Letter: Outcome After Decompressive Craniectomy for Middle Cerebral Artery Infarction: Timing of the Intervention

To the Editor: We appreciate Goedemans et al1 for their paper, based on their findings that showed the outcome of decompressive craniectomy (DC) performed after 48 h in patients with malignant middle cerebral artery (MCA) infarct was not worse than the outcome of DC performed within 48 h. In addition, the authors suggest not to set a restriction of ≤48 h on the time elapsed since stroke onset in the decision whether to perform DC. Inclusion of timing of extubation and/or tracheostomy would have helped with intensive care unit course and outcome. Malignant MCA infarct is a condition associated with intracranial hypertension and decompressive craniectomy is a useful tool for managing this condition.2 The DC has extended its use in the management of the supra and infratentorial ischemic stroke. The reduction in intracranial pressure associated after removal of bone flap and after dural opening supports its use in MCA infract where trans tentorial herniation is one of the representative pathobiomechanical event. This is linked to high mortality (80%) without neurosurgical management.2-4 One of the aspects not considered in the clinical guidelines for its recent development are the usefulness of biomarkers. Procalcitonin (PCT) has been associated with acute brain injury, both traumatic and nontraumatic; considering that this peptide is associated with mortality in this type of lesion, and possibly its most promising function, the diagnosis and prognosis of these patients. PCT is a peptide consisting of 116 amino acids, synthesized from the calcitonin gene, which has emerged as a marker of diagnostic utility for bacterial infections, septic shock, systemic inflammatory response syndrome, and multiorgan failure, regardless of the immunological status. In various clinical conditions, elevated PCT levels are associated with worse outcomes. PCT has been associated with acute brain injury, both traumatic and non-traumatic; considering that this peptide is associated with mortality in this type of lesion, and possibly its most promising function, the diagnosis and prognosis of these patients. Zhang et al5 recently reported the potential of PCT as early biomarker for malignant cerebral edema in patients with massive cerebral infarction (MCI). The availability of a biomarker can be an additional pillar in the management of patients with cerebral infarction (MCI).6 The use of biomarkers as PCT can help better define DC in malignant MCA infract beside intracranial hypertension. Combination of biomarkers with early insertion of intracranial monitor will help in cases where neurological examination cannot give early warning signs of progressive worsen of cerebral edema ie, in a febrile patient. Finally, we interpret the very relevant conclusions of this paper, which are: Decision of prophylactic craniectomy regarding the results presented should be taken in a multidisciplinary manner. Neurocritical management guided by neuromonitoring is cornerstone in the management of these patients. Exemplary decompressive craniectomy (hemicraniectomy) performed in the period decided by the team associated with the best medical management is a fundamental tool in the armamentarium or the malignant MCA infarct. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.