Strokectomy and Extensive Cisternal CSF Drain for Acute Management of Malignant Middle Cerebral Artery Infarction: Technical Note and Case Series

Fulvio Tartara,1 Elena Virginia Colombo,1 Daniele Bongetta,2 Giulia Pilloni,1,* Carlo Bortolotti,3 Davide Boeris,4 Francesco Zenga,5 Alessia Giossi,6 Alfonso Ciccone,7 Maria Sessa,6 and Marco Cenzato4

Materials and Methods

We retrospectively collected 15 non-consecutive cases of ischemic stroke treated with strokectomy between March 2010 and December 2017 in two different Hospital (Ospedale Molinette Torino; Ospedale Maggiore, Cremona). The study is an historical cohort study (retrospective, purely observational, non-sponsored): outcome and exposure of the patients occurred and consolidated before the start of the study and there is no ethical problem requiring approval of the ethical committee.

All patients were admitted to subintensive stroke unit because of stroke in the MCA territory. Sex, age, comorbidities, and side of the stroke were recorded upon admission, and the neurological status was evaluated with GCS and NIHSS. CT scan and angio-CT were employed for Diagnosis of MCA stroke and to monitor stroke evolution in the following days. Standard medical therapy including oxygen, homeostasis maintenance (volemia, blood pressure, temperature, glucose), diuretics, mannitol, and/or hypertonic saline infusion was attempted in all patients.

All patients reviewed presented clinical deterioration despite maximal medical therapy. Indication for surgery was placed after collegiate evaluations by neurologists and neurosurgeons based on CT-scan data and clinical status. Involvement of 2/3 of the MCA territory (stroke volume >140 ml); Midline shift >7 mm; basal cistern compression or signs of transtentorial herniation, progressive worsening of the neurological status (worsening of NIHSS item 1a from 1 to 2 and/or worsening of 2 points of GCS score). Neurological examination and CT-scan data were the decisional element both preoperatively and postoperatively. Surgery was made as soon as possible after initial clinical deterioration was observed.

Stroke involving other branches besides MCA, active anti-coagulation therapy, NIHSS >29, severely unstable hemodynamic were considered exclusion criteria while previous rTPA treatment was not.

Surgical Procedure

Under general anesthesia, we performed a curved linear temporal incision, starting just above and 1 cm anterior to the tragus (see Figure 1). After linear cutting of temporal muscle and self-retaining retractor positioning, a small craniotomy was designed moving from a single burr hole close to pterion. The dura was opened in a C-shaped fashion and the anterior portion of the T3 temporal circumvolution was exposed. We proceeded to remove the ischemic tissue by going anteriorly and deeply to the base of temporal fossa with the aid of suction and bipolar forceps. Normally, the Ischemic area is easily recognizable as grayish, squashy, hypo-vascularized tissue. Once the ischemic temporal lobe became manageable we proceeded to tentorial edge to open the basal cisterns (ambiens, carotic cisterns) to perform an extensive CSF drainage the obtain the maximum possible brain relaxation. The dura was then closed without the use of patches and the bone was set back in place in usual fashion.

Figure 1
(A) Drawing showing shape and position of skin incision, bone flap, and dural incision. (B) Small oval craniotomy with parapterional burr hole after temporal muscle incision and self-driving retractors placement; (C–D) dural exposure and opening with T3 herniation related to intracranial hypertension.