Decompressive hemicraniectomy in pediatric malignant arterial ischemic stroke: a case-based review,Child's Nervous System

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Decompressive hemicraniectomy in pediatric malignant arterial ischemic stroke: a case-based review
Child's Nervous System ( IF 1.3 ) Pub Date : 2023-07-26 , DOI: 10.1007/s00381-023-06086-w
Audrey Carlhan-Ledermann ₁ , Andrea Bartoli ₂ , Fabienne Gebistorf ₁ , Maurice Beghetti ₃ , Tornike Sologashvili ₄ , Monica Rebollo Polo ₅ , Joel Fluss ₆

Affiliation

Purpose

Malignant stroke is a life-threatening emergency, with a high mortality rate (1–3). Despite strong evidence showing decreased morbidity and mortality in the adult population, decompressive hemicraniectomy (DCH) has been scarcely reported in the pediatric stroke population, and its indication remains controversial, while it could be a potential lifesaving option.

Methods and results

We performed an extensive literature review on pediatric malignant arterial ischemic stroke (pmAIS) and selected 26 articles reporting 97 cases. Gathering the data together, a 67% mortality rate is observed without decompressive therapy, contrasting with a 95.4% survival rate with it. The median modified Rankin score (mRS) is 2.1 after surgery with a mean follow-up of 31.8 months. For the 33% of children who survived without surgery, the mRS is 3 at a mean follow-up of 19 months. As an illustrative case, we report on a 2-year-old girl who presented a cardioembolic right middle cerebral artery stroke with subsequent malignant edema and ongoing cerebral transtentorial herniation in the course of a severe myocarditis requiring ECMO support. A DCH was done 32 h after symptom onset. At the age of 5 years, she exhibits an mRS of 3.

Conclusion

Pediatric stroke with malignant edema is a severe condition with high mortality rate if left untreated and often long-lasting consequences. DCH might minimize the vicious circle of cerebral swelling, increasing intracranial pressure and brain ischemia. Our literature review underscores DCH as an efficient therapeutic measure management of pmAIS even when performed after a significant delay; however, long-lasting morbidities remain high.

中文翻译：

去骨瓣减压术治疗小儿恶性动脉缺血性卒中：基于病例的回顾

目的

恶性中风是一种危及生命的紧急情况，死亡率很高(1-3)。尽管有强有力的证据表明成人人群的发病率和死亡率有所下降，但去骨瓣减压术（DCH）在儿童卒中人群中的报道却很少，其适应症仍然存在争议，尽管它可能是一种潜在的救生选择。

方法和结果

我们对儿科恶性动脉缺血性卒中 (pmAIS) 进行了广泛的文献综述，并选择了 26 篇文章，报告了 97 例病例。将数据收集在一起后发现，在不进行减压治疗的情况下，死亡率为 67%，相比之下，采用减压治疗的存活率为 95.4%。术后平均随访时间为 31.8 个月，改良 Rankin 评分 (mRS) 中位数为 2.1。对于 33% 未接受手术而存活的儿童，平均随访 19 个月时的 mRS 为 3。作为一个说明性病例，我们报道了一名 2 岁女孩，她在严重心肌炎过程中出现心源性右大脑中动脉卒中，随后出现恶性水肿和持续性脑小幕疝，需要 ECMO 支持。症状出现 32 小时后进行 DCH。5 岁时，她的 mRS 为 3。