Department of Neurology, Baylor College of Medicine, Houston, Texas, USA.
World Neurosurg. 2013 Jul-Aug;80(1-2):126-33. doi: 10.1016/j.wneu.2013.06.001. Epub 2013 Jun 19.
Malignant middle cerebral artery infarction (mMCAI) is a life-threatening condition in pediatric patients. Despite strong evidence showing decreased morbidity and mortality in adult mMCAI patients with decompressive hemicraniectomy (DCH), there is a paucity of data on the use of DCH in children with similar conditions. Here we report experience from our center and perform a systematic review of published literature on outcomes after use of DCH in pediatric mMCAI patients.
By retrospective chart review, we identified 3 children with large ischemic stroke who underwent DCH for life-threatening cerebral edema. Information was obtained about patient characteristics on admission, radiological features of the stroke, surgical procedures, complications of the DCH and cranioplasty, and functional outcomes during follow-up visits. We also reviewed the current literature on DCH in pediatric stroke.
DCH was performed in all 3 cases after development of pupillary dilatation. All 3 children survived and were ambulatory at the time of follow-up. Review of literature identified 12 other published case series describing 26 cases of DCH in pediatric patients with ischemic stroke. Descriptive statistical analysis of these cases is presented. Published reports suggest that a good outcome is possible even in the presence of signs of herniation, low preoperative Glasgow Coma Scale score, involvement of multiple vascular territories, or longer time to surgery in pediatric ischemic stroke patients.
The current data suggest a role for DCH in the management of cerebral edema in pediatric patients with mMCAI. Factors that help in prognostication for adult stroke patients undergoing DCH do not appear to convey similar information about the pediatric population. This highlights the urgent need for collaboration across institutes to further investigate this potentially life-saving procedure in pediatric stroke.
恶性大脑中动脉梗死（mMCAI）是儿科患者的一种危及生命的情况。尽管有强有力的证据表明减压性颅骨切开术（DCH）可降低成人 mMCAI 患者的发病率和死亡率，但关于类似情况下儿童使用 DCH 的数据却很少。在此，我们报告我们中心的经验，并对发表的关于儿科 mMCAI 患者使用 DCH 后结局的文献进行系统回顾。
通过回顾性病历审查，我们确定了 3 例因危及生命的脑水肿而行 DCH 的大缺血性中风患儿。我们获得了入院时患者特征、中风的影像学特征、手术过程、DCH 和颅骨成形术的并发症以及随访期间的功能结局等信息。我们还回顾了关于儿科中风 DCH 的当前文献。
在瞳孔扩大后，所有 3 例患儿均进行了 DCH。所有 3 例患儿均存活，随访时可行走。对文献的回顾确定了另外 12 个描述了 26 例儿科缺血性中风患者行 DCH 的已发表病例系列。对这些病例进行了描述性统计分析。已发表的报告表明，即使存在脑疝迹象、术前格拉斯哥昏迷量表评分低、涉及多个血管区域或手术时间延长，在儿科缺血性中风患者中，DCH 也可能获得良好的结局。
目前的数据表明，DCH 在治疗儿科 mMCAI 患者脑水肿中具有一定作用。有助于预测接受 DCH 的成人中风患者预后的因素似乎并不能为儿科人群提供类似的信息。这突出表明，迫切需要跨机构合作，进一步研究这种可能拯救生命的儿科中风治疗方法。
