title: Cranial decompression for the treatment of malignant intracranial hypertension after ischemic cerebral infarction: decompressive craniectomy and hinge craniotomy.
abstract: OBJECTIVE
  Recent randomized trials have demonstrated a positive role (improved survival) in patients treated with cranial decompression for malignant cerebral infarction. However, many variables regarding operative decompression in this setting remain to be determined. Hinge craniotomy is an alternative to decompressive craniectomy, but its role in space-occupying cerebral infarctions has not been delineated. The objective of this study was to compare the authors' experiences with these 2 procedures in the management of space-occupying cerebral infarctions to determine the efficacy of each.
  
  
  METHODS
  The authors conducted a retrospective review of 28 cases involving patients who underwent cranial decompression (hinge craniotomy in 9 cases, decompressive craniectomy in 19) for treatment of malignant intracranial hypertension after ischemic cerebral infarction.
  
  
  RESULTS
  No significant differences were identified in baseline demographics, neurological examination, or Rotterdam score between the hinge craniotomy and decompressive craniectomy groups. Both treatments resulted in adequate control of intracranial pressure (ICP). The need for reoperation for persistent intracranial hypertension and duration of mechanical ventilation and intensive care unit stay were similar. Hospital survival was significantly higher in the decompressive craniectomy group (89% vs 56%), whereas long-term functional outcome was better in the hinge craniotomy group. Cranial defect size was comparable in the 2 groups. Postoperative imaging revealed a higher rate of subarachnoid hemorrhage, contusion/hematoma progression, and subdural effusions/hygromas after decompressive craniectomy. The requirement for cranial revision in survivors was higher for patients undergoing decompressive craniectomy (100%) than those undergoing hinge craniotomy (20%).
  
  
  CONCLUSIONS
  Hinge craniotomy appears to be at least as good as decompressive craniectomy in providing postoperative ICP control at a similar therapeutic index. Although the in-hospital mortality was higher in patients treated with hinge craniotomy, that procedure resulted in superior long-term functional outcomes and may help limit postoperative complications.
authors.affiliation: Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107, USA. tyler.kenning@jeffersonhospital.org
authors.forename: Tyler J
authors.initials: TJ
authors.lastname: Kenning
authors.forename: M Reid
authors.initials: MR
authors.lastname: Gooch
authors.forename: Ravi H
authors.initials: RH
authors.lastname: Gandhi
authors.forename: M Parvez
authors.initials: MP
authors.lastname: Shaikh
authors.forename: Alan S
authors.initials: AS
authors.lastname: Boulos
authors.forename: John W
authors.initials: JW
authors.lastname: German
mesh_terms: D000328:Adult; D000368:Aged; D001925:Brain Damage, Chronic / Q000175:diagnosis*; D002544:Cerebral Infarction / Q000150:complications / Q000401:mortality / Q000601:surgery*; D003399:Craniotomy / Q000379:methods* / Q000401:mortality; D056424:Decompressive Craniectomy / Q000379:methods* / Q000401:mortality; D004185:Disability Evaluation; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D006974:Hypertension, Malignant / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D019586:Intracranial Hypertension / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination; D011183:Postoperative Complications / Q000175:diagnosis*; D012189:Retrospective Studies