Decompressive Craniectomy, Reperfusion, or a Combination for Early Treatment of Acute “Malignant” Cerebral Hemispheric Stroke in Rats?

Background and Purpose —Both early reperfusion and decompressive craniectomy have proved beneficial in the treatment of large space-occupying “malignant” hemispheric stroke. The aim of this study was to directly compare the benefit of reperfusion with that of craniectomy and to study the effects of combined treatment in a rat model of focal cerebral ischemia.Methods —Cerebral ischemia was introduced in 28 rats. Four groups were investigated: (1) no treatment, (2) decompressive craniectomy, (3) reperfusion, and (4) reperfusion and craniectomy as treatment at 1 hour after middle cerebral artery occlusion. Perfusion- and diffusion-weighted MRI were performed serially from 0.5 to 6 hours after middle cerebral artery occlusion.Results —The 6-hour DWI-derived hemispheric lesion volumes in the reperfusion group (10.2±3.9%), the craniectomy group (23.0±6.4%), and the combination group (21.8±12.4) were significantly smaller than that in the control group (44.1±5.4%) (P <0.05). Reperfusion, craniectomy, and combined treatment led to higher perfusion in the cortex compared with the control group, whereas only reperfused animals achieved significantly higher perfusion in the basal ganglia. In 5 animals, combined reperfusion and decompressive craniectomy resulted in an early contrast media enhancement.Conclusions —Early reperfusion and craniectomy were shown to be effective in decreasing infarction volume by improving cerebral perfusion. Reperfusion remains the best therapy in malignant hemispheric stroke. Combined treatment yields no additional benefit compared with single treatment, probably because of early blood-brain barrier breakdown.