Decompressive craniectomy for massive neonatal arterial ischemic stroke: a case report

Abstract While perinatal arterial ischemic stroke occurs relatively commonly, its mid- or long-term outcomes have rarely been reported. Because of the accommodative mechanisms of a neonate skull against increases in intracranial pressure (ICP), conservative management has almost always been recommended for patients with perinatal arterial ischemic stroke, even when the infarction volume is massive. However, recent studies have suggested that their functional outcomes are unfavorable. Here, we report a case of massive neonatal arterial ischemic stroke (NAIS) for which decompressive craniectomy (DC) was performed successfully. The patient, a 2260-g girl born full-term with a 5-min Apgar score of 10, suddenly became apneic on the third day after birth. Imaging studies revealed the infarction of the right middle cerebral artery territory. DC without dural opening allowed for accommodating ICP increases, and apnea disappeared shortly after surgery. Spontaneous ossification over the removed bone flap occurred by 35 days, making cranioplasty unnecessary. One year after surgery, no significant delay in the patient’s developmental milestone was noted. This is the first report on the use of DC for massive NAIS. Unlike adults, DC may not be a life-saving procedure in patients with massive NAIS. Rather, DC may play an important role in improving functional outcomes by mitigating ischemic progression, and DC without dural opening may be a safe procedure worth being replicated.