognitive impairment (P < 0.001). Conclusion: Neuropsychological sequels are common in patients with aSAH, even if they classified as good functional outcome (mRS > 2). These complications could be found with appropriate neuropsychological evaluation of these patients to be managed as soon as possible.

Decompressive craniectomy after unsuccessful intravenous thrombolysis of malignant cerebral infarction.

BACKGROUND: Intravenous recombinant tissue plasminogen activator (rt-PA) is an approved treatment for acute ischemic stroke within 4.5 h of symptoms onset. Decompressive craniectomy (DC) has been shown as an effective therapeutic modality in malignant middle cerebral artery (MCA) infarction. As rt-PA could result in hemorrhagic complication during or after any surgery DC may be associated with severe bleeding after intravenous thrombolysis. CASE DESCRIPTION: A 57-year-old woman was presented 90 min after the sudden onset of left hemiplegia. Despite intravenous thrombolytic therapy, she lost consciousness within 48 h and brain CT scan showed a right malignant MCA infarction associated with a small bleeding. DC was performed without any complication. The patient improved dramatically. CONCLUSION: DC could be done safety for malignant MCA infarction after unsuccessful intravenous thrombolytic therapy even the later was complicated with intra-infarction hemorrhage.