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Background The use of extracorporeal membrane oxygenation (ECMO) for cardiopulmonary support is indicated for refractory respiratory failure but carries a high morbidity and mortality in the neurosurgical setting due to associated risks of intracranial hemorrhage. Case Description We describe the case of a 62-year-old man who underwent craniotomy for resection of an esthesioneuroblastoma involving the anterior skull base and extending intracranially, through the cribriform plate into the right epidural space. He developed refractory hypoxemic and hypercapnic respiratory failure and circulatory shock in the immediate postoperative period. Our patient was successfully treated with ECMO after other aggressive resuscitative measures proved unsuccessful for several hours. The patient was managed with ECMO for 6 days, after which he was successfully weaned without developing any neurologic complications. Conclusion Our case report is significant because it describes the safe use of ECMO in a controversial setting because our patient had recently undergone craniotomy. We conclude that in dire circumstances the use of ECMO is appropriate and may be safe even in the setting of recent craniotomy.

Object The aim of this study is to identify pre-operative clinical and/or radiological predictors of clinical failure of decompressive hemicraniectomy (DH) in the setting of malignant hemispheric infarction. These predictors could guide the decision for adjunctive internal brain decompression (e.g. strokectomy) at the time of the initial DH. Methods Retrospective chart review of all patients with malignant hemispheric infarction who underwent DH at our institution, from November 2008 to January 2013. Demographics, pre- and post-operative clinical characteristics and neuroimaging data were reviewed. The surgical outcome after DH was evaluated and clinical failure was defined as follows: lack of post-operative resolution of basal cistern effacement, and/or failure to achieve a post-operative decrease in midline shift by at least 50%, and/or post-operative neurological deterioration felt to be due to persistent mass effect, with or without a second, salvage operation (strokectomy). Results Out of 26 patients included in the study, 7 were considered to have clinical failure of their DH. Preoperative clinical and imaging variables were similar in the two groups, except that the presence of a nonreactive pupil immediately before surgery was associated clinical failure of the DH (p = 0.0015). Patients in the clinical failure group had a lower postoperative GCS motor score and a strong but not statistically significant trend towards less favorable functional outcome (GOS 1–3). Conclusions The presence of a nonreactive pupil before surgery is associated with clinical failure of DH, and should be taken into account when deciding whether to perform strokectomy at the time of DH.