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Attitudes of Nurses Toward Disability and Treatment in Space-Occupying Middle Cerebral Artery Stroke. Neurocrit Care 2019; 30:132-138. [PMID: 30073450 DOI: 10.1007/s12028-018-0586-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Attitudes toward the degree of acceptable disability and the importance of aphasia are critical in deciding on decompressive hemicraniectomy (DHC) in space-occupying middle cerebral artery stroke (SOS). The attitudes of nurses deserve strong attention, because of their close interaction with patients during acute stroke treatment. METHODS This is a multicenter survey among 627 nurses from 132 hospitals in Germany. Questions address the acceptance of disability, importance of aphasia, and the preferred treatment in the hypothetical case of SOS. RESULTS Modified Rankin Scale (mRS) scores of 1 and 2 were considered acceptable by the majority of all respondents (89.7%). A mRS of 3, 4, and 5 was considered acceptable by 60.0, 15.5, and 1.6%, respectively. DHC was indicated as the treatment of choice in 31.4%. Every third participant considered the presence of aphasia important for treatment decision (33.3%). Older respondents more often refrained from DHC, irrespective of the presence of aphasia (dominant hemisphere p = 0.001, non-dominant hemisphere p = 0.004). Differences regarding acceptable disability and treatment decision were dependent on age, sex, and having relatives with stroke. CONCLUSION Most German nurses indicate moderately severe disability after SOS not to be acceptable, without emphasizing the presence of aphasia. The results call for greater scientific efforts in order to find reliable predictors for outcome after SOS.
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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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Neugebauer H, Schnabl M, Lulé D, Heuschmann PU, Jüttler E. Attitudes of Patients and Relatives Toward Disability and Treatment in Malignant MCA Infarction. Neurocrit Care 2017; 26:311-318. [PMID: 27966092 DOI: 10.1007/s12028-016-0362-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Attitudes among patients and relatives toward the degree of acceptable disability and the importance of aphasia are critical in deciding on decompressive hemicraniectomy (DHC) in malignant middle cerebral artery infarction (MMI). However, most MMI patients are not able to communicate their will. Furthermore, attitudes of healthy individuals and relatives may not correspond to those of stroke patients. METHODS This is a multicenter survey among 355 patients and 199 relatives during treatment for acute minor or moderate severe ischemic stroke in Germany. Questions address the acceptance of disability, importance of aphasia, and the preferred treatment in the hypothetical case of future MMI. RESULTS mRS scores of 2 or better were considered acceptable by the majority of all respondents (72.9-88.1%). A mRS of 3, 4, and 5 was considered acceptable by 56.0, 24.5, and 6.8%, respectively. Except for a mRS of 1, relatives indicated each grade of disability significantly more often acceptable than patients. Differences regarding acceptable disability and treatment decision were depending on family status, housing situation, need of care, and disability. The presence of aphasia was considered important for treatment decision by both patients (46.5%) and relatives (39.2%). Older respondents more often refrained from DHC (p < 0.001). CONCLUSION In Germany, there is substantial heterogeneity in patients and relatives regarding acceptable disability, aphasia, and treatment decision in the hypothetical case of MMI. Relatives significantly overestimate the degree of disability that is acceptable to stroke patients. Further studies are warranted to determine whether differences in attitudes impact on the decision to undergo DHC.
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Affiliation(s)
- Hermann Neugebauer
- Department of Neurology, University of Ulm, Ulm, Germany.
- RKU - University and Rehabilitation Hospitals Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany.
| | - Matthias Schnabl
- Department of Trauma Surgery and Orthopedics, Community Hospital Kliniken Nordoberpfalz AG Klinikum Weiden, Weiden in der Oberpfalz, Germany
| | - Dorothée Lulé
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Peter U Heuschmann
- Institute for Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
| | - Eric Jüttler
- Department of Neurology, University of Ulm, Ulm, Germany
- Department of Neurology, Ostalb-Klinikum Aalen, Aalen, Germany
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