Hemicraniectomy for Ischemic Stroke: Temerity or Death Cure?

When we twist our ankle it swells promptly in minutes.But brain swelling after a stroke is a strange beast for its amazing delay: although some swelling is manifest within the first day, edema does not peak until 3 -5 days after the stroke.This was already recognized 40 years ago. 1 A sizeable number of patients may show brain mass effect at intervals longer than one week. 2Ischemic swelling of brain was initially described to "simulate an acutely expanding lesion". 2 Ischemic edema really is a rapidly expanding tumor from a clinical point of view, and is the most frequent cause of death in acute ischemic stroke. 3The delay in the onset of ischemic edema was initially thought to be a second infarct. 2 However, in light of the fact that second strokes are relatively less common in the immediate period after a first stroke 4 this seems unlikely a priori.Not long after recognition of ischemic cerebral edema as a lethal entity, the difficulty of treatment was recognized. 5he question in the pair of articles by Demchuk and Wijdicks in this issue is whether this ischemia-associated edema can be treated by removing a large portion of the hemicranium.Demchuk argues yes, and underscores that the size of the bone flap must be massive for this procedure to allow unhindered brain swelling.Such unfettered expansion of ischemic brain may be less likely to produce brain necrosis compared to edematous brain abutting against the cranium.We just don't know.Clearly, as Wijdicks emphasizes, this procedure is not for the timid, and to obtain benefit, must be done in an "all or none" fashion because of the geometry of the herniating brain, which acts like a sphere.In plain English: a huge whack of skull must be removed, later to be put back in place after storage in antibiotics or in the patient's own peritoneum.Neurosurgically, it is trivial to do such a large craniectomy, leaving patients, their families (and possibly neurologists!) to be counted among the timorous, with respect to this procedure.But it is not the psychological reaction to removing half of someone's skull for a few months that counts scientifically: it is fear of converting the dead into the impaired living.Some very useful cautions for hemicraniectomy trials are emphasized by Wijdicks, including control for identical postoperative handling to that in control patients.The reason is that a spurious positive result may come of a trial studying hemicraniectomy if postoperative patients receive more attention.Reducing stroke size could come from closely watching damaging high blood sugars, or high temperatures.Hence, monitoring and control of physiologic parameters must be identical in the untreated and surgically treated groups.Wijdicks, who is clearly not against a hemicraniectomy trial and is participating in the design of one, voices another caution: the natural course of malignant cerebral Hemicraniectomy for Ischemic Stroke: Temerity or Death Cure?

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