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Carlhan-Ledermann A, Bartoli A, Gebistorf F, Beghetti M, Sologashvili T, Rebollo Polo M, Fluss J. Decompressive hemicraniectomy in pediatric malignant arterial ischemic stroke: a case-based review. Childs Nerv Syst 2023; 39:2377-2389. [PMID: 37493722 PMCID: PMC10432330 DOI: 10.1007/s00381-023-06086-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/15/2023] [Indexed: 07/27/2023]
Abstract
PURPOSE Malignant stroke is a life-threatening emergency, with a high mortality rate (1-3). Despite strong evidence showing decreased morbidity and mortality in the adult population, decompressive hemicraniectomy (DCH) has been scarcely reported in the pediatric stroke population, and its indication remains controversial, while it could be a potential lifesaving option. METHODS AND RESULTS We performed an extensive literature review on pediatric malignant arterial ischemic stroke (pmAIS) and selected 26 articles reporting 97 cases. Gathering the data together, a 67% mortality rate is observed without decompressive therapy, contrasting with a 95.4% survival rate with it. The median modified Rankin score (mRS) is 2.1 after surgery with a mean follow-up of 31.8 months. For the 33% of children who survived without surgery, the mRS is 3 at a mean follow-up of 19 months. As an illustrative case, we report on a 2-year-old girl who presented a cardioembolic right middle cerebral artery stroke with subsequent malignant edema and ongoing cerebral transtentorial herniation in the course of a severe myocarditis requiring ECMO support. A DCH was done 32 h after symptom onset. At the age of 5 years, she exhibits an mRS of 3. CONCLUSION Pediatric stroke with malignant edema is a severe condition with high mortality rate if left untreated and often long-lasting consequences. DCH might minimize the vicious circle of cerebral swelling, increasing intracranial pressure and brain ischemia. Our literature review underscores DCH as an efficient therapeutic measure management of pmAIS even when performed after a significant delay; however, long-lasting morbidities remain high.
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Affiliation(s)
- Audrey Carlhan-Ledermann
- Neonatology and Pediatric Intensive Care Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Andrea Bartoli
- Neurosurgery Unit, Department of Clinical Neuroscience, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Fabienne Gebistorf
- Neonatology and Pediatric Intensive Care Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Maurice Beghetti
- Pediatric Cardiology Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Tornike Sologashvili
- Cardiovascular Surgery Unit, Department of Surgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Monica Rebollo Polo
- Pediatric Radiology Unit, Department of Radiology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Joel Fluss
- Pediatric Neurology Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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Krishnan K, Hollingworth M, Nguyen TN, Kumaria A, Kirkman MA, Basu S, Tolias C, Bath PM, Sprigg N. Surgery for Malignant Acute Ischemic Stroke: A Narrative Review of the Knowns and Unknowns. Semin Neurol 2023; 43:370-387. [PMID: 37595604 DOI: 10.1055/s-0043-1771208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
Malignant acute ischemic stroke (AIS) is characterized by acute neurological deterioration caused by progressive space-occupying brain edema, often occurring in the first hours to days after symptom onset. Without any treatment, the result is often fatal. Despite advances in treatment for AIS, up to 80% of patients with a large hemispheric stroke or cerebellar stroke are at risk of poor outcome. Decompressive surgery can be life-saving in a subgroup of patients with malignant AIS, but uncertainties exist on patient selection, predictors of malignant infarction, perioperative management, and timing of intervention. Although survivors are left disabled, most agree with the original decision to undergo surgery and would make the same decision again. In this narrative review, we focus on the clinical and radiological predictors of malignant infarction in AIS and outline the technical aspects of decompressive surgery as well as duraplasty and cranioplasty. We discuss the current evidence and recommendations for surgery in AIS, highlighting gaps in knowledge, and suggest directions for future studies. KEY POINTS: · Acute ischemic stroke from occlusion of a proximal intracranial artery can progress quickly to malignant edema, which can be fatal in 80% of patients despite medical management.. · Decompression surgery is life-saving within 48 hours of stroke onset, but the benefits beyond this time and in the elderly are unknown.. · Decompressive surgery is associated with high morbidity, particularly in the elderly. The decision to operate must be made after considering the individual's preference and expectations of quality of life in the context of the clinical condition.. · Further studies are needed to refine surgical technique including value of duraplasty and understand the role monitoring intracranial pressure during and after decompressive surgery.. · More studies are needed on the pathophysiology of malignant cerebral edema, prediction models including imaging and biomarkers to identify which subgroup of patients will benefit from decompressive surgery.. · More research is needed on factors associated with morbidity and mortality after cranioplasty, safety and efficacy of implants, and comparisons between them.. · Further studies are needed to assess the long-term effects of physical disability and quality of life of survivors after surgery, particularly those with severe neurological deficits..
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Affiliation(s)
- Kailash Krishnan
- Stroke Unit, Department of Acute Medicine Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Milo Hollingworth
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Thanh N Nguyen
- Department of Neurology, Neurosurgery and Radiology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Ashwin Kumaria
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Matthew A Kirkman
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Surajit Basu
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Christos Tolias
- Department of Neurosurgery, King's College Hospitals NHS Foundation Trust, London, United Kingdom
| | - Philip M Bath
- Stroke Unit, Department of Acute Medicine Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Nikola Sprigg
- Stroke Unit, Department of Acute Medicine Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
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3
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Heck C. Decompressive Hemicraniectomy in the Stroke Patient. Crit Care Nurs Clin North Am 2023; 35:67-81. [PMID: 36774008 DOI: 10.1016/j.cnc.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Decompressive hemicraniectomy (DHC) is a life-saving procedure involving removal of large portions of the skull to relieve intracranial pressure in patients with space occupying cerebral edema such as traumatic brain injury (TBI) and stroke. Although the procedure has been shown to decrease mortality in patients, the risk of severe disability is significant. Quality of life, not just survival, following DHC has emerged as an important consideration when the decision is made to perform a DHC.
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Affiliation(s)
- Carey Heck
- Adult-Gerontology Acute Care Nurse Practitioner Program, Thomas Jefferson University, 901 Walnut Street, Suite 815, Philadelphia, PA 19107, USA.
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4
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Rønning OM, Carlsson M, Ihle-Hansen H, Aamodt AH, Tveiten A, Eltoft A, Fromm A, Ellekjær H, Kurz M. Monitoring following acute stroke should be improved. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2022; 142:22-0401. [PMID: 36226425 DOI: 10.4045/tidsskr.22.0401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
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Decompressive Hemicraniectomy in the Modern Era of Mechanical Thrombectomy. World Neurosurg 2021; 156:e77-e84. [PMID: 34500100 DOI: 10.1016/j.wneu.2021.08.138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES We aim to determine the incidence of decompressive hemicraniectomy (DHC) in the modern era of mechanical thrombectomy techniques and improved revascularization outcomes. METHODS We performed a retrospective analysis of 512 patients admitted with acute ischemic strokes with anterior circulation large-vessel occlusion that were treated by mechanical thrombectomy from 2010-2019. The primary endpoint was the need for surgical decompression. Secondary endpoints were infarct size, hemorrhagic conversion, and functional outcome at hospital discharge. RESULTS Of the 512 patients, 18 (3.5%) underwent DHC at a median 2.0 days from stroke onset. The DHC group was significantly younger than the non-DHC group (P < 0.001), had worse reperfusion rates (P = 0.024) and larger infarct size (P < 0.001). Hemorrhagic conversion was more frequent in the DHC group but did not reach statistical significance (P = 0.08). From 2010-2015, 196 patients underwent a mechanical thrombectomy, 13 of whom (6.6%) required a DHC, while 316 patients underwent mechanical thrombectomy from 2016-2019 and only 5 patients required a DHC (1.6%; P = 0.002). Younger age (P < 0.001), urinary tract infection (P < 0.001) and increasing infarct size were significantly associated with needing a DHC. When controlling for other risk factors, higher thrombolysis in cerebral infarction score significantly reduced the need for decompressive hemicraniectomy (P = 0.004). CONCLUSIONS This is one of the largest single-center experiences demonstrating that improved recanalization decreased the need for DHC without increasing the risk of hemorrhagic conversion.
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Naidoo D. Decompressive craniotomy for malignant middle cerebral artery infarction: The quest for an African perspective. Surg Neurol Int 2021; 12:200. [PMID: 34084627 PMCID: PMC8168709 DOI: 10.25259/sni_303_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/10/2021] [Indexed: 11/05/2022] Open
Abstract
Background: Although associated with controversy, decompressive craniotomy (DC) for malignant middle cerebral artery infarction (MMCAI) is an unequivocally lifesaving intervention. DC for MMCAI is rarely performed in lower- to middle-income countries. Methods: A systemic review was performed in attempt to determine the rates of utilization and outcomes of DC on the African continent. Results: Only two African studies describing DC for MMCAI were found. Conclusion: DC for MMCAI is rarely performed and/or reported on the African continent. The African perspective for this needs to be urgently broadened.
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Affiliation(s)
- Dinesh Naidoo
- Department of Neurosciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
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van der Worp HB, Hofmeijer J, Jüttler E, Lal A, Michel P, Santalucia P, Schönenberger S, Steiner T, Thomalla G. European Stroke Organisation (ESO) guidelines on the management of space-occupying brain infarction. Eur Stroke J 2021; 6:XC-CX. [PMID: 34414308 PMCID: PMC8370072 DOI: 10.1177/23969873211014112] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/13/2021] [Indexed: 01/29/2023] Open
Abstract
Space-occupying brain oedema is a potentially life-threatening complication in the first days after large hemispheric or cerebellar infarction. Several treatment strategies for this complication are available, but the size and quality of the scientific evidence on which these strategies are based vary considerably. The aim of this Guideline document is to assist physicians in their management decisions when treating patients with space-occupying hemispheric or cerebellar infarction. These Guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. A working group identified 13 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence-based recommendations. An expert consensus statement was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high-quality evidence to recommend surgical decompression to reduce the risk of death and to increase the chance of a favourable outcome in adult patients aged up to and including 60 years with space-occupying hemispheric infarction who can be treated within 48 hours of stroke onset, and low-quality evidence to support this treatment in older patients. There is continued uncertainty about the benefit and risks of surgical decompression in patients with space-occupying hemispheric infarction if this is done after the first 48 hours. There is also continued uncertainty about the selection of patients with space-occupying cerebellar infarction for surgical decompression or drainage of cerebrospinal fluid. These Guidelines further provide details on the management of specific subgroups of patients with space-occupying hemispheric infarction, on the value of monitoring of intracranial pressure, and on the benefits and risks of medical treatment options. We encourage new high-quality studies assessing the risks and benefits of different treatment strategies for patients with space-occupying brain infarction.
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Affiliation(s)
- H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
- Department of Clinical Neurophysiology, University of Twente, Enschede, the Netherlands
| | - Eric Jüttler
- Department of Neurology, Kliniken Ostalb, Aalen, Germany
| | - Avtar Lal
- European Stroke Organisation, Basel, Switzerland
| | - Patrik Michel
- Centre Cérébrovasculaire, Service de Neurologie, Département des Neurosciences Cliniques CHUV, Lausanne, Switzerland
| | - Paola Santalucia
- Neurology-Stroke Unit, San Giuseppe Hospital-Multimedica, Milan, Italy
| | | | - Thorsten Steiner
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Götz Thomalla
- Department of Neurology, Center for Clinical Neurosciences, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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8
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Moughal S, Uberti M, Al-Mousa A, Al-Dwairy S, Shtaya A, Pereira E. Malignant middle cerebral artery infarction following subacute subdural hematoma: A case report and literature review. Surg Neurol Int 2021; 12:105. [PMID: 33880210 PMCID: PMC8053464 DOI: 10.25259/sni_838_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 02/18/2021] [Indexed: 11/05/2022] Open
Abstract
Background: Subacute subdural hematomas (ASDH) are only treated surgically when they cause mass effect significant enough to give symptoms. Rarely, sub-ASDH may cause enough pressure to result in a malignant middle cerebral artery (MCA) territory infarction. Decompressive craniectomy (DC) is the last resort to reduce intracranial pressure following malignant MCA infarction. Herein, we review the literature and describe a case of MCA/posterior cerebral artery (PCA) territories infarction following drainage of a sub-ASDH that was treated with DC with good outcome. Case Description: We report a case of malignant right-sided MCA/PCA infarction in a 62-year-old man who presented with progressive headache following a cycling incident leading to a head injury. Initial CT head demonstrated a small right ASDH. He had no neurological deficit, headache settled on analgesia, and there was no expansion of the SDH on the repeat CT; therefore, he was managed conservatively. He was admitted 6-days later with worsening headaches and hyponatremia. Repeat CT revealed an increase in size of the hematoma and mass effect leading to a mini-craniotomy and evacuation of hematoma. He developed left-sided hemiplegia, slurred speech and hyponatremia, and CT head demonstrated a right-sided MCA/PCA infarction with significant mass effect. He underwent emergent DC and subsequent cranioplasty and ultimately recovered to mRS of 2. Conclusion: SDH are frequent neurosurgical entities. Malignant MCA/PCA strokes following mini-craniotomies are rare but need to be considered especially during the consent process.
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Affiliation(s)
- Saad Moughal
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, London, United Kingdom
| | - Micaela Uberti
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, Atkinson Morley Neurosurgery Centre, St George's, University of London, Tooting, London, United Kingdom
| | - Alaa Al-Mousa
- Department of General and Special Surgery, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Salem Al-Dwairy
- Department of General and Special Surgery, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Anan Shtaya
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, Atkinson Morley Neurosurgery Centre, St George's, University of London, Tooting, London, United Kingdom
| | - Erlick Pereira
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, Atkinson Morley Neurosurgery Centre, St George's, University of London, Tooting, London, United Kingdom
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9
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Diener HC, Wachter R. [Diagnosis and treatment of acute ischemic insults]. Herz 2021; 46:195-204. [PMID: 33598821 DOI: 10.1007/s00059-021-05021-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2021] [Indexed: 11/26/2022]
Abstract
In cases of stroke a distinction is made between a transient ischemic attack (TIA), a manifest ischemic infarction and cerebral hemorrhage. Cerebral ischemia can be caused by large vessel disease, small vessel disease, embolic causes, rare causes or stroke of unknown etiology. Acute diagnostic tests include a neurological examination, computed tomography (CT) and/or magnetic resonance imaging (MRI) with angiography, electrocardiography (ECG), and laboratory tests. The basic treatment of patients with TIA or acute ischemic infarction is performed in the stroke unit and includes monitoring of respiratory function, cardiac function, treatment of potential heart failure, detection of swallowing disorders, prophylaxis of thromboembolism, control of blood pressure and elevated blood sugar levels, and lowering of elevated body temperature. In patients with cardioembolic infarction, oral anticoagulation is initiated depending on the severity of the stroke and the size of the stroke on imaging.
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Affiliation(s)
- H C Diener
- Institut für Medizinische Informatik, Biometrie und Epidemiologie (IMIBE), Medizinische Fakultät, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| | - R Wachter
- Klinik und Poliklinik für Kardiologie, Universität Leipzig, Leipzig, Deutschland
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Alzayiani M, Schmidt T, Veldeman M, Riabikin A, Brockmann MA, Schiefer J, Clusmann H, Schubert GA, Albanna W. Risk profile of decompressive hemicraniectomy for malignant stroke after revascularization treatment. J Neurol Sci 2020; 420:117275. [PMID: 33352507 DOI: 10.1016/j.jns.2020.117275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 12/10/2020] [Accepted: 12/12/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Revascularization by pharmacological and/or endovascular treatment is an effective therapy for acute ischemic stroke caused by artery occlusion. In the context of malignant middle cerebral artery infarction (MMI), decompressive hemicraniectomy (DHC) can be life-saving. However, its effectiveness and safety after revascularization have not been thoroughly assessed. This retrospective study aimed to determine the risk profile of pre-surgical revascularization treatment (RT) for subsequent DHC. METHODS A total of 152 consecutive patients treated by DHC after MMI were identified between 2012 and 2015. After elimination of cases with previous stroke and cases pre-treated with antiplatelets or anticoagulants (increased postoperative bleeding), twenty-four out of fifty patients (n = 24/50, 48%) received pre-surgical revascularization treatment by intravenous thrombolysis (TL), mechanical thrombectomy (MT) or a combination of both. Demographic data was compared alongside perioperative, postoperative complications (intra-/extracerebral hemorrhage, revision surgery due to hemorrhage or infection, and overall mortality) and economic parameters. RESULTS Comparing patients with and without prior RT, there was no statistically significant difference in duration of surgery (RT: 83 [57-116] min vs. no-RT: 96 [69-119] min, p = 0.308), intraoperative blood loss (RT: 300 [225-375] ml vs. no-RT: 300 [250-400] ml, p = 0.763), intraoperative transfusion requirement (RT: 12.5% vs. no-RT: 26.9%, p = 0.294), or need for volume substitution (RT: 1300 [1200-1400] ml vs. no-RT: 1200 [1100-1400] ml, p = 0.359). The rate of postoperative complications was also comparable in both groups, including intra-/extracerebral hemorrhage, revision due to hemorrhage or infections, and mortality (p = 0.814, p = 0.520, p = 0.697, and p = 0.769). Health economic parameters were not affected (ventilation time: RT: 309 [12-527] hrs. vs. no-RT: 444 [171-605] hrs., p = 0.120, length of stay: RT: 23 [13-32] days vs. no-RT: 28 [19-41], p = 0.156, and stay costs: RT: 27768 [13044-60,248] € vs. no-RT: 35422 [21225-49,585] €, p = 0.312). CONCLUSION DHC for patients with MMI who previously received revascularization therapy appears to be safe and not associated with a higher complication rate or increased health economic burden.
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Affiliation(s)
| | - Tobias Schmidt
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Alexander Riabikin
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Marc A Brockmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany; Department of Neuroradiology, University Medical Center Mainz, Mainz, Germany
| | | | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | | | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
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Decompressive hemicraniectomy versus medical treatment of malignant middle cerebral artery infarction: a systematic review and meta-analysis. Biosci Rep 2020; 40:221641. [PMID: 31854446 PMCID: PMC6944664 DOI: 10.1042/bsr20191448] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 11/23/2019] [Accepted: 12/18/2019] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES To estimate evidence for decompressive hemicraniectomy (DHC) versus medical treatment effects on survival rate and favorable functional recovery among patients of malignant middle cerebral artery infarction (MMCAI) in randomized controlled trials (RCTs). DESIGN The present study is a systematic review and meta-analysis of RCTs. SETTING The MEDLINE/PubMed, EMBASE, Springer, Cochrane Collaboration database, China National Knowledge Infrastructure (CNKI) database, and Wanfang database were comprehensively searched for RCTs regarding the effects of DHC versus medical treatment among patients of MMCAI in these English and Chinese electronic databases from inception to 1 June 2019. Two reviewers independently retrieved RCTs and extracted relevant information. The methodological quality of the included trials was estimated using the Cochrane risk of bias tool. Review Manager5.3.5 software was used for statistical analyses. The statistical power of meta-analysis was estimated by Power and Precision, version 4 software. PARTICIPANTS Nine RCTs with a total of 425 patients with MMCAI, containing 210 cases in the DHC group and 215 cases in the medical treatment group, met the inclusion criteria were included. Primary outcomes were measured by survival rate, defined as modified Rankin scale (mRS) score 0-5 and favorable functional recovery as mRS score 0-3. The follow-up time of all studies was at 6-12months. RESULTS First, compared with the medical treatment group, DHC was associated with a statistically significant increase survival rate (RR: 1.96, 95%CI 1.61-2.38, P < 0.00001) and favorable functional recovery (RR: 1.62, 95%CI 1.11-2.37, P = 0.01). Second, subgroup analysis: (1) Compared with the medical treatment group among patients age ≤60 years, DHC was associated with a statistically significant increase survival rate (RR = 2.20, 95%CI 1.60-3.04, P < 0.00001); (2) Compared with the medical treatment group among patients of age >60 years, DHC was also associated with a statistically significant increase survival rate (RR: 1.93, 95%CI 1.45-2.59, P < 0.00001); (3) Compared with the medical treatment group, the time of DHC was preformed within 48 h from the onset of stroke that could statistically significant increase survival rate (RR: 2.16, 95%CI 1.69-2.75, P < 0.00001). Third, sensitivity analyses that measured the results were consistent, indicating that the results were stable. Fourth, the results of statistical power analysis were ≥80%. Finally, the funnel plot of the survival rate included nine RCTs showed no remarkable publication bias. CONCLUSIONS Our study results indicated that DHC could increase survival rate and favorable functional recovery among patients age ≤60 or >60 years. The optimal time for DHC might be no more than 48 h from the onset of symptoms. However, due to the limitations of this research, it is necessary to design high quality, large-scale RCTs to further evaluate these findings.
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12
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Ultrasound-Guided Ventricular Puncture During Cranioplasty. World Neurosurg 2020; 146:e779-e785. [PMID: 33181379 DOI: 10.1016/j.wneu.2020.11.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND In patients with brain parenchyma extending beyond the craniectomy defect, cerebrospinal fluid diversion may be necessary to facilitate proper bone flap replacement during cranioplasty. In this study, we present our case series of patients who underwent ultrasound-guided ventricular puncture during cranioplasty and report periprocedural metrics and clinical outcomes. METHODS A retrospective study of patients who presented for cranioplasty that required ultrasound-guided ventricular puncture was performed. We also describe our operative technique for safely and accurately performing ultrasound-guided ventricular puncture. RESULTS Ten consecutive patients were included in the overall patient cohort, all of whom required intraoperative ventricular puncture to achieve brain relaxation. The mean time between decompressive hemicraniectomy and cranioplasty was 145.4 days (range 19-419). The mean duration of cranioplasty operation was 146 minutes (range 74-193). All patients underwent ultrasound-guided ventricular puncture, and 5 patients had an external ventricular drain left in place for postoperative intracranial pressure monitoring and possible cerebrospinal fluid drainage. There were no instances of pericatheter hemorrhage. One patient presented postoperatively with wound infection, and this same patient was the only one in the cohort who required subsequent ventriculoperitoneal shunt for symptomatic hydrocephalus. CONCLUSIONS Ultrasound-guided ventricular puncture is safe, feasible, and efficacious for use during cranioplasty to help facilitate bone flap replacement in patients with "full" brains, with an overall low rate of associated periprocedural complications. Although further studies are needed in a larger patient cohort, this technique should be considered to help reduce the morbidity associated with cranioplasty.
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13
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Li J, Gu Y, Li G, Wang L, Cheng X, Wang M, Zhao M. The Role of Hypothermia in Large Hemispheric Infarction: A Systematic Review and Meta-Analysis. Front Neurol 2020; 11:549872. [PMID: 33192981 PMCID: PMC7653189 DOI: 10.3389/fneur.2020.549872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 09/18/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Hypothermia is used in the treatment of large hemispheric infarction (LHI); however, its role in outcomes for LHI patients remains ambiguous. This systematic review and meta-analysis was conducted to evaluate the effect of hypothermia on the outcomes of LHI patients. Methods: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, China Biological Medicine Database, and clinical trials registers before September 21, 2018, and then scanned the reference lists. Randomized controlled trials that compared hypothermia with normothermia in LHI patients were included. Primary outcomes that we reviewed were mortality and neurological outcome. Adverse events during treatment were defined as secondary outcomes. We performed a meta-analysis to calculate pooled risk ratios (RRs), standardized mean differences (SMDs), and 95% confidence intervals (CIs) using fixed-effect models. Results: Three randomized controlled trials involving 131 participants were included. No statistically significant association was revealed between hypothermia and mortality (RR, 1.12; 95% CI, 0.76-1.65). There was significant association between hypothermia and good neurological outcome as assessed by modified Rankin Scale score (mRS of 0-3) of survivors (RR, 2.09; 95% CI, 1.14-3.82), and with neurological outcome by mRS (SMD, -0.54; 95% CI, -1.07 to -0.01). However, significant associations were found between hypothermia and gastrointestinal bleeding, gastric retention, electrolyte derangement, and shivering. No significant differences were detected in the incidence of developing herniation in the rewarming process, pneumonia, cardiac arrhythmia, hemorrhagic transformation, hyperglycemia, hypotension, acute kidney injury, and venous thrombotic events in LHI patients who underwent hypothermia compared with those who had normothermia. Conclusions: This meta-analysis suggested that hypothermia was not associated with mortality in LHI patients. However, it was associated with the improvement of neurological outcome, but with a higher risk of adverse events during treatment. Future studies are needed to demonstrate the efficacy and safety of hypothermia for LHI. The protocol for this systematic review was obtained from PROSPERO (registration number: CRD42018111761).
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Affiliation(s)
- Jing Li
- Department of Intensive Care Unit, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Yanghui Gu
- Department of Cardiology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Gang Li
- Department of Intensive Care Unit, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Lixin Wang
- Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaobin Cheng
- Department of Intensive Care Unit, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Min Wang
- Department of Intensive Care Unit, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Min Zhao
- Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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14
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Parish JM, Asher AM, Pfortmiller D, Smith MD, Clemente JD, Stetler WR, Bernard JD. Outcomes After Decompressive Craniectomy for Ischemic Stroke: A Volumetric Analysis. World Neurosurg 2020; 145:e267-e273. [PMID: 33065347 DOI: 10.1016/j.wneu.2020.10.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Decompressive hemicraniectomy (DHC) is a treatment of space-occupying hemispheric infarct. Current surgical guidelines use criteria of age <60 years and surgery within 48 hours of stroke onset. OBJECTIVE The purpose of this study was to evaluate the neurologic outcome after DHC and evaluate the relationship of stroke volume and outcomes. METHODS A retrospective review was performed of patients undergoing DHC for cerebral infarct from 2016 to 2019. Unfavorable outcome was defined as modified Rankin Scale (mRS) score >3. Patients with precraniectomy magnetic resonance imaging were selected as a subset for volumetric stroke volume analysis using RAPID software (iSchemaView, Redwood City, California), with stroke volume defined as apparent diffusion coefficient <620 on diffusion-weighted imaging. RESULTS Fifty-two patients met the inclusion criteria. At 90 days, favorable outcome was achieved in 11 patients (21.2%), and 41 patients (78.8%) had unfavorable outcomes (15 [29%] died). Surgery after 48 hours, age >60 years, and multivessel distribution did not significantly affect 90-day mRS score (P = 0.091, 0.111, and 0.664, respectively). In volumetric subset analysis, 10 patients of 41 (31.3%) achieved favorable outcomes, and no patients with volume of infarct >280 mL had a favorable outcome. There was a trend of lower volumes associated with favorable outcomes, but this did not meet significance (favorable 207 ± 68.7 vs. unfavorable 262 ± 117.1; P = 0.163). CONCLUSIONS Outcomes after DHC for malignant hemispheric infarct were not affected by current accepted guidelines. Volume of infarct may have an effect on outcome after DHC. Further research to aid in predicting which patients benefit from decompressive craniectomy is warranted.
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Affiliation(s)
- Jonathan M Parish
- Department of Neurological Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA.
| | - Anthony M Asher
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | | | - Mark D Smith
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
| | | | - William R Stetler
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
| | - Joe D Bernard
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
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15
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Wen X, Li Y, He X, Xu Y, Shu Z, Hu X, Chen J, Jiang H, Gong X. Prediction of Malignant Acute Middle Cerebral Artery Infarction via Computed Tomography Radiomics. Front Neurosci 2020; 14:708. [PMID: 32733197 PMCID: PMC7358521 DOI: 10.3389/fnins.2020.00708] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/11/2020] [Indexed: 12/23/2022] Open
Abstract
Malignant middle cerebral artery infarction (mMCAi) is a serious complication of cerebral infarction usually associated with poor patient prognosis. In this retrospective study, we analyzed clinical information as well as non-contrast computed tomography (NCCT) and computed tomography angiography (CTA) data from patients with cerebral infarction in the middle cerebral artery (MCA) territory acquired within 24 h from symptoms onset. Then, we aimed to develop a model based on the radiomics signature to predict the development of mMCAi in cerebral infarction patients. Patients were divided randomly into training (n = 87) and validation (n = 39) sets. A total of 396 texture features were extracted from each NCCT image from the 126 patients. The least absolute shrinkage and selection operator regression analysis was used to reduce the feature dimension and construct an accurate radiomics signature based on the remaining texture features. Subsequently, we developed a model based on the radiomics signature and Alberta Stroke Program Early CT Score (ASPECTS) based on NCCT to predict mMCAi. Our prediction model showed a good predictive performance with an AUC of 0.917 [95% confidence interval (CI), 0.863-0.972] and 0.913 [95% CI, 0.795-1] in the training and validation sets, respectively. Additionally, the decision curve analysis (DCA) validated the clinical efficacy of the combined risk factors of radiomics signature and ASPECTS based on NCCT in the prediction of mMCAi development in patients with acute stroke across a wide range of threshold probabilities. Our research indicates that radiomics signature can be an instrumental tool to predict the risk of mMCAi.
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Affiliation(s)
- Xuehua Wen
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Yumei Li
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xiaodong He
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Yuyun Xu
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Zhenyu Shu
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xingfei Hu
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Junfa Chen
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Hongyang Jiang
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xiangyang Gong
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China.,Institute of Artificial Intelligence and Remote Imaging, Hangzhou Medical College, Hangzhou, China
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16
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Furie KL, Sheth KN. Big strokes can cause big problems. J Neurol Neurosurg Psychiatry 2020; 91:453. [PMID: 32165375 DOI: 10.1136/jnnp-2020-322964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 02/13/2020] [Accepted: 02/16/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Karen L Furie
- Neurology, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Kevin N Sheth
- Neurology, Yale University, New Haven, Connecticut, USA
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17
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Rumalla K, Ottenhausen M, Kan P, Burkhardt JK. Recent Nationwide Impact of Mechanical Thrombectomy on Decompressive Hemicraniectomy for Acute Ischemic Stroke. Stroke 2019; 50:2133-2139. [DOI: 10.1161/strokeaha.119.025063] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The treatment of patients with acute ischemic stroke has been revolutionized by endovascular mechanical thrombectomy (MT), leading to dramatically improved outcomes. Here, we analyzed the impact of recent changes in stroke management on nationwide trends in patient characteristics, treatment modalities, and outcomes.
Methods—
The National Inpatient Sample was analyzed using
International Classification of Diseases, Ninth and Tenth Editions
, Clinical Modification codes to identify adult stroke patients with anterior-circulation, large-vessel occlusion in the pre- (2012–2014) and the post-MT trial period (2015–2016). Univariate and multivariable predictors of decompressive hemicraniectomy (DHC) were ascertained in patients developing malignant cerebral edema.
Results—
The nationwide query identified 519 320 adult stroke patients with annually increasing volume (92 320 to 129 340), stroke severity, and treatment at urban teaching centers. DHC was performed in 9.5% of patients developing malignant cerebral edema (n=33 530) and was associated with a high rate of discharge to long-term nursing care (65%) and mortality (23%). Over time, the rate of MT (3.4% to 9.8%) increased whereas the rate of DHC for malignant cerebral edema declined from 11.4% to 4.8% (
P
<0.001). In a binary logistic regression model controlling for potential confounders (eg, age, severity of illness), MT patients were 43% less likely to require DHC (odds ratio, 0.7; 95% CI, 0.6–0.9).
Conclusions—
Nationwide trends indicated that successful reperfusion of penumbra with MT in stroke patients leads to a declining indication for DHC whereas stroke volume increases over time.
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Affiliation(s)
- Kavelin Rumalla
- From the School of Medicine, University of Missouri-Kansas City (K.R.)
| | - Malte Ottenhausen
- Department of Neurosurgery, University Hospital Mainz, Germany (M.O.)
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX (P.K., J.-K.B.)
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX (P.K., J.-K.B.)
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18
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Williams V, Jayashree M, Bansal A, Baranwal A, Nallasamy K, Singhi SC, Singhi P, Gupta SK. Spontaneous intracranial haemorrhage in children-intensive care needs and predictors of in-hospital mortality: a 10-year single-centre experience. Childs Nerv Syst 2019; 35:1371-1379. [PMID: 31165253 DOI: 10.1007/s00381-019-04209-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 05/15/2019] [Indexed: 01/10/2023]
Abstract
PURPOSE Spontaneous intracranial haemorrhage (SICH) in children, although uncommon, is associated with significant mortality and morbidity. Paediatric data is however limited. MATERIAL AND METHODS Case records of 105 children with SICH, > 1 month to 12 years, admitted to a tertiary level PICU of a teaching and referral hospital between January 2009 and May 2018 were analysed retrospectively. In-hospital mortality was the primary outcome. Variables between survivors and non-survivors were compared to determine predictors of mortality. RESULTS The median (IQR) age of subjects was 6 (2.25, 70) months. Common clinical features were altered sensorium (n = 87, 82.9%), seizures (n = 73, 69.5%), pallor (n = 66, 62.9%) and bulging anterior fontanelle (n = 52, 49.5%). Median (IQR) Glasgow Coma Scale (GCS) at admission was 10 (6, 13) with herniation noted in 27 (25.7%) children. Vitamin K deficiency bleeding (VKDB) and arteriovenous malformation (AVM) were the most common etiology for bleeding among infants and older children respectively. The most common site of bleeding was intracerebral (n = 47, 44.8%) followed by subdural (n = 26; 24.8%). Sixteen (15.2%) children died during hospital stay. On univariate analysis, GCS < 8, Pediatric Risk of Mortality score (PRISM III) > 20, need for intubation, thiopentone coma for refractory intracranial pressure (ICP) and progression to shock and acute kidney injury (AKI) predicted mortality. Seizures were favourably associated with survival. Age, site of bleeding, etiology or type of management for raised ICP (conservative versus decompressive craniectomy) did not affect the outcome. On multivariable analysis, progression to AKI (OR 5.86; 95% CI, 1.53-22.4; p 0.01) predicted poor outcome. Seizures, however, were associated with better odds for survival (OR 0.12; 95% CI, 0.03-0.47; p 0.002). CONCLUSIONS VKDB and AVM were the common etiologies among infants and older children respectively. Age, site, etiology of bleeding and type of management did not affect outcome. Severe decompensation at presentation, thiopentone for refractory ICP and progression to multiorgan dysfunction determined mortality.
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Affiliation(s)
- Vijai Williams
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Muralidharan Jayashree
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Arun Bansal
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arun Baranwal
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Karthi Nallasamy
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | - Pratibha Singhi
- Department of Pediatrics, Medanta The Medicity, Gurgaon, India
| | - S K Gupta
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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19
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Pallesen LP, Barlinn K, Puetz V. Role of Decompressive Craniectomy in Ischemic Stroke. Front Neurol 2019; 9:1119. [PMID: 30687210 PMCID: PMC6333741 DOI: 10.3389/fneur.2018.01119] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/06/2018] [Indexed: 12/12/2022] Open
Abstract
Ischemic stroke is one of the leading causes for death and disability worldwide. In patients with large space-occupying infarction, the subsequent edema complicated by transtentorial herniation poses a lethal threat. Especially in patients with malignant middle cerebral artery infarction, brain swelling secondary to the vessel occlusion is associated with high mortality. By decompressive craniectomy, a significant proportion of the skull is surgically removed, allowing the ischemic tissue to shift through the surgical defect rather than to the unaffected regions of the brain, thus avoiding secondary damage due to increased intracranial pressure. Several studies have shown that decompressive craniectomy reduces the mortality rate in patients with malignant cerebral artery infarction. However, this is done for the cost of a higher proportion of patients who survive with severe disability. In this review, we will describe the clinical and radiological features of malignant middle cerebral artery infarction and the role of decompressive craniectomy and additional therapies in this condition. We will also discuss large cerebellar stroke and the possibilities of suboccipital craniectomy.
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Affiliation(s)
- Lars-Peder Pallesen
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Volker Puetz
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
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20
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Pandhi A, Tsivgoulis G, Goyal N, Ishfaq MF, Male S, Boviatsis E, Chang JJ, Zand R, Voumvourakis K, Elijovich L, Alexandrov AW, Malkoff MD, Hoit D, Arthur AS, Alexandrov AV. Hemicraniectomy for Malignant Middle Cerebral Artery Syndrome: A Review of Functional Outcomes in Two High-Volume Stroke Centers. J Stroke Cerebrovasc Dis 2018; 27:2405-2410. [PMID: 29776804 DOI: 10.1016/j.jstrokecerebrovasdis.2018.04.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/11/2018] [Accepted: 04/23/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND AND PURPOSE Despite recent landmark randomized controlled trials showing significant benefits for hemicraniectomy (HCT) compared with medical therapy (MT) in patients with malignant middle cerebral artery infarction (MMCAI), HCT rates have not substantially increased in the United States. We sought to evaluate early outcomes in patients with MMCAI who were treated with HCT (cases) in comparison to patients treated with MT due to the perception of procedural futility by families (controls). METHODS We retrospectively evaluated consecutive patients with acute MMCAI treated in 2 tertiary care centers during a 7-year period. Pretreatment National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 3 months were documented. Functional independence (FI) and survival without severe disability (SWSD) were defined as mRS of 0-2 and 0-4, respectively. RESULTS A total of 66 patients (37 cases and 29 controls) fulfilled the study inclusion criteria (mean age 59 ± 15 years, 52% men, median admission NIHSS score: 19 points [interquartile range {IQR}: 16-22]). Cases were younger (51 ± 11 versus 68 ± 13 years; P < .001) and tended to have lower median admission NIHSS than controls (18 [IQR:16-20] versus 20 [IQR:18-23]; P = .072). The rates of FI and SWSD at 3 months were higher in cases than controls (16% versus 0% [P = .031] and 62% versus 0% [P < .001]), while 3-month mortality was lower (24% versus 77%; P < .001). Multivariable Cox regression analyses adjusting for potential confounders identified HCT as the most important predictor of lower risk of 3-month mortality (hazard ratio: .02, 95% confidence interval: .01-0.10; P < .001). CONCLUSIONS HCT is a critical and effective therapy for patients with MMCAI but cannot provide a guarantee of functional recovery.
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Affiliation(s)
- Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee.
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee; Second Department of Neurology, "Attikon University Hospital", School of Medicine, University of Athens, Athens, Greece
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Muhammad F Ishfaq
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Shailesh Male
- Department of Neurology, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Efstathios Boviatsis
- Second Department of Neurosurgery, "Attikon University Hospital", School of Medicine, University of Athens, Athens, Greece
| | - Jason J Chang
- Neurointensivist, Medstar Washington Hospital Medical Center, Washington, DC
| | - Ramin Zand
- Neurology Director of Clinical Stroke Operations & Northeastern Regional Stroke Director, Geisinger Health System
| | | | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Anne W Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee; Professor and US Principle Investigator, Australian Catholic University, Sydney, Australia
| | - Marc D Malkoff
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Daniel Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
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21
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Chen M, Yu W, Sun S, Dong C, Huang N, Mao L, Wang H. Stereotactic Aspiration of Necrotic Brain Tissue for Treating Malignant Middle Cerebral Artery Infarction: A Report of 13 Consecutive Cases. World Neurosurg 2018; 124:S1878-8750(18)32497-5. [PMID: 30404052 DOI: 10.1016/j.wneu.2018.10.190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 10/24/2018] [Accepted: 10/26/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND This study aimed to evaluate the efficacy and safety of stereotactic aspiration of necrotic brain tissue for treating malignant middle cerebral artery infarction (MMI) in patients older than 60 years of age. CASE DESCRIPTION A total of 13 consecutive patients with MMI (mean age, 67 ± 6.62 years) were enrolled in the study. These patients were treated with stereotactic aspiration of necrotic brain tissue within 72 hours from stroke onset between January 2016 and June 2017. The surgical results and clinical outcomes were evaluated in response to stereotactic aspiration of necrotic brain tissue. The mean preoperative infarction volume in the patients was found to be 153.46 ± 9.39 mL according to the latest computed tomography scan. The 30-day mortality was 2 out of 13 patients (15.4%). Patients were followed-up for 6 months to evaluate the efficacy of stereotactic aspiration of necrotic brain tissue using the modified Rankin Scale (mRS). Among the 11 surviving surgical patients, 6 (54.5%) had an mRS score of 3 (defined as moderate disability), 4 (36.4%) had an mRS score of 4 (defined as moderate to severe disability), and 1 (9.1%) had an mRS score of 5 (defined as severe disability). The probability of 6-month unfavorable outcome, defined as an mRS score of 5 or 6 (death), was 3 out of 13 (23.1%). CONCLUSIONS Our results suggest the stereotactic aspiration of necrotic brain tissue is an effective and safe method in patients with MMI who are over 60 years of age.
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Affiliation(s)
- Maogang Chen
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu Province, China; Department of Emergency, Yancheng Clinical Institute, Xuzhou Medical University (Yancheng City No.1 People's Hospital), Yancheng, JiangSu Province, China
| | - Wensu Yu
- Department of Neurology, Yancheng Clinical Institute, Xuzhou Medical University (Yancheng City No.1 People's Hospital), Yancheng, JiangSu Province, China
| | - Shujie Sun
- Neurosurgery Department, Shanghai Clinical Center of Chinese Academy of Sciences, Shanghai, China
| | - Chenglong Dong
- Department of Emergency, Yancheng Clinical Institute, Xuzhou Medical University (Yancheng City No.1 People's Hospital), Yancheng, JiangSu Province, China
| | - Na Huang
- Department of Emergency, Yancheng Clinical Institute, Xuzhou Medical University (Yancheng City No.1 People's Hospital), Yancheng, JiangSu Province, China
| | - Lei Mao
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu Province, China
| | - Handong Wang
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu Province, China.
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22
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Geisler F, Ali SF, Ebinger M, Kunz A, Rozanski M, Waldschmidt C, Weber JE, Wendt M, Winter B, Schwamm LH, Audebert HJ. Evaluation of a score for the prehospital distinction between cerebrovascular disease and stroke mimic patients. Int J Stroke 2018; 14:400-408. [DOI: 10.1177/1747493018806194] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Patients with a sudden onset of focal neurological deficits consistent with stroke, who turn out to have alternative conditions, have been labeled stroke mimics. Aims We assessed a recently validated telemedicine-based stroke mimic score (TeleStroke mimic score; TM-score) and individual patient characteristics with regard to its discriminative value between cerebrovascular disease and stroke mimic patients in the in-person, pre-hospital setting. Methods We evaluated patients cared for in a mobile stroke unit in Berlin, Germany. We investigated whether the TM-score (comprising six parameters), Face Arm Speech Time test, and individual patient characteristics were able to differentiate cerebrovascular disease from stroke mimic patients. Results We included 423 patients (299 (70.7%) cerebrovascular disease and 124 (29.3%) stroke mimic) in the final analysis. A TM-score > 30 indicated a high probability of a cerebrovascular disease and a score ≤15 of a stroke mimic. The TM-score performed well to identify stroke mimics (area under the curve of 0.74 under receiver-operating characteristic curve analysis). The cerebrovascular disease patients were older (74.8 vs. 69.8 years, p = 0.001), had more often severe strokes (NIHSS > 14 25.8% vs. 11.3%, p = 0.001), presented more often with weakness of the face (70.9% vs. 42.7%, p = 0.001) or arm (60.9% vs. 33.9%, p = 0.001), dysarthria (59.5% vs. 40.3%, p < 0.001), history of atrial fibrillation (38.1% vs. 21.0%, p = 0.001), arterial hypertension (78.9% vs. 53.2%, p < 0.001), and less often with seizure (0.7% vs. 21.0%, p < 0.001). Conclusions The TM-score and certain patient characteristics can help paramedics and emergency physicians in the field to identify stroke mimic patients and select the most appropriate hospital destination.
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Affiliation(s)
- Frederik Geisler
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Syed F Ali
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Martin Ebinger
- Department of Neurology, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Alexander Kunz
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Michal Rozanski
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Carolin Waldschmidt
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Joachim E Weber
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Wendt
- Department of Neurology, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Benjamin Winter
- Department of Neurology, St. Josefs-Krankenhaus, Potsdam-Sanssouci, Germany
| | - Lee H Schwamm
- Department of Neurology, MGH Stroke Services, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Heinrich J Audebert
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
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Medley TL, Miteff C, Andrews I, Ware T, Cheung M, Monagle P, Mandelstam S, Wray A, Pridmore C, Troedson C, Dale RC, Fahey M, Sinclair A, Walsh P, Stojanovski B, Mackay MT. Australian Clinical Consensus Guideline: The diagnosis and acute management of childhood stroke. Int J Stroke 2018; 14:94-106. [DOI: 10.1177/1747493018799958] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke is among the top 10 causes of death in children and survivors carry resulting disabilities for decades, at substantial cost to themselves and their families. Children are not currently able to access reperfusion therapies, due to limited evidence supporting safety and efficacy and long diagnostic delays. The Australian Clinical Consensus Guideline for the Diagnosis and Acute Management of Childhood Stroke was developed to minimize unwarranted variations in care and document best evidence on the risk factors, etiologies, and conditions mimicking stroke that differ from adults. Clinical questions were formulated to inform systematic database searches from 2007 to 2017, limited to English and pediatric studies. SIGN methodology and the National Health and Medical Research Council system were used to screen and classify the evidence. The Grades of Recommendation, Assessment, Development, and Evaluation system (GRADE) was used to grade evidence as strong or weak. The Guideline provides more than 60 evidence-based recommendations to assist prehospital and acute care clinicians in the rapid identification of childhood stroke, choice of initial investigation, to confirm diagnosis, determine etiology, selection of the most appropriate interventions to salvage brain at risk, and prevent recurrence. Recommendations include advice regarding the management of intracranial pressure and congenital heart disease. Implementation of the Guideline will require reorganization of prehospital and emergency care systems, including the development of regional stroke networks, pediatric Code Stroke, rapid magnetic resonance imaging and accreditation of primary pediatric stroke centers with the capacity to offer reperfusion therapies. The Guideline will allow auditing to benchmark timelines of care, access to acute interventions, and outcomes. It will also facilitate the development of an Australian childhood stroke registry, with data linkage to international registries, to allow for accurate data collection on stroke incidence, treatment, and outcomes.
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Affiliation(s)
- Tanya L Medley
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
| | | | - Ian Andrews
- Sydney Children's Hospital, School of Women's and Children's Health, University of New South Wales, Sydney, Australia
| | - Tyson Ware
- Royal Hobart Hospital, Hobart, Australia
| | - Michael Cheung
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Department of Cardiology Royal Children's Hospital, Melbourne, Australia
| | - Paul Monagle
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | - Simone Mandelstam
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | - Alison Wray
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | | | - Christopher Troedson
- Children's Hospital at Westmead, Discipline of Child and Adolescent Health, University of Sydney, Sydney, Australia
| | - Russell C Dale
- Children's Hospital at Westmead and University of Sydney, Sydney Australia
| | - Michael Fahey
- Department of Paediatrics Monash University, Department of Medicine Melbourne University, and Monash Children's Hospital, Melbourne, Australia
| | - Adriane Sinclair
- Lady Cilento Children's Hospital, University of Queensland, Brisbane, Australia
| | | | - Belinda Stojanovski
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | - Mark T Mackay
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Department of Neurology Royal Children's Hospital, Melbourne Australia
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Faigle R, Urrutia VC, Cooper LA, Gottesman RF. Racial Differences in Utilization of Life-Sustaining vs Curative Inpatient Procedures After Stroke. JAMA Neurol 2018; 73:1151-3. [PMID: 27454260 DOI: 10.1001/jamaneurol.2016.1914] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lisa A Cooper
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rebecca F Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Macleod MJ, Counsell CE. Stroke: Are care and outcomes better for participants of stroke trials? Nat Rev Neurol 2018; 12:498-9. [PMID: 27562652 DOI: 10.1038/nrneurol.2016.123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Mary Joan Macleod
- School of Medicine, Medical Sciences and Nutrition, Polwarth Building, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZN, UK
| | - Carl E Counsell
- School of Medicine, Medical Sciences and Nutrition, Polwarth Building, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZN, UK
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Kürten S, Munoz C, Beseoglu K, Fischer I, Perrin J, Steiger HJ. Decompressive hemicraniectomy for malignant middle cerebral artery infarction including patients with additional involvement of the anterior and/or posterior cerebral artery territory-outcome analysis and definition of prognostic factors. Acta Neurochir (Wien) 2018; 160:83-89. [PMID: 28965156 DOI: 10.1007/s00701-017-3329-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 09/08/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND According to current evidence, adding decompressive craniectomy (DC) to best medical therapy reduces case fatality rate of malignant middle cerebral artery infarction by 50-75%. There is currently little information available regarding the outcome of subgroups, in particular of patients with extensive infarctions exceeding the territory of the middle cerebral artery. METHODS The records of 101 patients with large hemispheric infarctions undergoing DC were retrospectively reviewed. Twenty-seven patients had additional ACA and/or PCA infarcts. Sequential CTs were used for postoperative follow-up. Intracranial pressure (ICP) was monitored via a ventricular catheter in comatose patients. The main aim of treatment was to keep midline shift below 10 mm and ICP below 20 mmHg. If midline shift increased despite preceding DC, repeat surgery with removal of clearly necrotic tissue was considered. For the current analysis, Glasgow Coma Scale (GCS) at 14 days and modified Rankin Scale (mRS) at 3 months were used as outcome parameters. mRS 2 and 3 were defined as "moderate disability", mRS 4 as "severe disability", and mRS 5 and 6 as "poor outcome". These outcome parameters were correlated to age, gender, side, vascular territory, and time delay after stroke, GCS at the time of decompression, maximum ICP, maximum midline shift, and delay of maximum shift. RESULTS The median age of the 39 female and 62 male patients was 56 years (range, 5-79 years). Overall, 12 patients died in the acute stage (11.9%). Twenty-three (22.8%) patients recovered to moderate disability at 3 months (mRS ≤ 3), 45 (44.6%) to severe disability and 33 (32.6%) suffered a poor outcome (mRS 5 or 6). Twenty patients (19.8%) required additional necrosectomy due to secondary increasing midline shift and/or intracranial hypertension. Patients recovering to moderate disability at 3 months were in the median 10 years younger than patients with less favorable outcome (P < 0.001) and had a higher GCS prior to surgery (P < 0.001). Eleven of the 27 patients with infarctions exceeding the MCA territory needed secondary surgery, indicating a higher necrosectomy rate as for isolated MCA infarction. At 3 months, the distribution of the outcomes in terms of mRS was comparable between the patients suffering from extended infarctions and patients having isolated MCA stroke. Infarctions exceeding the territory of the middle cerebral artery were seen in 30% of the group recovering to moderate disability and thus as frequent as in the groups suffering a less favorable outcome. CONCLUSIONS Intensified postoperative management including possible secondary decompression with necrosectomy may further reduce case fatality rate of patients with large hemispheric infarction. Age above 60 years and severely reduced level of consciousness are the most significant factors heralding unfavorable recovery. Patients suffering infarctions exceeding the MCA territory have a comparable chance of favorable recovery as patients with isolated MCA infarction.
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Yue JK, Rick JW, Deng H, Feldman MJ, Winkler EA. Efficacy of decompressive craniectomy in the management of intracranial pressure in severe traumatic brain injury. J Neurosurg Sci 2017; 63:425-440. [PMID: 29115100 DOI: 10.23736/s0390-5616.17.04133-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Traumatic brain injury (TBI) is a common cause of permanent disability for which clinical management remains suboptimal. Elevated intracranial pressure (ICP) is a common sequela following TBI leading to death and permanent disability if not properly managed. While clinicians often employ stepwise acute care algorithms to reduce ICP, a number of patients will fail medical management and may be considered for surgical decompression. Decompressive craniectomy (DC) involves removing a component of the bony skull to allow cerebral tissue expansion in order to reduce ICP. However, the impact of DC, which is performed in the setting of neurological instability, ongoing secondary injury, and patient resuscitation, has been challenging to study and outcomes are not well understood. This review summarizes historical and recent studies to elucidate indications for DC and the nuances, risks and complications in its application. The pathophysiology driving ICP elevation, and the corresponding medical interventions for their temporization and treatment, are thoroughly described. The current state of DC - including appropriate injury classification, surgical techniques, concurrent medical therapies, mortality and functional outcomes - is presented. We also report on the recent updates from large randomized controlled trials in severe TBI (Decompressive Craniectomy [DECRA] and Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of ICP [RESCUEicp]), and recommendations for early DC to treat refractory ICP elevations in malignant middle cerebral artery syndrome. Limitations for DC, such as the equipoise between immediate reduction in ICP and clinically meaningful functional outcomes, are discussed in support of future investigations.
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Affiliation(s)
- John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Jonathan W Rick
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael J Feldman
- Department of Neurological Surgery, Vanderbilt University, Nashville, TN, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, CA, USA -
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James KP, Leahy A, Lee SKK, O’Brien DPK, Williams DJ. 053Decompressive Craniectomy for Malignant Middle Cerebral Artery Syndrome: The Irish Experience. Age Ageing 2017. [DOI: 10.1093/ageing/afx145.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kamran S, Salam A, Akhtar N, Alboudi A, Ahmad A, Khan R, Nazir R, Nadeem M, Inshasi J, ElSotouhy A, Al Sulaiti G, Shuaib A. Predictors of In-Hospital Mortality after Decompressive Hemicraniectomy for Malignant Ischemic Stroke. J Stroke Cerebrovasc Dis 2017; 26:1941-1947. [PMID: 28694110 DOI: 10.1016/j.jstrokecerebrovasdis.2017.06.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 10/27/2016] [Accepted: 06/11/2017] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The purpose of this retrospective multicenter, pooled-data analysis was to determine the factors associated with in-hospital mortality in decompressive hemicraniectomy (DHC) for malignant middle cerebral artery (MMCA) stroke. PATIENTS AND METHODS The authors reviewed pooled DHC database from 3 countries for patients with MMCA with hospital mortality in spite of DHC to identify factors that predicted in-hospital mortality after DHC. The identified factors were applied to the group of patients who were selected for DHC but either refused surgery and died or stabilized and did not undergo DHC. FINDINGS There were 137 patients who underwent DHC. Multiple logistic regression analysis showed middle cerebral artery (MCA) with additional infarcts (odds ratio [OR], 7.9: 95% confidence interval [CI], 2.4-26; P = .001), preoperative midline shift of septum pellucidum of 1 cm or more (OR, 3.83: 95% CI, 1.13-12.96; P = .031), and patients who remained unconscious on day 7 postoperatively (8.82: 95% CI; OR, 1.08-71.9; P = .042) were significant independent predictors for in-hospital mortality. The identified factors were applied to the group of MMCA patients not operated (n = 19 refused, n = 47 stabilized) single (P < .001), and two predictive factors (P < .001) were significantly more common in patients who died. Whereas two predicative factors were identified in only 9%-18.2% of survivors, the presence of all three predictive factors was seen only in patients who expired (P < .001). The Hosmer-Lemeshow goodness-of-fit statistics (chi-square = 4.65; P value = .589) indicate that the model adequately describes the data. CONCLUSION Direct physical factors, such as MCA with additional territory infarct, extent of midline shift, and postoperative consciousness level, bore a significant relationship to in-hospital mortality in MMCA patients undergoing DHC.
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Affiliation(s)
- Saadat Kamran
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Weill Cornell School of Medicine, Qatar.
| | - Abdul Salam
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Naveed Akhtar
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Weill Cornell School of Medicine, Qatar
| | - Aymen Alboudi
- Department of Neurology, Rashid Hospital, Dubai, United Arab Emirates
| | - Arsalan Ahmad
- Department of Neurology and Neurosurgery, Shifa International Hospital, Islamabad, Pakistan
| | - Rabia Khan
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Rashed Nazir
- Department of Neurology and Neurosurgery, Shifa International Hospital, Islamabad, Pakistan
| | - Muhammad Nadeem
- Department of Neurology and Neurosurgery, Shifa International Hospital, Islamabad, Pakistan
| | - Jihad Inshasi
- Department of Neurology, Rashid Hospital, Dubai, United Arab Emirates
| | - Ahmed ElSotouhy
- Department of Radiology, Hamad General Hospital, Hamad Medical Corporation, Qatar
| | - Ghanim Al Sulaiti
- Department of Neurosurgery, The Neuroscience Institute Hamad General Hospital, Medical Corporation, Doha, Qatar
| | - Ashfaq Shuaib
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Stroke Program, University of Alberta, Canada
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Mohan Rajwani K, Crocker M, Moynihan B. Decompressive craniectomy for the treatment of malignant middle cerebral artery infarction. Br J Neurosurg 2017; 31:401-409. [DOI: 10.1080/02688697.2017.1329518] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | - Matthew Crocker
- Department of Neurosurgery, St George’s Hospital, London, UK
| | - Barry Moynihan
- Department of Neurology, St George’s Hospital, London, UK
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Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke: South Asian Experience. J Stroke Cerebrovasc Dis 2017; 26:2306-2312. [PMID: 28579508 DOI: 10.1016/j.jstrokecerebrovasdis.2017.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 04/15/2017] [Accepted: 05/14/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The randomized trials showed improved outcome and reduced mortality in malignant middle cerebral artery (MMCA) undergoing Decompressive hemicraniectomy (DHC) within 48 hours of stroke onset. Despite high prevalence of stroke, especially in younger individuals, high and short-term mortality from stroke in South Asian and Middle East, there is little published data on DHC in patients with MMCA stroke. METHODS This is a retrospective, multicenter cross-sectional study to measure outcome following DHC using the modified Rankin Scale (mRS) and dichotomized as favorable (mRS ≤ 4) or unfavorable (mRS > 4), at 3 months. RESULTS In total, 137 patients underwent DHC. At 90 days, mortality was 16.8%; 61.3% of patients survived with an mRS of 4 or less and 38.7% had an mRS greater than 4. Age (55 years), diabetes (P = .004), hypertension (P = .021), pupillary abnormality (P = .048), uncal herniation (P = .007), temporal lobe involvement (P = .016), additional infarction (MCA + anterior cerebral artery, posterior cerebral artery) (P = .001), and infarction growth rates (P = .025) were significantly higher in patients with unfavorable prognosis in univariate analysis. Multivariate analysis showed age, additional infarction, septum pellucidum deviation greater than 1 cm, and uncal herniation to be associated with a significantly poor prognosis. Time to surgery had no impact on outcome (P = .109). CONCLUSIONS Similar to the results of the studies from the West, DHC Improves functional outcome in predominantly South Asian patients with MMCA Stroke.
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Budhdeo S, Kolias AG, Clark DJ, Chari A, Hutchinson PJ, Warburton EA. A Retrospective Cohort Study to Assess Patient and Physician Reported Outcome Measures After Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke. Cureus 2017; 9:e1237. [PMID: 28620567 PMCID: PMC5467774 DOI: 10.7759/cureus.1237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Decompressive hemicraniectomy for malignant middle cerebral artery (MCA) infarction is known to reduce mortality. However, there are on-going concerns in terms of the quality of life in survivors. We aimed to examine the correlation between patient and physician reported outcome measures in decompressive hemicraniectomy. Patients and methods We analyzed outcomes in 21 patients who underwent decompressive hemicraniectomy for malignant MCA infarction between September 2003 and August 2013 within a regional health system. Patient and physician reported outcome measures were collected at follow-up. These were Stroke Impact Scale (SIS) Version 3, modified Rankin Scale (mRS), National Hospital Seizure Severity Scale, Headache Impact Test and Patient Health Questionnaire for depression. Results There was a good correlation between physician and patient reported outcome measures. The Spearman's rank correlation coefficient between mRS and structured SIS Version 3 was -0.887 (p < 0.001); with unstructured SIS results, the correlation coefficient was -0.663 (p = 0.001). There was no statistically significant correlation between life worth and modified Rankin Scale: r = -0.3383 (p = 0.087). Discussion Our findings of a statistically significant correlation between mRS and SIS have not previously been reported in patients with this condition. These findings provide further information to inform patient and next of kin discussions regarding outcomes from decompressive hemicraniectomy in malignant MCA infarction.
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Affiliation(s)
- Sanjay Budhdeo
- Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge
| | - Angelos G Kolias
- Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge
| | - David J Clark
- Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge
| | - Aswin Chari
- Division of Brain Sciences, Faculty of Medicine, Imperial College London
| | - Peter J Hutchinson
- Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge
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Mian AZ, Edasery D, Sakai O, Mustafa Qureshi M, Holsapple J, Nguyen T. Radiological imaging features of the basal ganglia that may predict progression to hemicraniectomy in large territory middle cerebral artery infarct. Neuroradiology 2017; 59:477-484. [DOI: 10.1007/s00234-017-1823-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 02/06/2017] [Indexed: 10/19/2022]
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Leung KY(Q, Jala S, Elliott R. Malignant middle cerebral artery infarct: A clinical case report. AUSTRALASIAN JOURNAL OF NEUROSCIENCE 2017. [DOI: 10.21307/ajon-2017-008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Neurologic Functional Outcomes of Decompressive Hemicraniectomy Versus Conventional Treatment for Malignant Middle Cerebral Artery Infarction: A Systematic Review and Meta-Analysis. World Neurosurg 2016; 99:709-725.e3. [PMID: 28024976 DOI: 10.1016/j.wneu.2016.12.069] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 12/12/2016] [Accepted: 12/15/2016] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The aims of this study were to evaluate decompressive hemicraniectomy (DHC) versus conventional treatment (CT) for patients with malignant middle cerebral artery (MCA) infarction and to investigate the impact of age and surgical timing on neurologic function and mortality. METHODS We searched English and Chinese databases for randomized controlled trials or observational studies published before August 2016. Outcomes included good functional outcome (GFO), mortality, and National Institutes of Health Stroke Scale and Barthel index scores. RESULTS This meta-analysis included 25 studies (1727 patients). There were statistically significant differences between DHC and CT groups in terms of GFO (P < 0.0001), mortality (P < 0.00001), and National Institutes of Health Stroke Scale and Barthel index scores (P < 0.0001) at different follow-up points. Significant differences were observed between the groups in survival with moderately severe disability (P < 0.00001); no differences were observed in survival with severe disability. In the subgroup analysis, in the DHC group, GFO was less in patients >60 years old (9.65%) versus ≤60 years old (38.94%); more patients >60 years old had moderately severe or severe disability (55.27%) compared with patients ≤60 years old (44.21%). CONCLUSIONS DHC could significantly improve GFO and reduces mortality of patients of all ages with malignant MCA infarction compared with CT, without increasing the number of patients surviving with severe disability. However, patients in the DHC group more frequently had moderately severe disability. Patients >60 years old with malignant MCA infarction had a higher risk of surviving with moderately severe or severe disability and less GFO.
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Alexander P, Heels-Ansdell D, Siemieniuk R, Bhatnagar N, Chang Y, Fei Y, Zhang Y, McLeod S, Prasad K, Guyatt G. Hemicraniectomy versus medical treatment with large MCA infarct: a review and meta-analysis. BMJ Open 2016; 6:e014390. [PMID: 27884858 PMCID: PMC5168488 DOI: 10.1136/bmjopen-2016-014390] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE Large middle cerebral artery stroke (space-occupying middle-cerebral-artery (MCA) infarction (SO-MCAi)) results in a very high incidence of death and severe disability. Decompressive hemicraniectomy (DHC) for SO-MCAi results in large reductions in mortality; the level of function in the survivors, and implications, remain controversial. To address the controversy, we pooled available randomised controlled trials (RCTs) that examined the impact of DHC on survival and functional ability in patients with large SO-MCAi and cerebral oedema. METHODS We searched MEDLINE, EMBASE and Cochrane library databases for randomised controlled trials (RCTs) enrolling patients suffering SO-MCAi comparing conservative management to DHC administered within 96 hours after stroke symptom onset. Outcomes were death and disability measured by the modified Rankin Scale (mRS). We used a random effects meta-analytical approach with subgroup analyses (time to treatment and age). We applied GRADE methods to rate quality/confidence/certainty of evidence. RESULTS 7 RCTs were eligible (n=338 patients). We found DHC reduced death (69-30% in medical vs surgical groups, 39% fewer), and increased the number of patients with mRS of 2-3 (slight to moderate disability: 14-27%, increase of 13%), those with mRS 4 (severe disability: 10-32%, increase of 22%) and those with mRS 5 (very severe disability 7-11%: increase of 4%) (all differences p<0.0001). We judged quality/confidence/certainty of evidence high for death, low for functional outcome mRS 0-3, and moderate for mRS 0-4 (wide CIs and problems in concealment, blinding of outcome assessors and stopping early). CONCLUSIONS DHC in SO-MCAi results in large reductions in mortality. Most of those who would otherwise have died are left with severe or very severe disability: for example, inability to walk and a requirement for help with bodily needs, though uncertainty about the proportion with very severe, severe and moderate disability remains (low to moderate quality/confidence/certainty evidence).
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Affiliation(s)
- Paul Alexander
- Department of Clinical Epidemiology and Biostatistics, Health Research Methods, McMaster University, Hamilton, Ontario, Canada
| | - Diane Heels-Ansdell
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Reed Siemieniuk
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, University of Toronto, Ontario, Ontario, Canada
| | - Neera Bhatnagar
- Medical Librarian, Health Sciences Library, McMaster University, Hamilton, Ontario, Canada
| | - Yaping Chang
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Yutong Fei
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Yuqing Zhang
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Shelley McLeod
- Department of Family and Community Medicine, Schwartz/Reisman Emergency Medicine Institute, University of Toronto, Toronto, Ontario, Canada
| | - Kameshwar Prasad
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Gordon Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Abstract
Malignant cerebral edema is a potential consequence of large territory cerebral infarction, as the resultant elevation in intracranial pressure may progress to transtentorial herniation, brainstem compression, and death. In appropriate patients, decompressive hemicraniectomy (DHC) reduces mortality without increasing the risk of severe disability. However, as the foundational DHC randomized, controlled trials excluded patients greater than 60 years of age, the appropriateness of DHC in older adults remains controversial. Recent clinical trials among elderly participants, including DESTINY II, reported that DHC reduces mortality, but may leave patients with substantial morbidity. Nationwide analyses have demonstrated generalizability of such data. However, what constitutes an acceptable outcome - the perspective on quality of life after survival with substantial disability - varies between clinicians, patients, and caregivers. Consequently, quality of life measures are being increasingly incorporated into stroke research. This review summarizes the impact of DHC in space-occupying cerebral infarction, and the influence of patient age on postoperative survival, functional capacity, and quality of life-all key factors in the clinical decision process. Ultimately, these data underscore the inherent complexity in balancing scientific evidence, clinical expertise, and patient and family preference when pursuing hemicraniectomy among the elderly.
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Affiliation(s)
- Faith C Robertson
- Harvard Medical School, Boston, Massachusetts, United States of America.,Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Hormuzdiyar H Dasenbrock
- Harvard Medical School, Boston, Massachusetts, United States of America.,Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.,Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - William B Gormley
- Harvard Medical School, Boston, Massachusetts, United States of America.,Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.,Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
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Miller K, Eljamel S. Does Size and Site Matter in Therapeutic Decompressive Craniectomy? A Laboratory-Based Experimental Study. World Neurosurg 2016; 95:441-446. [DOI: 10.1016/j.wneu.2016.08.061] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/12/2016] [Accepted: 08/13/2016] [Indexed: 11/30/2022]
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Qureshi AI, Ishfaq MF, Rahman HA, Thomas AP. Hemicraniectomy versus Conservative Treatment in Large Hemispheric Ischemic Stroke Patients: A Meta-analysis of Randomized Controlled Trials. J Stroke Cerebrovasc Dis 2016; 25:2209-14. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.03.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 03/27/2016] [Indexed: 10/21/2022] Open
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40
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Hankey GJ. Glyburide for cerebral oedema: could an old dog have a new trick? Lancet Neurol 2016; 15:1109-11. [PMID: 27567242 DOI: 10.1016/s1474-4422(16)30198-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 08/03/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Graeme J Hankey
- School of Medicine and Pharmacology, University of Western Australia, Perkins Institute of Medical Research, QEII Medical Centre, Perth 6009, WA, Australia; Department of Neurology, Sir Charles Gairdner Hospital, Perth, WA, Australia; Western Australian Neuroscience Research Institute, Perth, WA, Australia.
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Patient Age and the Outcomes after Decompressive Hemicraniectomy for Stroke: A Nationwide Inpatient Sample Analysis. Neurocrit Care 2016; 25:371-383. [DOI: 10.1007/s12028-016-0287-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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42
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Outcome Following Decompressive Hemicraniectomy for Malignant Cerebral Infarction. Stroke 2015; 46:2695-8. [DOI: 10.1161/strokeaha.115.010078] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 07/02/2015] [Indexed: 11/16/2022]
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Blacker DJ, Honeybul S. Decompressive hemicraniectomy in the management of extensive middle cerebral artery stroke: increased survival, at a price. Intern Med J 2015; 45:694-5. [DOI: 10.1111/imj.12811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 05/06/2015] [Indexed: 12/01/2022]
Affiliation(s)
- D. J. Blacker
- Department of Neurology; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- The Western Australian Neurosciences Research Institute; Perth Western Australia Australia
| | - S. Honeybul
- Department of Neurosurgery; Sir Charles Gairdner Hospital; Royal Perth Hospital; Fiona Stanley Hospital; Perth Western Australia Australia
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