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Hemicraniectomy for Subarachnoid Hemorrhage from a Giant Middle Cerebral Artery Aneurysm

Introduction

Hemicraniectomy (creation of a large skull opening) has been used in the past to treat brain swelling associated with trauma with limited success during the past three decades. Recently it has been recognized that brain swelling associated with large strokes may be amenable to this treatment. In this case a young man presented to Mount Sinai with three intracranial problems: a giant aneurysm, a large intracerebral hemorrhage, and a severe subarachnoid hemorrhage, and he benefited from hemicraniectomy.

Presentation

A 32-year-old male with no past medical history collapsed while at work. Prior to this episode he complained of sudden onset of headache and then proceded to vomit. He was brought to a Mount Sinai afffiliate hospital where physical exam found the patient to be comatose with the left pupil fixed and dilated, and a right-sided hemiplegia. A CT scan demonstrated a severe subarachnoid hemorrhage and a large intracerebral hemorrhage located primarily within the left temporal lobe. The scan was suggestive of a giant intracranial aneurysm. The patient was transferred immediately to The Mount Sinai Hospital.

Hospital Course

Because of his rapidly deteriorating neurological condition, the patient was taken for emergency surgery and intraoperative angiography.

Surgical Procedure

Surgery was performed by Joshua Bederson, M.D. A hemicraniectomy was performed. Intraoperative angiography revealed a giant partially thrombosed aneurysm of the anterior temporal branch of the middle cerebral artery. The intracerebral hematoma was removed, a temporal lobectomy was performed, and the aneurysm was obliterated.

Postoperative Course

The patient tolerated the surgical procedure, and was noted to improve neurologically within 12 hours. By 24 hours after surgery he was awake and moving all four extremities to command. He continued to improve, and after cosmetic cranioplasty was left with a mild right hemiparesis and moderate aphasia.

Discussion

Hemicraniectomy is a relatively rarely performed procedure, but is seeing a resurgence as the indications become clearer, particularly for massive cerebral infarctions. Its use in this case facilitated definitive treatment of the aneurysm, the hemorrhage, and the brain swelling.

Further References

• Wijdicks, E.F., Management of massive hemispheric cerebral infarct: is there a ray of hope? Mayo Clin Proc, 2000. 75(9): p. 945-52.
• Rabb, C.H., Surgical treatment strategies in ischemic stroke. Neuroimaging Clin N Am, 1999. 9(3): p. 527-38.
• Lindsberg, P.J., et al., The future of stroke treatment. Neurol Clin, 2000. 18(2): p. 495-510.