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Abdulla E, Das K, Sridharan K, Waheed M, Abdulla F, Ravindra J, Luther H, Wireko AA. Prognostic variables predict clinical outcome after decompressive craniectomy: A single institute experience; A retrospective study. Medicine (Baltimore) 2024; 103:e36876. [PMID: 38181236 PMCID: PMC10766213 DOI: 10.1097/md.0000000000036876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/15/2023] [Indexed: 01/07/2024] Open
Abstract
Decompressive craniectomy (DC) is a well-established neurosurgical intervention in patients with high intracranial pressure who fail to respond to medical treatment. Data on predictive factors for functional outcomes in patients with DC who have malignant middle cerebral artery (MCA) infarction as opposed to intracranial hemorrhage (ICH) are scarce. Eighty-four patients who underwent DC treatment for ICH and malignant MCA infarction were examined. All patients underwent surgery in the Bahrain Salmaniya Medical Complex Neurosurgery Unit between January 2017 and June 2021. To determine whether any of these demonstrated a link to the functional outcome, radiographic factors were compared with clinical data. The postsurgical midline shift (MLS) (ICH group) showed the strongest correlation (ρ = 0.434; P = .006), as in the MCA infarction group as well (ρ = 0.46; P = .005). Further analyses using binary logistic regression with postsurgical basal cistern status and ∆ MLS, and it was observed to be statistically significant (odds ratios: 0.067, 95% CI: 0.007, 0.67; P = .021). The initial Glasgow coma scale, postsurgical MLS, basal cistern status, and ∆ are Measurable variables that can be used to predict outcomes in the groups with ICH and MCA infarction.
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Affiliation(s)
- Ebtesam Abdulla
- Department of Neurosurgery, Salmaniya Medical Complex, Manama, Bahrain
| | - Krishna Das
- Department of Neurosurgery, Salmaniya Medical Complex, Manama, Bahrain
| | - Kannan Sridharan
- Department of Pharmacology and Therapeutics, Arabian Gulf University, Manama, Bahrain
| | - Mohammed Waheed
- Department of Neurosurgery, Salmaniya Medical Complex, Manama, Bahrain
| | - Fatima Abdulla
- Department of Neurology, Salmaniya Medical Complex, Manama, Bahrain
| | - Joseph Ravindra
- Department of Neurosurgery, Salmaniya Medical Complex, Manama, Bahrain
| | - Harleen Luther
- Department of Neurosurgery, Salmaniya Medical Complex, Manama, Bahrain
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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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3
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Buffagni D, Zamarron A, Melgosa I, Gutierrez-Gonzalez R. Long-term quality of life after decompressive craniectomy. Front Neurol 2023; 14:1222080. [PMID: 37564730 PMCID: PMC10410286 DOI: 10.3389/fneur.2023.1222080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/03/2023] [Indexed: 08/12/2023] Open
Abstract
Introduction This study aims to assess the quality of life (QoL) in patients who have undergone decompressive craniectomy (DC) for any pathology that has caused life-threatening intracranial hypertension. Similarly, it aims to evaluate QoL perceived by caregivers or external informants. In addition to that, the last purpose is to determine which clinical or therapeutic factors could correlate with a better QoL. Methods A single-center cross-sectional study was designed. All patients over 18 years old who underwent a supratentorial DC at our department due to intracranial hypertension of any etiology, from January 2015 to December 2021, were retrospectively selected. Patients with incomplete follow-up (under 1 year from the event or those who died) or who declined to participate in the study were excluded. QoL was assessed with SF-36 and CAVIDACE scales. The correlation between clinical and therapeutic variables and SF-36 subscales was studied with Spearman's correlation and the Mann-Whitney U-test. Results A total of 55 consecutive patients were recruited: 22 patients had died, three were missed for follow-up, and 15 declined to participate, thus 15 subjects were finally included. The mean follow-up was 47 months (IQR 21.5-67.5). A significant reduction in the "role physical" and "role emotional" subscales of SF-36 was observed compared with the general population. According to caregivers, a significant reduction was assigned to the "physical wellbeing" and "rights" domains. The "physical functioning" score was poorer in women, older patients, those with dominant hemisphere disease, those who required tracheostomy, and those with poor outcomes in the modified Rankin scale. A strong correlation was found between the QoL index at the CAVIDACE scale and the SF-36 subscales "physical functioning" and "role physical". Conclusion Most patients and caregivers reported acceptable QoL after DC due to a life-threatening disease. A significant reduction in SF- 36 subscales scores "role limitation due to physical problems" and "role limitation due to emotional problems" was referred by patients. According to caregivers' QoL perception, only 25% of the survey's participants showed low scores in the QoL index of the CAVIDACE scale. Only 26.7% of the patients showed mood disorders.
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Affiliation(s)
- Daniel Buffagni
- Department of Surgery, Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Alvaro Zamarron
- Department of Neurosurgery, Puerta de Hierro University Hospital, IDIPHISA, Madrid, Spain
| | - Isabel Melgosa
- Department of Anesthesiology, Marques de Valdecilla University Hospital, Santander, Spain
| | - Raquel Gutierrez-Gonzalez
- Department of Surgery, Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
- Department of Neurosurgery, Puerta de Hierro University Hospital, IDIPHISA, Madrid, Spain
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4
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Lehrieder D, Müller HP, Kassubek J, Hecht N, Thomalla G, Michalski D, Gattringer T, Wartenberg KE, Schultze-Amberger J, Huttner H, Kuramatsu JB, Wunderlich S, Steiner HH, Weissenborn K, Heck S, Günther A, Schneider H, Poli S, Dohmen C, Woitzik J, Jüttler E, Neugebauer H. Large diameter hemicraniectomy does not improve long-term outcome in malignant infarction. J Neurol 2023:10.1007/s00415-023-11766-3. [PMID: 37162579 DOI: 10.1007/s00415-023-11766-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/11/2023]
Abstract
INTRODUCTION In malignant cerebral infarction decompressive hemicraniectomy has demonstrated beneficial effects, but the optimum size of hemicraniectomy is still a matter of debate. Some surgeons prefer a large-sized hemicraniectomy with a diameter of more than 14 cm (HC > 14). We investigated whether this approach is associated with reduced mortality and an improved long-term functional outcome compared to a standard hemicraniectomy with a diameter of less than 14 cm (HC ≤ 14). METHODS Patients from the DESTINY (DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY) registry who received hemicraniectomy were dichotomized according to the hemicraniectomy diameter (HC ≤ 14 cm vs. HC > 14 cm). The primary outcome was modified Rankin scale (mRS) score ≤ 4 after 12 months. Secondary outcomes were in-hospital mortality, mRS ≤ 3 and mortality after 12 months, and the rate of hemicraniectomy-related complications. The diameter of the hemicraniectomy was examined as an independent predictor of functional outcome in multivariable analyses. RESULTS Among 130 patients (32.3% female, mean (SD) age 55 (11) years), the mean hemicraniectomy diameter was 13.6 cm. 42 patients (32.3%) had HC > 14. There were no significant differences in the primary outcome and mortality by size of hemicraniectomy. Rate of complications did not differ (HC ≤ 14 27.6% vs. HC > 14 36.6%, p = 0.302). Age and infarct volume but not hemicraniectomy diameter were associated with outcome in multivariable analyses. CONCLUSION In this post-hoc analysis, large hemicraniectomy was not associated with an improved outcome or lower mortality in unselected patients with malignant middle cerebral artery infarction. Randomized trials should further examine whether individual patients could benefit from a large-sized hemicraniectomy. CLINICAL TRIAL REGISTRATION INFORMATION German Clinical Trials Register (URL: https://www.drks.de ; Unique Identifier: DRKS00000624).
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Affiliation(s)
- Dominik Lehrieder
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany.
| | | | - Jan Kassubek
- Department of Neurology, University Hospital Ulm, Ulm, Germany
| | - Nils Hecht
- Department of Neurosurgery and Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dominik Michalski
- Department of Neurology, University Hospital Leipzig, Leipzig, Germany
| | | | - Katja E Wartenberg
- Department of Neurology, University Hospital Leipzig, Leipzig, Germany
- Department of Neurology, University of Halle-Wittenberg, Halle/Saale, Germany
| | | | - Hagen Huttner
- Department of Neurology, University Hospital Giessen, Giessen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Silke Wunderlich
- Department of Neurology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | | | - Suzette Heck
- Department of Neurology, University of Munich, Ludwig Maximilian University, Munich, Germany
| | - Albrecht Günther
- Department of Neurology, University Hospital Jena, Jena, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital Dresden, Dresden, Germany
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Sven Poli
- Department of Neurology and Stroke, Eberhard-Karls University Tuebingen, Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Christian Dohmen
- Department of Neurology, University Hospital Cologne, Cologne, Germany
- Department for Neurology and Neurological Intensive Care, LVR Clinic Bonn, Bonn, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, University Hospital Oldenburg, Oldenburg, Germany
| | - Eric Jüttler
- Department of Neurology, Ostalb-Klinikum Aalen, Aalen, Germany
| | - Hermann Neugebauer
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
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5
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Decompressive hemicraniectomy versus medical treatment for malignant middle cerebral artery infarction: Eleven years experience in a Tunisian center. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Lim JX, Liu SJ, Cheong TM, Saffari SE, Han JX, Chen MW. Intracranial Pressure as an Objective Biomarker of Decompression Adequacy in Large Territory Infarction: A Multicenter Observational Study. Front Surg 2022; 9:823899. [PMID: 35769152 PMCID: PMC9235838 DOI: 10.3389/fsurg.2022.823899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 04/06/2022] [Indexed: 12/21/2022] Open
Abstract
Background Decompressive craniectomy (DC) improves the survival and functional outcomes in patients with malignant cerebral infarction. Currently, there are no objective intraoperative markers that indicates adequate decompression. We hypothesise that closure intracranial pressure (ICP) correlates with postoperative outcomes. Methods This is a multicentre retrospective review of all 75 DCs performed for malignant cerebral infarction. The patients were divided into inadequate ICP (iICP) and good ICP (gICP) groups based on a suitable ICP threshold determined with tiered receiver operating characteristic and association analysis. Multivariable logistic regression was performed for various postoperative outcomes. Results An ICP threshold of 7 mmHg was determined, with 36 patients (48.0%) and 39 patients (52.0%) in the iICP and gICP group, respectively. After adjustment, postoperative osmotherapy usage was more likely in the iICP group (OR 6.32, p = 0.003), and when given, was given for a longer median duration (iICP, 4 days; gICP, 1 day, p = 0.003). There was no difference in complications amongst both groups. When an ICP threshold of 11 mmHg was applied, there was significant difference in the duration on ventilator (ICP ≥11 mmHg, 3–9 days, ICP <11 mmHg, 3–5 days, p = 0.023). Conclusion Surgical decompression works complementarily with postoperative medical therapy to manage progressive cerebral edema in malignant cerebral infarctions. This is a retrospective study which showed that closure ICP, a novel objective intraoperative biomarker, is able to guide the adequacy of DC in this condition. Various surgical manoeuvres can be performed to ensure that this surgical aim is accomplished.
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Affiliation(s)
- Jia Xu Lim
- National Neuroscience Institute, Department of Neurosurgery, Singhealth, Singapore, Singapore
- Correspondence: Jia Xu Lim
| | - Sherry Jiani Liu
- National Neuroscience Institute, Department of Neurosurgery, Singhealth, Singapore, Singapore
| | - Tien Meng Cheong
- National Neuroscience Institute, Department of Neurosurgery, Singhealth, Singapore, Singapore
| | - Seyed Ehsan Saffari
- Center for Qualitative Medicine, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Julian Xinguang Han
- National Neuroscience Institute, Department of Neurosurgery, Singhealth, Singapore, Singapore
| | - Min Wei Chen
- National Neuroscience Institute, Department of Neurosurgery, Singhealth, Singapore, Singapore
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7
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Sheth KN, Yuen MM, Mazurek MH, Cahn BA, Prabhat AM, Salehi S, Shah JT, By S, Welch EB, Sofka M, Sacolick LI, Kim JA, Payabvash S, Falcone GJ, Gilmore EJ, Hwang DY, Matouk C, Gordon-Kundu B, Rn AW, Petersen N, Schindler J, Gobeske KT, Sansing LH, Sze G, Rosen MS, Kimberly WT, Kundu P. Bedside detection of intracranial midline shift using portable magnetic resonance imaging. Sci Rep 2022; 12:67. [PMID: 34996970 PMCID: PMC8742125 DOI: 10.1038/s41598-021-03892-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 12/02/2021] [Indexed: 12/17/2022] Open
Abstract
Neuroimaging is crucial for assessing mass effect in brain-injured patients. Transport to an imaging suite, however, is challenging for critically ill patients. We evaluated the use of a low magnetic field, portable MRI (pMRI) for assessing midline shift (MLS). In this observational study, 0.064 T pMRI exams were performed on stroke patients admitted to the neuroscience intensive care unit at Yale New Haven Hospital. Dichotomous (present or absent) and continuous MLS measurements were obtained on pMRI exams and locally available and accessible standard-of-care imaging exams (CT or MRI). We evaluated the agreement between pMRI and standard-of-care measurements. Additionally, we assessed the relationship between pMRI-based MLS and functional outcome (modified Rankin Scale). A total of 102 patients were included in the final study (48 ischemic stroke; 54 intracranial hemorrhage). There was significant concordance between pMRI and standard-of-care measurements (dichotomous, κ = 0.87; continuous, ICC = 0.94). Low-field pMRI identified MLS with a sensitivity of 0.93 and specificity of 0.96. Moreover, pMRI MLS assessments predicted poor clinical outcome at discharge (dichotomous: adjusted OR 7.98, 95% CI 2.07–40.04, p = 0.005; continuous: adjusted OR 1.59, 95% CI 1.11–2.49, p = 0.021). Low-field pMRI may serve as a valuable bedside tool for detecting mass effect.
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Affiliation(s)
- Kevin N Sheth
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA.
| | - Matthew M Yuen
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Mercy H Mazurek
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Bradley A Cahn
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Anjali M Prabhat
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | | | - Jill T Shah
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | | | | | | | | | - Jennifer A Kim
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | | | - Guido J Falcone
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Emily J Gilmore
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - David Y Hwang
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Barbara Gordon-Kundu
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Adrienne Ward Rn
- Neuroscience Intensive Care Unit, Yale New Haven Hospital, New Haven, CT, USA
| | - Nils Petersen
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Joseph Schindler
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Kevin T Gobeske
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Lauren H Sansing
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Gordon Sze
- Department of Neuroradiology, Yale School of Medicine, New Haven, CT, USA
| | - Matthew S Rosen
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - W Taylor Kimberly
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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Decompressive Craniectomy for Infarction and Intracranial Hemorrhages. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00078-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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9
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Abstract
Large hemispheric infarcts occur in up to 10% of all ischemic strokes and can cause devastating disability. Significant research and clinical efforts have been made in hopes of mitigating the morbidity and mortality of this disease. Areas of interest include identifying predictors of malignant edema, optimizing medical and surgical techniques, selecting the patient population that would benefit most from decompressive hemicraniectomy, and studying the impact on quality of life of those who survive. Decompressive surgery can be a life-saving measure, and here we discuss the most up-to-date literature and provide a review on the surgical management of large hemispheric ischemic strokes.
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Affiliation(s)
- Jessica Lin
- Division of Neurocritical Care, Department of Neurology, New York University Langone Health (J.L., J.A.F.), New York, NY.,Department of Neurology, Bellevue Hospital Center (J.L.), New York, NY
| | - Jennifer A Frontera
- Division of Neurocritical Care, Department of Neurology, New York University Langone Health (J.L., J.A.F.), New York, NY
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10
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Panagopoulos D, Karydakis P, Markogiannakis G, Themistocleous M. Pediatric arterial ischemic stroke: Overview of the literature and of the most cited relevant articles. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.100924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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11
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Schwake M, Schipmann S, Müther M, Stögbauer L, Hanning U, Sporns PB, Ewelt C, Dziewas R, Minnerup J, Holling M, Stummer W. Second-look strokectomy of cerebral infarction areas in patients with severe herniation. J Neurosurg 2019; 132:1-9. [PMID: 30611135 DOI: 10.3171/2018.8.jns18692] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/14/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Decompressive craniectomies (DCs) are performed on patients suffering large cerebral infarctions. The efficacy of this procedure has been demonstrated in several trials. In some cases, however, this procedure alone is not sufficient and patients still suffer refractory elevations of intracranial pressure (ICP). The goal of this study was to determine whether resection of infarcted tissue, termed strokectomy, performed as a second-look procedure after DC, improves outcome in selected cases. METHODS The authors retrospectively evaluated data of patients who underwent a DC due to a cerebral infarction at their institution from 2009 to 2016, including patients who underwent a strokectomy procedure after DC. Clinical records, imaging data, outcome scores, and neurological symptoms were analyzed, and clinical outcomes and mortality rates in the strokectomy group were compared to those for similar patients in recently published randomized controlled trials. RESULTS Of 198 patients who underwent DC due to cerebral infarction, 12 patients underwent strokectomy as a second surgical procedure, with a median National Institutes of Health Stroke Scale (NIHSS) score of 19 for patients with versus 16 for those without secondary strokectomy (p = 0.029). Either refractory increases of ICP > 20 mm Hg or dilated pupils in addition to herniation visible on CT images were triggers for strokectomy surgery. Ten of 12 (83%) patients had infarctions in more than one territory (p < 0.001). After 12 months, 43% of patients had a good outcome according to the modified Rankin Scale (mRS) score (≤ 3). In the subgroup of patients suffering infarctions in more than one vascular territory, functional outcome after 12 months was better (mRS ≤ 3 in 40% of patients in comparison to 9%; p = 0.027). A 1:3 case-control analysis matched to age, side of infarction, sex, and vascular territory confirmed these results (mRS ≤ 3, 42% in comparison to 11%; p = 0.032). Age, NIHSS score on admission, and number of vascular territories involved were identified as risk factors in multivariate analysis (p < 0.05). Patients in the strokectomy group had more infections (p < 0.001). According to these results, the authors developed a scale (Münster Stroke Score, 0-6 points) to predict whether patients might benefit from additional strokectomy. Receiver-operating characteristic (ROC) curve analysis revealed an area under the curve (AUC) of 0.86 (p < 0.001). The authors recommend a Münster Stroke Score of ≥ 3 as a cutoff, with a sensitivity of 92% and specificity of 66%, for predicting benefit from strokectomy. CONCLUSIONS In this study in comparison to former studies, mortality rates were lower and clinical outcome was comparable to that of previously published trials regarding large cerebral infarctions. Second surgery including strokectomy may help achieve better outcomes, especially in cases of infarction of more than one vascular territory.
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Affiliation(s)
- Michael Schwake
- 1Department of Neurosurgery, University Hospital Münster, Münster
| | | | - Michael Müther
- 1Department of Neurosurgery, University Hospital Münster, Münster
| | - Louise Stögbauer
- 1Department of Neurosurgery, University Hospital Münster, Münster
| | - Uta Hanning
- 2Institute for Clinical Radiology, Münster
- 3Department of Diagnostic and Interventional Neuroradiology, University of Hamburg, Hamburg; and
| | | | - Christian Ewelt
- 1Department of Neurosurgery, University Hospital Münster, Münster
| | - Rainer Dziewas
- 4Department of Neurology, University Hospital Münster, Münster, Germany
| | - Jens Minnerup
- 4Department of Neurology, University Hospital Münster, Münster, Germany
| | - Markus Holling
- 1Department of Neurosurgery, University Hospital Münster, Münster
| | - Walter Stummer
- 1Department of Neurosurgery, University Hospital Münster, Münster
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Khurana D, Padma MV, Bhatia R, Kaul S, Pandian J, Sylaja PN, Arjundas D, Uppal A, Pradeep VG, Suri V, Nagaraja D, Alurkar A, Narayan S. Recommendations for the Early Management of Acute Ischemic Stroke: A Consensus Statement for Healthcare Professionals from the Indian Stroke Association. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/2516608518777935] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dheeraj Khurana
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | - Rohit Bhatia
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Subhash Kaul
- Nizam’s Institute of Medical Sciences (NIMS), Hyderabad, India
| | | | - P. N. Sylaja
- Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum, India
| | | | | | | | - Vinit Suri
- Indraprastha Apollo Hospital, New Delhi, India
| | - D. Nagaraja
- National Institute of Mental Health & Neuro Sciences (NIMHANS), Hyderabad, India
| | | | - Sunil Narayan
- Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
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13
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Estimation of the Craniectomy Surface Area by Using Postoperative Images. Int J Biomed Imaging 2018; 2018:5237693. [PMID: 29971096 PMCID: PMC6008696 DOI: 10.1155/2018/5237693] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 04/24/2018] [Indexed: 11/30/2022] Open
Abstract
Decompressive craniectomy (DC) is a neurosurgical procedure performed to relieve the intracranial pressure engendered by brain swelling. However, no easy and accurate method exists for determining the craniectomy surface area. In this study, we implemented and compared three methods of estimating the craniectomy surface area for evaluating the decompressive effort. We collected 118 sets of preoperative and postoperative brain computed tomography images from patients who underwent craniectomy procedures between April 2009 and April 2011. The surface area associated with each craniectomy was estimated using the marching cube and quasi-Monte Carlo methods. The surface area was also estimated using a simple AC method, in which the area is calculated by multiplying the craniectomy length (A) by its height (C). The estimated surface area ranged from 9.46 to 205.32 cm2, with a median of 134.80 cm2. The root-mean-square deviation (RMSD) between the marching cube and quasi-Monte Carlo methods was 7.53 cm2. Furthermore, the RMSD was 14.45 cm2 between the marching cube and AC methods and 12.70 cm2 between the quasi-Monte Carlo and AC methods. Paired t-tests indicated no statistically significant difference between these methods. The marching cube and quasi-Monte Carlo methods yield similar results. The results calculated using the AC method are also clinically acceptable for estimating the DC surface area. Our results can facilitate additional studies on the association of decompressive effort with the effect of craniectomy.
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14
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Hecht N, Neugebauer H, Fiss I, Pinczolits A, Vajkoczy P, Jüttler E, Woitzik J. Infarct volume predicts outcome after decompressive hemicraniectomy for malignant hemispheric stroke. J Cereb Blood Flow Metab 2018; 38:1096-1103. [PMID: 28665171 PMCID: PMC5999005 DOI: 10.1177/0271678x17718693] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The decision to perform decompressive hemicraniectomy (DHC) by default in malignant hemispheric stroke (MHS) remains controversial. Even under ideal conditions, DHC usually results in moderate to severe disability. The present study for the first time uses neuroimaging to identify independent outcome predictors in a prospective cohort of 96 MHS patients undergoing DHC. The primary outcome was functional status according to the modified Rankin Scale (mRS) at 12 months and categorized as favorable (mRS 0-3) or unfavorable (mRS 4-6). At 12 months, 19 patients (20%) reached favorable and 77 patients (80%) unfavorable outcome. The overall mean infarct volume was 328 ± 114 ml. Multivariable logistic regression identified age per year (OR 1.14, 95% CI 1.04-1.24; p = 0.005), infarct volume per cm3 (OR 1.012, 95% CI 1.003-1.022; p = 0.013), thalamic involvement (OR 8.65, 95% CI 1.04-72.15; p = 0.046) and postoperative pneumonia (OR 5.52, 95% CI 1.03-29.57; p = 0.046) as independent outcome predictors, which was confirmed by multivariable ordinal regression for age ( p = 0.004) and infarct volume ( p = 0.015). The infarct volume threshold for reasonable prediction of unfavorable outcome in our patients was 270 cm3, which in the future may help prognostication and development of clinical trials on DHC and outcome in MHS.
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Affiliation(s)
- Nils Hecht
- 1 Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Ingo Fiss
- 3 Department of Neurosurgery, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Alexandra Pinczolits
- 1 Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- 1 Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Eric Jüttler
- 2 Department of Neurology, Universitätsklinikum Ulm, Ulm, Germany.,4 Department of Neurology, Ostalb-Klinikum Aalen, Aalen, Germany
| | - Johannes Woitzik
- 1 Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
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15
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Hinduja A, Samant R, Feng D, Hannawi Y. Herniation despite Decompressive Hemicraniectomy in Large Hemispherical Ischemic Strokes. J Stroke Cerebrovasc Dis 2018; 27:418-424. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/04/2017] [Accepted: 09/14/2017] [Indexed: 01/25/2023] Open
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16
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Utilization of long-term care after decompressive hemicraniectomy for severe stroke among older patients. Aging Clin Exp Res 2017; 29:631-638. [PMID: 27495258 DOI: 10.1007/s40520-016-0615-5] [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: 06/05/2016] [Accepted: 07/26/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND While clinical trial data support decompressive hemicraniectomy (DHC) as improving survival among patients with severe ischemic stroke, quality of life outcomes among older persons remain controversial. AIMS To aid decision-making and understand practice variation, we measured long-term outcomes and patterns of regional variation for a nationwide cohort of ischemic stroke patients after DHC. METHODS Medicare fee-for-service ischemic stroke cases over age 65 during the year 2008 were used to create a cohort followed for 2 years (2009-2010) after stroke and DHC procedure. Rates of mortality, acute hospital readmission, and long-term care (LTC) utilization were calculated. Multiple logistic regression was used to identify individual predictors of institutional LTC. Regional variation in DHC was calculated through aggregation and merging with the state-level data. RESULTS Among 397,503 acute ischemic stroke patients, 130 (0.03 %) underwent DHC. Mean age was 72 years, and 75 % were between the ages of 65 and 74. Mortality was highest (38 %) within the first 30 days. At 2 years, 59 % of the original cohort had died. The 30-day rate of acute hospital readmission was 25 %. Among survivors, 75 % returned home 1 year after index stroke admission. States with higher per capita health expenditures were associated with wider variation in utilization of DHC. CONCLUSIONS There is a high rate of mortality among older stroke patients undergoing DHC. Although most survivors of DHC are not permanently institutionalized, there is wide variation in utilization of DHC across the USA.
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17
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Revisiting Hemicraniectomy: Late Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke and the Role of Infarct Growth Rate. Stroke Res Treat 2017; 2017:2507834. [PMID: 28409051 PMCID: PMC5376465 DOI: 10.1155/2017/2507834] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 02/22/2017] [Indexed: 11/25/2022] Open
Abstract
Objective and Methods. The outcome in late decompressive hemicraniectomy in malignant middle cerebral artery stroke and the optimal timings of surgery has not been addressed by the randomized trials and pooled analysis. Retrospective, multicenter, cross-sectional study to measure outcome following DHC under 48 or over 48 hours using the modified Rankin scale [mRS] and dichotomized as favorable ≤4 or unfavorable >4 at three months. Results. In total, 137 patients underwent DHC. Functional outcome analyzed as mRS 0–4 versus mRS 5-6 showed no difference in this split between early and late operated on patients [P = 0.140] and mortality [P = 0.975]. Multivariate analysis showed that age ≥ 55 years, MCA with additional infarction, septum pellucidum deviation ≥1 cm, and uncal herniation were independent predictors of poor functional outcome at three months. In the “best” multivariate model, second infarct growth rate [IGR2] >7.5 ml/hr, MCA with additional infarction, and patients with temporal lobe involvement were independently associated with surgery under 48 hours. Both first infarct growth rate [IGR1] and second infarct growth rate [IGR2] were nearly double [P < 0.001] in patients with early surgery [under 48 hours]. Conclusions. The outcome and mortality in malignant middle cerebral artery stroke patients operated on over 48 hours of stroke onset were comparable to those of patients operated on less than 48 hours after stroke onset. Our data identifies IGR, temporal lobe involvement, and middle cerebral artery with additional infarct as independent predictors for early surgery.
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18
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Ragland J, Lee K. Critical Care Management and Monitoring of Intracranial Pressure. JOURNAL OF NEUROCRITICAL CARE 2016. [DOI: 10.18700/jnc.160101] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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19
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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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20
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Yoo BR, Yoo CJ, Kim MJ, Kim WK, Choi DH. Analysis of the Outcome and Prognostic Factors of Decompressive Craniectomy between Young and Elderly Patients for Acute Middle Cerebral Artery Infarction. J Cerebrovasc Endovasc Neurosurg 2016; 18:175-184. [PMID: 27847759 PMCID: PMC5104840 DOI: 10.7461/jcen.2016.18.3.175] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 09/05/2016] [Accepted: 09/15/2016] [Indexed: 11/23/2022] Open
Abstract
Objective We compared the effect of decompressive craniectomy between patients < 65 and ≥ 65 years age and investigated prognostics factors that may help predict favorable outcome in acute stroke patients undergoing decompressive surgery. Materials and Methods 52 patients diagnosed with acute middle cerebral artery (MCA) territory infarction that underwent decompressive craniectomy were retrospectively reviewed. The outcome of all patients were evaluated by assessing the Glasgow coma scale, Glasgow outcome scale (GOS), and Modified Rankin scale (mRS) six months after the onset of the disease. 21 patients were preoperatively evaluated with a computed tomography angiography (CTA). Leptomeningeal collateral (LMC) circulation was graded using CTA by experienced neurosurgeons to assess its prognostic value. Results The thirty day mortality for patients ≥ 65 was 35.0% compared to 37.5% in patients < 65. There was no significant difference in the clinical and function outcome between the two groups (4.8 ± 1.2 vs. 4.5 ± 1.5, p = 0.474). Mortality was lower with early surgery (within 24 hours) group for both age groups (25% vs. 37.5% in ≥ 65, 20% vs. 40.7% in < 65). Longer intensive care units stay time and good collateral supply score were correlated with favorable outcome (p = 0.028, p = 0.018). Conclusion Decompressive craniectomy within 24 hours of stroke symptom onset improved survival in both the < 65 and ≥ 65 age groups. There was no significant difference in the functional outcome of both age groups. Unlike previous reports, old age, delayed operation, and multiple of infarct territories were not predictive of poor functional outcome. The presence of good collateral circulation may be a predictor of positive clinical outcome in acute ischemic stroke patients undergoing decompressive craniectomy.
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Affiliation(s)
- Byung Rhae Yoo
- Department of Neurosurgery, Gachon University, Gil Medical Center, Incheon, Korea
| | - Chan Jong Yoo
- Department of Neurosurgery, Gachon University, Gil Medical Center, Incheon, Korea
| | - Myeong Jin Kim
- Department of Neurosurgery, Gachon University, Gil Medical Center, Incheon, Korea
| | - Woo-Kyung Kim
- Department of Neurosurgery, Gachon University, Gil Medical Center, Incheon, Korea
| | - Dae Han Choi
- Department of Neurosurgery, Gachon University, Gil Medical Center, Incheon, Korea
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21
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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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22
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Torbey MT, Bösel J, Rhoney DH, Rincon F, Staykov D, Amar AP, Varelas PN, Jüttler E, Olson D, Huttner HB, Zweckberger K, Sheth KN, Dohmen C, Brambrink AM, Mayer SA, Zaidat OO, Hacke W, Schwab S. Evidence-based guidelines for the management of large hemispheric infarction : a statement for health care professionals from the Neurocritical Care Society and the German Society for Neuro-intensive Care and Emergency Medicine. Neurocrit Care 2016; 22:146-64. [PMID: 25605626 DOI: 10.1007/s12028-014-0085-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Large hemispheric infarction (LHI), also known as malignant middle cerebral infarction, is a devastating disease associated with significant disability and mortality. Clinicians and family members are often faced with a paucity of high quality clinical data as they attempt to determine the most appropriate course of treatment for patients with LHI, and current stroke guidelines do not provide a detailed approach regarding the day-to-day management of these complicated patients. To address this need, the Neurocritical Care Society organized an international multidisciplinary consensus conference on the critical care management of LHI. Experts from neurocritical care, neurosurgery, neurology, interventional neuroradiology, and neuroanesthesiology from Europe and North America were recruited based on their publications and expertise. The panel devised a series of clinical questions related to LHI, and assessed the quality of data related to these questions using the Grading of Recommendation Assessment, Development and Evaluation guideline system. They then developed recommendations (denoted as strong or weak) based on the quality of the evidence, as well as the balance of benefits and harms of the studied interventions, the values and preferences of patients, and resource considerations.
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Affiliation(s)
- Michel T Torbey
- Cerebrovascular and Neurocritical Care Division, Department of Neurology and Neurosurgery, The Ohio State University Wexner Medical Center Comprehensive Stroke Center, 395 W. 12th Avenue, 7th Floor, Columbus, OH, 43210, USA,
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Neugebauer H, Jüttler E, Mitchell P, Hacke W. Decompressive Craniectomy for Infarction and Hemorrhage. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00076-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sauvigny T, Göttsche J, Vettorazzi E, Westphal M, Regelsberger J. New Radiologic Parameters Predict Clinical Outcome after Decompressive Craniectomy. World Neurosurg 2015; 88:519-525.e1. [PMID: 26548831 DOI: 10.1016/j.wneu.2015.10.072] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 10/18/2015] [Accepted: 10/19/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Decompressive craniectomy (DC) is an established part of the management of patients with increased intracranial pressure due to malignant middle cerebral artery (MCA) infarction or traumatic brain injury (TBI). The aim of this study was to determine prognostic radiologic parameters regarding the functional outcome of patients with increased intracranial pressure (ICP) undergoing DC. Special focus was put on the potential differences between malignant MCA infarction and TBI. METHODS A total of 113 patients were analyzed for their clinical course where preoperative and postoperative radiologic features in computed tomography (CT) scans were correlated to the clinical outcome assessed by the Glasgow Outcome Scale. The difference between presurgical and postsurgical midline shift (ΔMLS) and the ratio between the diameter of the affected and contralateral hemisphere (HDratio) in presurgical and postsurgical CT scans were calculated. RESULTS ΔMLS (MCA infarction group) and postsurgical HDratio (TBI group) were found to be highly correlating with the clinical outcome on Spearman-correlation testing and underwent further analysis using a binary logistic regression model to evaluate their prognostic value on the outcome, which showed the predictive power of ΔMLS in malignant MCA infarction patients (odds ratio [OR] 0.715; confidence interval [CI] 0.551-0.865). Postsurgical HDratio correlated significantly (OR 0.620; CI 0.384-0.901) with the outcome in the TBI group. CONCLUSION ΔMLS is an objectifiable parameter, predicting outcome in malignant MCA infarction. In contrast, ΔMLS was of no predictive value in TBI patients. Here postsurgical HDratio serves as a strong predictor of clinical outcome. We recommend applying postsurgical HDratio to TBI patients in order to estimate their clinical outcome and adjust treatment.
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Affiliation(s)
- Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Jennifer Göttsche
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Vikholmen K, Persson HC, Sunnerhagen KS. Stroke treated at a neurosurgical ward: a cohort study. Acta Neurol Scand 2015; 132:329-36. [PMID: 25819421 DOI: 10.1111/ane.12404] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Little is known about the long-term recovery of patients treated with neurosurgery after stroke. This study aimed to explore the recovery of patients with first-time stroke treated in a neurosurgical ward, including their function, the presence of disability and life situation at admission, discharge and 4 years later. METHODS In this cohort study, 28 subjects (average age 55 years) were included. All had first-time stroke and were treated at the neurosurgical ward consecutively for 18 months. Baseline characteristics were identified, and follow-up home visits (n = 13) were performed 4 years post-stroke to explore the life situation, health status and recovery. RESULTS At admission, the median Glasgow Coma Scale score was 8 (range 3-15). Craniectomy or craniotomy was performed on 12 of the subjects. Average hospitalization time was 58 days. Two subjects died during the hospital stay, and an additional five died before the follow-up. Significant improvement in function from discharge to follow-up was noted: four of 13 were back at work, two were in need of personal assistance and one lived in a nursing home. Follow-up questionnaires showed a relatively high level of participation and independence. CONCLUSIONS Patients with stroke who were admitted to a neurosurgical ward had a low mortality rate during the acute treatment, and at 4 years post-stroke, the survival rate was 75%. The level of disability and dependence at discharge was high, but at 4 years post-stroke, there was both measurable and self-perceived improvement in function.
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Affiliation(s)
- K. Vikholmen
- Department of Clinical Neuroscience and Rehabilitation; Institute of Neuroscience and Physiology; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - H. C. Persson
- Department of Clinical Neuroscience and Rehabilitation; Institute of Neuroscience and Physiology; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - K. S. Sunnerhagen
- Department of Clinical Neuroscience and Rehabilitation; Institute of Neuroscience and Physiology; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
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Rastogi V, Lamb DG, Williamson JB, Stead TS, Penumudi R, Bidari S, Ganti L, Heilman KM, Hedna VS. Hemispheric differences in malignant middle cerebral artery stroke. J Neurol Sci 2015; 353:20-7. [PMID: 25959980 DOI: 10.1016/j.jns.2015.04.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 04/21/2015] [Accepted: 04/23/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND We recently reported that left versus right hemisphere cerebral infarctions patients more frequently have worse outcomes. However our clinical experience led us to suspect that the incidence of malignant middle cerebral artery infarctions (MMCA) was higher in the right compared to the left hemispheric strokes. OBJECTIVE To determine whether laterality in MMCA stroke is an important determinant of stroke sequelae. METHODS A systematic search was performed for publications in PubMed using "malignant middle cerebral artery and infarction". A total of 73 relevant studies were abstracted. RESULTS MMCA laterality data were available for 2673 patients, with 1687 (63%) right hemispheric involvement, thus right being more commonly associated with MMCA (binomial test, p<0.05). While mortality rates were similar, right hemispheric MMCA (n=271) had mortality of 31% (n=85) whereas left hemispheric MMCA (n=144) had mortality of 36% (n=53), morbidity rates were worse on the right. CONCLUSION MMCA stroke appears to be more common on the right, and this laterality is also associated with significantly higher morbidity. Further prospective studies are needed to more completely understand the nature of this laterality as well as test possible new treatments to reduce mortality and morbidity associated with MMCA.
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Affiliation(s)
- Vaibhav Rastogi
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States
| | - Damon G Lamb
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States; Malcom Randall VAMC, Gainesville, FL 32608, United States
| | - John B Williamson
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States; Malcom Randall VAMC, Gainesville, FL 32608, United States
| | - Thor S Stead
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States
| | - Rachel Penumudi
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States
| | - Sharathchandra Bidari
- Department of Radiology, University of Florida College of Medicine, Gainesville, FL 32611, United States
| | - Latha Ganti
- Lake City VAMC, NF/SGVHS, Lake City, FL 32025-5808, United States
| | - Kenneth M Heilman
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States; Malcom Randall VAMC, Gainesville, FL 32608, United States
| | - Vishnumurthy S Hedna
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States.
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Wiwanitkit S, Wiwanitkit V. Craniectomy size, mortality, outcome and complications: a short summary. JOURNAL OF ACUTE DISEASE 2015. [DOI: 10.1016/s2221-6189(14)60090-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Esquenazi Y, Savitz SI, Khoury RE, McIntosh MA, Grotta JC, Tandon N. Decompressive hemicraniectomy with or without clot evacuation for large spontaneous supratentorial intracerebral hemorrhages. Clin Neurol Neurosurg 2015; 128:117-22. [DOI: 10.1016/j.clineuro.2014.11.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 10/18/2014] [Accepted: 11/20/2014] [Indexed: 10/24/2022]
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Paldor I, Rosenthal G, Cohen JE, Leker R, Harnof S, Shoshan Y, Itshayek E. Intracranial pressure monitoring following decompressive hemicraniectomy for malignant cerebral infarction. J Clin Neurosci 2015; 22:79-82. [DOI: 10.1016/j.jocn.2014.07.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 07/15/2014] [Indexed: 11/27/2022]
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Abstract
Objective:Decompressive hemicraniectomy (DH) has been shown to reduce mortality in patients with malignant middle cerebral artery (MCA) territory infarction. However, many patients survive with moderate-to-severe disability and controversy exists as to whether this should be considered good outcome. To answer this question, we assessed the quality of life (QoL) of patients after DH for malignant MCA territory infarction in our milieu.Methods:The outcome of all patients undergoing DH for malignant MCAterritory infarction between 2001 and 2009 was assessed using retrospective chart analysis and telephone follow-up in survivors. Functional outcome was determined using Glasgow outcome scale, modifed Rankin scale (mRS), and Barthel index (BI). The stroke impact scale was used to assess QoL.Results:There were 14 patients, 6 men and 8 women, with a mean age of 44 years (range 27-57). All patients had reduced level of consciousness preoperatively. Five had dominant-hemisphere stroke. Median time to surgery was 45 hours (range 1- 96). Two patients died and one was lost to follow-up. Of 11 survivors, 7 (63.6%) had a favorable functional outcome (mRS<4). No patient was in persistent vegetative state. Despite impaired QoL, particularly in physical domains, the majority of interviewed patients and caregivers (7 of 8), including those with dominant-hemisphere stroke, were satisfied after a median follow-up of 18 months (range 6-43).Conclusion:Most patients report satisfactory QoL despite significant disability even in the face of moderate-to-severe disability and dominant-hemsiphere stroke. Dominant-hemisphere malignant MCA territory infarction should not be considered a contraindication to DH.
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Zweckberger K, Juettler E, Bösel J, Unterberg WA. Surgical Aspects of Decompression Craniectomy in Malignant Stroke: Review. Cerebrovasc Dis 2014; 38:313-23. [DOI: 10.1159/000365864] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 07/02/2014] [Indexed: 11/19/2022] Open
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Sundseth J, Sundseth A, Thommessen B, Johnsen LG, Altmann M, Sorteberg W, Lindegaard KF, Berg-Johnsen J. Long-Term Outcome and Quality of Life After Craniectomy in Speech-Dominant Swollen Middle Cerebral Artery Infarction. Neurocrit Care 2014; 22:6-14. [DOI: 10.1007/s12028-014-0056-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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van Middelaar T, Nederkoorn PJ, van der Worp HB, Stam J, Richard E. Quality of Life after Surgical Decompression for Space-Occupying Middle Cerebral Artery Infarction: Systematic Review. Int J Stroke 2014; 10:170-6. [DOI: 10.1111/ijs.12329] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 05/20/2014] [Indexed: 01/05/2023]
Abstract
Background and Purpose In patients with space-occupying middle cerebral artery infarction, surgical decompression strongly reduces risk of death and increases the chance of a favorable outcome. This comes at the expense of an increase in the risk of survival with (moderately) severe disability. We assessed quality of life, depression, and caregiver burden in these patients. Summary of Review We systematically reviewed the literature by searching MEDLINE, EMBASE, and PsycINFO up to March 2014. We included randomized controlled trials, cohort studies, case–control studies, and case series with quality of life, depression, or caregiver burden as primary or secondary outcome. Seventeen articles reporting on 459 patients were included. At final follow-up at 7 to 51 months, 1344 patients (30%) had died, and 34 (11%) were lost to follow up. Data on 291 patients were available, of whom 81 of 213 survivors (39%) achieved good functional outcome at final follow-up (modified Rankin Scale ⩽3). Mean quality of life was 46% to 67% of the best possible score when based on questionnaires or visual analogue scales. At final follow-up, 143 of 189 patients (76%) would in retrospect again choose for surgical decompression. Severe depressive symptoms were present in 14 of 113 patients (16%). Three studies investigated caregiver burden and reported substantial burden. Patients more than 60 years old had a lower quality of life in comparison with younger patients. Conclusions Most patients treated with surgical decompression for space-occupying infarction have a reasonable quality of life at long-term follow-up and are satisfied with the treatment received. Severe depressive symptoms are uncommon.
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Affiliation(s)
- Tessa van Middelaar
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Paul J. Nederkoorn
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - H. Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Stam
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Edo Richard
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
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Itshayek E, Or O, Kaplan L, Schroeder J, Barzilay Y, Rosenthal G, Shoshan Y, Fraifeld S, Cohen JE. Are they too old? Surgical treatment for metastatic epidural spinal cord compression in patients aged 65 years and older. Neurol Res 2014; 36:530-43. [DOI: 10.1179/1743132814y.0000000368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Mendelsohn D, Haw CS, Illes J. Convergent Expert Views on Decision-Making for Decompressive Craniectomy in Malignant MCA Syndrome. NEUROETHICS-NETH 2014. [DOI: 10.1007/s12152-014-9206-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Agarwalla PK, Stapleton CJ, Ogilvy CS. Craniectomy in Acute Ischemic Stroke. Neurosurgery 2014; 74 Suppl 1:S151-62. [DOI: 10.1227/neu.0000000000000226] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Anterior and posterior circulation acute ischemic stroke carries significant morbidity and mortality as a result of malignant cerebral edema. Decompressive craniectomy has evolved as a viable neurosurgical intervention in the armamentarium of treatment options for this life-threatening edema. In this review, we highlight the history of craniectomy for stroke and discuss recent data relevant to its efficacy in modern neurosurgical practice.
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Affiliation(s)
- Pankaj K. Agarwalla
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Christopher J. Stapleton
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Christopher S. Ogilvy
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Wijdicks EFM, Sheth KN, Carter BS, Greer DM, Kasner SE, Kimberly WT, Schwab S, Smith EE, Tamargo RJ, Wintermark M. Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:1222-38. [PMID: 24481970 DOI: 10.1161/01.str.0000441965.15164.d6] [Citation(s) in RCA: 306] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE There are uncertainties surrounding the optimal management of patients with brain swelling after an ischemic stroke. Guidelines are needed on how to manage this major complication, how to provide the best comprehensive neurological and medical care, and how to best inform families facing complex decisions on surgical intervention in deteriorating patients. This scientific statement addresses the early approach to the patient with a swollen ischemic stroke in a cerebral or cerebellar hemisphere. METHODS The writing group used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. The panel reviewed the most relevant articles on adults through computerized searches of the medical literature using MEDLINE, EMBASE, and Web of Science through March 2013. The evidence is organized within the context of the American Heart Association framework and is classified according to the joint American Heart Association/American College of Cardiology Foundation and supplementary American Heart Association Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive American Heart Association internal peer review. RESULTS Clinical criteria are available for hemispheric (involving the entire middle cerebral artery territory or more) and cerebellar (involving the posterior inferior cerebellar artery or superior cerebellar artery) swelling caused by ischemic infarction. Clinical signs that signify deterioration in swollen supratentorial hemispheric ischemic stroke include new or further impairment of consciousness, cerebral ptosis, and changes in pupillary size. In swollen cerebellar infarction, a decrease in level of consciousness occurs as a result of brainstem compression and therefore may include early loss of corneal reflexes and the development of miosis. Standardized definitions should be established to facilitate multicenter and population-based studies of incidence, prevalence, risk factors, and outcomes. Identification of patients at high risk for brain swelling should include clinical and neuroimaging data. If a full resuscitative status is warranted in a patient with a large territorial stroke, admission to a unit with neurological monitoring capabilities is needed. These patients are best admitted to intensive care or stroke units attended by skilled and experienced physicians such as neurointensivists or vascular neurologists. Complex medical care includes airway management and mechanical ventilation, blood pressure control, fluid management, and glucose and temperature control. In swollen supratentorial hemispheric ischemic stroke, routine intracranial pressure monitoring or cerebrospinal fluid diversion is not indicated, but decompressive craniectomy with dural expansion should be considered in patients who continue to deteriorate neurologically. There is uncertainty about the efficacy of decompressive craniectomy in patients ≥60 years of age. In swollen cerebellar stroke, suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically. Ventriculostomy to relieve obstructive hydrocephalus after a cerebellar infarct should be accompanied by decompressive suboccipital craniectomy to avoid deterioration from upward cerebellar displacement. In swollen hemispheric supratentorial infarcts, outcome can be satisfactory, but one should anticipate that one third of patients will be severely disabled and fully dependent on care even after decompressive craniectomy. Surgery after a cerebellar infarct leads to acceptable functional outcome in most patients. CONCLUSIONS Swollen cerebral and cerebellar infarcts are critical conditions that warrant immediate, specialized neurointensive care and often neurosurgical intervention. Decompressive craniectomy is a necessary option in many patients. Selected patients may benefit greatly from such an approach, and although disabled, they may be functionally independent.
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Shah S, Murthy SB, Whitehead WE, Jea A, Nassif LM. Decompressive hemicraniectomy in pediatric patients with malignant middle cerebral artery infarction: case series and review of the literature. World Neurosurg 2013; 80:126-33. [PMID: 23791748 DOI: 10.1016/j.wneu.2013.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 05/07/2013] [Accepted: 06/12/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Malignant middle cerebral artery infarction (mMCAI) is a life-threatening condition in pediatric patients. Despite strong evidence showing decreased morbidity and mortality in adult mMCAI patients with decompressive hemicraniectomy (DCH), there is a paucity of data on the use of DCH in children with similar conditions. Here we report experience from our center and perform a systematic review of published literature on outcomes after use of DCH in pediatric mMCAI patients. METHODS By retrospective chart review, we identified 3 children with large ischemic stroke who underwent DCH for life-threatening cerebral edema. Information was obtained about patient characteristics on admission, radiological features of the stroke, surgical procedures, complications of the DCH and cranioplasty, and functional outcomes during follow-up visits. We also reviewed the current literature on DCH in pediatric stroke. RESULTS DCH was performed in all 3 cases after development of pupillary dilatation. All 3 children survived and were ambulatory at the time of follow-up. Review of literature identified 12 other published case series describing 26 cases of DCH in pediatric patients with ischemic stroke. Descriptive statistical analysis of these cases is presented. Published reports suggest that a good outcome is possible even in the presence of signs of herniation, low preoperative Glasgow Coma Scale score, involvement of multiple vascular territories, or longer time to surgery in pediatric ischemic stroke patients. CONCLUSIONS The current data suggest a role for DCH in the management of cerebral edema in pediatric patients with mMCAI. Factors that help in prognostication for adult stroke patients undergoing DCH do not appear to convey similar information about the pediatric population. This highlights the urgent need for collaboration across institutes to further investigate this potentially life-saving procedure in pediatric stroke.
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Affiliation(s)
- Shreyansh Shah
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA.
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Honeybul S, Ho KM. The current role of decompressive craniectomy in the management of neurological emergencies. Brain Inj 2013; 27:979-91. [DOI: 10.3109/02699052.2013.794974] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJB, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44:870-947. [PMID: 23370205 DOI: 10.1161/str.0b013e318284056a] [Citation(s) in RCA: 3193] [Impact Index Per Article: 290.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. METHODS Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. RESULTS The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. CONCLUSIONS Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.
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Lee SC, Wang YC, Huang YC, Tu PH, Lee ST. Decompressive surgery for malignant middle cerebral artery syndrome. J Clin Neurosci 2013; 20:49-52. [DOI: 10.1016/j.jocn.2012.05.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 05/27/2012] [Accepted: 05/27/2012] [Indexed: 11/26/2022]
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Hemicraniectomy in the management of space-occupying ischemic stroke. J Clin Neurosci 2013; 20:6-12. [DOI: 10.1016/j.jocn.2012.02.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Revised: 02/10/2012] [Accepted: 02/13/2012] [Indexed: 01/04/2023]
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Omary R, Chernoguz D, Lasri V, Leker RR. Decompressive hemicraniectomy reduces mortality in an animal model of intracerebral hemorrhage. J Mol Neurosci 2012; 49:157-61. [PMID: 23152135 DOI: 10.1007/s12031-012-9922-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 11/05/2012] [Indexed: 11/25/2022]
Abstract
Decompressive hemicraniectomy (DHC) significantly reduces mortality in patients with large hemispheric ischemic strokes but has not been studied in intracranial hemorrhage (ICH). Male Sabra mice were subjected to large experimental ICH. The animals then underwent DHC or sham surgery. Early (1 day post-op) and late (5 days post-op) mortality rates and neurological disability were monitored. The animals were perfusion-fixed at 5 days post-ICH induction, and their brains were studied for hematoma volume and presence of active caspase 3 as a measure of apoptotic death in the area surrounding the hematoma. Our results show that DHC significantly reduced early (7 vs. 75 %, p < 0.001) and late (46 vs. 83 %, p = 0.017) mortality after large ICH. No significant differences in neurological disability were observed between surviving animals in both groups. Hematoma volumes did not differ between the groups on histological evaluation. The number of active caspase 3-positive neurons at the hematoma boundary was significantly higher in animals that underwent DHC. In conclusion, DHC reduces early and late mortality after devastating ICH without changing the hematoma volumes and without notable effects on motor and sensory functions in survivors. Further evaluation of this method to reduce mortality in ICH patients is warranted.
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Affiliation(s)
- R Omary
- Peritz and Chantal Scheinberg Cerebrovascular Research Laboratory, Department of Neurology, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Hadassah Ein Kerem, Jerusalem 91120, Israel
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Kostov DB, Singleton RH, Panczykowski D, Kanaan HA, Horowitz MB, Jovin T, Jankowitz BT. Decompressive Hemicraniectomy, Strokectomy, or Both in the Treatment of Malignant Middle Cerebral Artery Syndrome. World Neurosurg 2012; 78:480-6. [DOI: 10.1016/j.wneu.2011.12.080] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 09/27/2011] [Accepted: 12/19/2011] [Indexed: 11/29/2022]
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Decompressive craniectomy in childhood posterior circulation stroke: a case series and review of the literature. Pediatr Neurol 2012; 47:193-7. [PMID: 22883284 DOI: 10.1016/j.pediatrneurol.2012.05.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 05/09/2012] [Indexed: 11/23/2022]
Abstract
Few reports address the role of decompressive craniectomy in children with space-occupying cerebral edema attributable to severe ischemic infarction of the posterior cerebral arterial circulation. We describe four children with posterior circulation arterial ischemic stroke who required decompressive craniectomy. These children accounted for 11% of all cases of posterior circulation ischemic stroke at our institution from 2002-2010. Three manifested large, cerebellar hemispheric infarcts, and one manifested a large, temporo-occipital posterior cerebral artery infarct. Deterioration occurred within 72 hours of stroke onset. Two patients demonstrated minimal functional deficits at follow-up, and two demonstrated moderate deficits with functional limitations. Because decompressive craniectomy can be lifesaving in children with severe posterior circulation arterial ischemic stroke, early neurosurgical referral should be considered.
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Rahme R, Zuccarello M, Kleindorfer D, Adeoye OM, Ringer AJ. Decompressive hemicraniectomy for malignant middle cerebral artery territory infarction: is life worth living? J Neurosurg 2012; 117:749-54. [PMID: 22920962 DOI: 10.3171/2012.6.jns111140] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Although decompressive hemicraniectomy has been shown to reduce death and improve functional outcome following malignant middle cerebral artery territory infarction, there is ongoing debate as to whether surgery should be routinely performed, considering the very high rates of disability and functional dependence in survivors. Through a systematic review of the literature, the authors sought to determine the outcome from a patient's perspective. METHODS In September 2010, a MEDLINE search of the English-language literature was performed using various combinations of 12 key words. A total of 16 papers were reviewed and individual study data were extracted. RESULTS There was significant variability in study design, patient eligibility criteria, timing of surgery, and methods of outcome assessment. There were 382 patients (59% male, 41% female) with a mean age of 50 years, 25% with dominant-hemisphere infarction. The mortality rate was 24% and the mean follow-up in survivors was 19 months (range 3-114 months). Of 156 survivors with available modified Rankin Scale (mRS) scores, 41% had favorable functional outcome (mRS Score ≤ 3), whereas 47% had moderately severe disability (mRS Score 4). Among 157 survivors with quality of life assessment, the mean overall reduction was 45%: 67% for physical aspect and 37% for psychosocial aspect. Of 114 screened survivors, depression affected 56% and was moderate or severe in 25%. Most patients and/or caregivers (77% of the 209 interviewed) were satisfied and would give consent again for the procedure. CONCLUSIONS Despite high rates of physical disability and depression, the vast majority of patients are satisfied with life and do not regret having undergone surgery.
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Affiliation(s)
- Ralph Rahme
- Departments of Neurosurgery, University of Cincinnati and Mayfield Clinic, Cincinnati, OH, USA.
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von Sarnowski B, Kleist-Welch Guerra W, Kohlmann T, Moock J, Khaw A, Kessler C, Schminke U, Schroeder H. Long-term health-related quality of life after decompressive hemicraniectomy in stroke patients with life-threatening space-occupying brain edema. Clin Neurol Neurosurg 2012; 114:627-33. [DOI: 10.1016/j.clineuro.2011.12.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 12/06/2011] [Accepted: 12/17/2011] [Indexed: 11/16/2022]
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Nizami FA, Ramzan AU, Wani AA, Wani MA, Malik NK, Shah PA, Asimi R. Decompressive hemicraniectomy in supra-tentorial malignant infarcts. Surg Neurol Int 2012; 3:29. [PMID: 22439120 PMCID: PMC3307248 DOI: 10.4103/2152-7806.93410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 01/02/2012] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Decompressive hemicraniectomy not only reduces the intracranial pressure but has been demonstrated to increase survival and decrease the morbidity in patients with supratentorial malignant brain infarcts (STMBI). The aim of this study was to assess the efficacy of surgical decompression to decrease the mortality and morbidity in patients with STMBI refractory to medical therapy and to compare the results with those of the medically managed patients. METHODS All the 24 consecutive patients with clinical and radiological diagnosis of STMBI, refractory to medical management in 2 years, were included. Option of surgical decompression after explaining the outcome, risk and benefits of the procedure was given to the attendants/relatives of all patients who were fulfilling the inclusion criteria. The patient group, whose attendants/relatives were not willing to undergo surgery, were subjected to the same medical therapy and they were taken as the "control group." RESULTS Supratentorial malignant infarcts were more common in the age group of 41-60 years. Mean age of presentation was 42.16 ± 16.2 years and the mean GCS on admission was 7.83 ± 2.1. Mortality was 16.7% in the surgically and 25.0% in the medically managed group. Patients operated early (<48 h), age ≤60 years, midline shift <5 mm and size of infarct less than 2/3(rd) of the vascular territory involved showed good prognosis. The functional outcome revealed by modified Rankin Score (mRS) and Glasgow Outcome Score (GOS) was better in surgically managed patients. Results of the Zung Self-Rating Depression Score were better in surgically managed patients at 1 year. Barthal Index in the surgically managed group showed statistically significant results. CONCLUSIONS Decompressive hemicraniectomy with duroplasty if performed early in STMBI not only decreases the mortality but also increases the functional outcome when compared with patients who were managed conservatively with medical therapy only.
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Affiliation(s)
- Furqan A Nizami
- Department of Neurosurgery, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Soura, Jammu and Kashmir, India
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McKenna A, Wilson CF, Caldwell SB, Curran D. Functional outcomes of decompressive hemicraniectomy following malignant middle cerebral artery infarctions: a systematic review. Br J Neurosurg 2012; 26:310-5. [DOI: 10.3109/02688697.2012.654835] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Schmidt H, Heinemann T, Elster J, Djukic M, Harscher S, Neubieser K, Prange H, Kastrup A, Rohde V. Cognition after malignant media infarction and decompressive hemicraniectomy--a retrospective observational study. BMC Neurol 2011; 11:77. [PMID: 21699727 PMCID: PMC3141399 DOI: 10.1186/1471-2377-11-77] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 06/23/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Decompressive hemicraniectomy is a life-saving procedure for patients with malignant middle cerebral artery infarctions. However, the neuropsychological sequelae in such patients have up to now received little attention. In this study we not only describe neuropsychological deficits but also the quality of life and the extent of depression and other psychiatric symptoms in patients after complete media infarction of the non-speech dominant hemisphere. METHODS 20 patients from two different university hospitals (mean ± standard deviation: 52 ± 14 years of age) who had undergone hemicraniectomy with duraplasty above the non-speech dominant hemisphere at least one year previously were examined using a thorough neurological and neuropsychological work-up. The quality of life and the extent of psychiatric problems were determined on the basis of self-estimation questionnaires. The patients were asked whether they would again opt for the surgical treatment when considering their own outcome. 20 healthy persons matched for age, gender and education served as a control group. RESULTS All patients but one were neurologically handicapped, half of them severely. Age was significantly correlated with poorer values on the Rankin scale and Barthel index. All cognitive domain z values were significantly lower than in the control group. Upon re-examination, 18 of 20 patients were found to be cognitively impaired to a degree that fulfilled the formal DSM IV criteria for dementia. CONCLUSIONS Patients with non-speech dominant hemispheric infarctions and decompressive hemicraniectomy are at high risk of depression and severe cognitive impairment.
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Affiliation(s)
- Holger Schmidt
- University of Göttingen, Department of Neurology, Göttingen, Germany.
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