In recent years, the incidence of ischemic cerebrovascular diseases has been gradually increasing due to the aging of our population, and acute massive cerebral infarction is a special type of ischemic cerebrovascular disease, and its clinical occurrence is also increasing. Because of its rapid onset and extensive lesions, large cerebral infarction rapidly causes intracranial hypertensive crisis and endangers life. Internal medical treatment is often ineffective. Therefore, from 1996 to 2005, 86 cases of large cerebral infarction were treated by standard internal and external decompression with large bone flap craniotomy, and 21 patients with large cerebral infarction were treated by internal medicine during the same period.
1. Clinical data
1.1 General data Surgical treatment group: male, 52 cases; female, 34 cases, age 51-78 years old, average 64 years old. Among them, 15 cases were elderly people (those aged over 70 years). Internal medicine treatment group: male, 11 cases; female, 10 cases, age 49 to 80 years old. The average age was 65 years.
1.2 Clinical manifestations Eighty-five cases started with clear consciousness, headache, vomiting, and weakness of one side of the limb, and then turned to consciousness disorder and aggravation of hemiplegia, among which 34 cases were accompanied by aphasia; 22 cases started with epilepsy and then turned to consciousness disorder; surgical group: 67 cases of complete hemiplegia, 14 cases of incomplete hemiplegia; 18 cases with unequal pupils, 5 cases with dilated pupils; internal treatment group: 12 cases of complete hemiplegia, 5 cases of incomplete hemiplegia In the medical treatment group, there were 12 cases of complete hemiparesis and 5 cases of incomplete hemiparesis; 2 cases with unequal pupils and 4 cases with dilated pupils; 28 cases with acute onset (peak symptoms in minutes or hours) and 79 cases with progressive development (usually peak in 3-4 days). 17 cases had no obvious abnormality in the first CT, and the CT was repeated after the symptoms worsened, showing large cerebral infarction. All cases in this group lost the best interventional thrombolytic treatment time when they were admitted to the hospital.
1.3 Imaging manifestations All the cases occurred on the curtain and were confirmed by CT or MR examination. 77 cases had cerebral infarction extending to 2-3 lobes, and 9 cases had infarction extending to one cerebral hemisphere. CT examination mainly showed lamellar hypointense shadow in the blood supply area of the infarcted artery, with varying degrees of compression, reduction or occlusion of the ipsilateral ventricles, disappearance of the lateral ventricles and sulci, and varying degrees of displacement of the midline structures. MRI examination mainly showed abnormal signal areas with long T1 and long T2. 24 cases had somewhat lamellar hemorrhage within the infarct foci.
1.4 Treatment Patients in both the surgical treatment group and the medical treatment group were given standardized treatment such as enhanced dehydration, diuresis, improvement of cerebral circulation, nutritional support, early tracheotomy, prevention and treatment of pulmonary infection, water-electrolyte disorders, stress ulcers, etc. In the surgical treatment group, all cases were treated under general anesthesia with endotracheal inhalation, and a standard traumatic large bone flap was used to open the skull with a question mark-shaped bone window, i.e., the surgical incision started at the upper edge of the zygomatic arch 1 cm before the ear screen, curved upward to the level of the auricle 4-6 cm posteriorly, and turned forward 1-2 cm from the ipsilateral midline to the frontal hairline to form a bone flap, about 12 cm x 15 cm in size, and the temporal bone and the outer 1/3 of the pterygoid crest were bitten off to make the bone window to If the brain tissue is bulging, sufficient internal decompression is performed, and the degenerated necrotic brain tissue is removed. If cerebral herniation is still severe, the dura mater may not be sutured, and the capitellum and scalp may be sutured directly.
2.Results
The cases in this group were followed up from 1 to 5 years. In the surgically treated group: 20 cases (23.3%) recovered the ability to take care of themselves, 27 cases (31.4%) with mild disability requiring care, 21 cases (24.4%) with severe disability, and 18 cases (20.9%) died, including 3 cases died of renal failure, 7 cases died of severe respiratory infection, 4 cases had unequal pupils before surgery, and 5 cases had dilated pupils before surgery. There were 8 deaths in the elderly (those aged over 70 years), accounting for 53.3% of the elderly group. In the medical treatment group: 0 cases recovered the ability to take care of themselves, 1 case (4.76%) with mild disability requiring care, 8 cases (38.1%) with severe disability, and 12 cases (57.14%) died. It can be seen that the efficacy of the 4-surgical treatment group was significantly better than that of the medical treatment group, and the mortality rate of the former was significantly lower than that of the latter.
3, Discussion
Massive cerebral infarction is an acute, widespread ischemic disease of one cerebral hemisphere caused by embolism or infarction of one internal carotid artery or middle cerebral artery with or without occlusion of the anterior cerebral artery. The middle cerebral artery is the direct continuation of the internal carotid artery, and the embolus dislodged from the heart and internal carotid artery can enter the middle cerebral artery directly along the blood flow and cause embolism in the blood supply area of this artery, so the infarction in the blood supply area of the middle cerebral artery is the most common, accounting for 84.8% of the cases in this group. The common primary diseases include cerebral arteriosclerosis, diabetes mellitus, wind heart disease, pregnancy combined with amniotic fluid embolism, etc. The occlusion of the internal carotid artery or middle cerebral artery rapidly causes the obstruction of blood supply and oxygen supply to a large area of brain tissue, resulting in edema, swelling, necrosis and brain dysfunction of brain tissue, coupled with secondary hemorrhage, which further increases the intracranial pressure and leads to brain herniation in severe cases, endangering life.
Therefore, acute massive cerebral infarction is dangerous, with mortality and disability rates as high as 80%. In order to solve this problem, our hospital has treated 86 patients with large cerebral infarction by standard large bone flap craniotomy with adequate internal and external decompression in the past 10 years, and the results show that the operation can effectively control the progressive increase of intracranial pressure, relieve brain herniation and improve the rescue rate.
Since “intracranial hypertension” is the key to the pathological development of large cerebral infarction, adequate internal and external decompression with large bone flap craniotomy compensates the cranial cavity volume, relieves intracranial pressure, promotes blood return, dilates the blood vessels in the ischemic area and surrounding brain tissue, and at the same time attaches the temporalis muscle to the brain surface, which facilitates the establishment of collateral circulation, improves the blood supply to the cerebral infarct foci, and stops the ischemic area. This helps to establish collateral circulation, improve the blood supply to the infarct, prevent the expansion of the ischemic area, promote the recovery of brain function, and greatly reduce the death rate.
All the cases in this group had missed the best time for interventional thrombolysis, and were referred to neurosurgery after a period of conservative treatment in neurology due to deterioration of their conditions. At that time, the patients’ cerebral infarction area was enlarged or accompanied by post-infarction cerebral hemorrhage, and the intracranial pressure increased sharply, which was difficult to solve the problem of intracranial hypertension despite further conservative treatment such as strengthening dehydration and diuresis, and easily led to electrolyte disorder and renal function damage. In this internal medicine treatment group, 21 patients continued to receive conventional medical treatment because their families refused to operate, resulting in a mortality and severe disability rate of 95.24%, which shows that conservative treatment is extremely ineffective. Therefore, if the vital signs are stable, surgery should be performed as early as possible before the onset of brain herniation (i.e., dilated pupil on one side and loss of light reflex). This, together with active treatment of dehydration, thrombolysis, vasodilation, and neurotrophic support, may truly relieve intracranial hypertension and save life.
It has been reported in the literature that in an experimental study of cranial decompression for acute cerebral infarction in cats, the earlier the cranial decompression was performed, the smaller the extent of cerebral infarction, the degree of blood-brain barrier disruption and brain swelling in the animals, and especially the better the results of surgery within 6 to 12 hours after infarction. Through clinical practice, we have learned that the following conditions should be actively decompressed by cranial debridement.
1.Increased intracranial pressure, which cannot be effectively controlled after dehydration and diuretic treatment.
2.Progressive deterioration of the state of consciousness and limb movement disorders.
3.Preliminary cerebral herniation or cerebral herniation has occurred and is not advanced.
4.CT shows non-compensatory manifestations, or the scope of cerebral infarction is enlarged or accompanied by hemorrhage, and the midline structure is displaced more than 5 mm and the basal pool is compressed. When performing surgery, it should be noted that the bone flap must be large enough and the skull bone at the base of the skull should be occluded as much as possible, so as to effectively reset the brain herniation and rapidly relieve intracranial hypertension. The age factor is not an absolute contraindication to surgery.
Some data show that age is one of the key factors affecting the prognosis of patients with large cerebral infarction, and some domestic literature suggests that surgery for patients older than 70 years old cannot fundamentally reduce the morbidity and mortality rate, and may even accelerate the death of patients and include them as contraindications to surgery. However, we believe that the age restriction for surgery should be relaxed, and as long as the patient is in good physical condition and has no important organ malfunction, surgery should be actively considered even if the patient is older than 70 years old.
In our group, there were 15 cases of elderly people (those aged over 70 years), among which 8 cases died, with a morbidity and mortality rate of 53.3%, indicating that elderly people have nearly half the chance to fight for saving their lives. In conclusion, patients with acute massive cerebral infarction should undergo debulking decompression as early as possible, together with effective drug therapy, in order to truly relieve intracranial hypertension and improve the salvage rate.