1. Hemicraniectomy in Ischaemic Stroke Dr Rajesh Acharya Dr Samir Kalra

2. New stroke : Every 3 second ( globally) Stroke: 2 nd cause of death 80% of all strokes-Ischaemic Of these- 10% Large hemispheric leading to significant disability and mortality

3. History Harvey Cushing(1900s)Father of Neurosurgery Primary brain injury( vessel injury) Secondary brain injury( edema) Similar progression can be seen in LHI: Defined as all or most of MCA territory +_ ACA /PCA territory

6. Malignant( Space occupying& rapidly expanding) MCA Infarction

7. Malignant MCA Infarction(1996) Severe hemispheric syndrome Hemiparesis,eye and head deviation Altered sensorium Pupillary asymmetry Increased ICP Edema : progresses over 2-5 days; increased risk of herniation and death in 1 st week Without surgery: 40-80% mortality If survive: severely disabled

8. Radiology ( Malignant infarct) Early Hypodensity on CT > half MCA territory Carotid occlusion on Angiography Poor collateral blood flow Infarct volume > 220 ml Midline shift > 5 mm in 24-48 hours of stroke onset

9. Sir Ganga Ram Hospital (1968- 2006) HOD Neurosurgery, Member BOM, Legal Cell, Organ Transplant Established Sehgal Neurological Research Institute - 1969 GB Pant,Holy Family Hospital Dr AD Sehgal (1939-2006)

11. President Neurological Society of India President – Indian Society of Stereotactic & Functional Neurosurgery President Neuro Trauma Society of India President Health Care Fed of India Vice President – International CS 1 st CT Scan in North India 1 st MRI in North India

12. Contributions Intrathecal steroids Sehgal’s Stereotactic Frame Modification of Gardner’s Neurosurgical chair Modified Gardner’s Tongs (skull traction) Numerous publications / Conferences Helped / inspired numerous neurosurgeons

13. Conservative treatment Mannitol Hypertonic saline Anticonvulsants Steroids – no role Hyper-ventilation

14. Large Cerebellar Infarct

15. Posterior Fossa Decompression

16. Decompressive Hemicraniectomy Life saving procedure Aim: Part of ipsilateral cranium is removed Provides more space to the swollen brain Decreases ICP Improves perfusion and blood flow In penumbral tissue as well as contralateral hemisphere

18. Guidelines(AHA/ASA) Age < 60years Malignant MCA infarct Neuro deterioration 48hours Maximal medical Rx

19. Hemicraniectomy Typical approach: Fronto-temporo-parietal Incision : ? Mark Temporalis muscle-scalp flap reflected Skull opened by drill – AP 12-13 cms suprior-inferior-10 cms Floor of MCF is exposed Dura opened widely Loosely approximated with pericranium Resection of infarcted brain – not preformed

20. Bone flap Kept in the abdomen ( subcutaneously) Regrigerator – Minus 80 degree C Cranioplasty Early – before 8-12 weeks Late - After 8-12 weeks

21. Complications External brain herniation Haemorrhagic progression Seizures infection Subdural, extradural collection, Hydrocephalus Sunken flap syndrome

22. Sunken flap Syndrome

23. Sunken flap syndrome Syndrome of the trephine 10% of large craniectomies Weeks/months after surgery Pathophysiology: (1)atmospheric pressure (2) Difference between AP-ICP=hypovolaemia (3) EVD/Shunt/LP may aggravate Decreased regional blood flow-leads to cortical dysfunction and neurodeficits.

28. Conclusion and Future DHC improves survival and functional outcome. Majority of survivors have moderate disability Predictors- who will require surgery ?? Optimal timing of surgery ?? Optimization of medical & neurocritical care Future:Thrombolytics/thrombectomy may mitigate the need for hemicraniectomy