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Ovenden CD, Barot DD, Gupta A, Aujayeb N, Nathin K, Hewitt J, Kovoor J, Stretton B, Bacchi S, Edwards S, Kaukas L, Wells AJ. Incidence of hydrocephalus following decompressive craniectomy for ischaemic stroke: A systematic review and meta-analysis. Clin Neurol Neurosurg 2023; 234:107989. [PMID: 37826959 DOI: 10.1016/j.clineuro.2023.107989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/22/2023] [Accepted: 09/23/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE Decompressive craniectomy (DC) following malignant ischaemic stroke is a potentially life-saving procedure. Event rates of ventriculomegaly following DC performed in this setting remain poorly defined. Accordingly, we performed a systematic review to determine the incidence of hydrocephalus and the need for cerebrospinal fluid (CSF) diversion following DC for malignant stroke. METHODS MEDLINE, EMBASE and Cochrane libraries were searched from database inception to 17 July 2021. Our search strategy consisted of "Decompressive Craniectomy", AND "Ischaemic stroke", AND "Hydrocephalus", along with synonyms. Through screening abstracts and then full texts, studies reporting on rates of ventriculomegaly following DC to treat ischaemic stroke were included for analysis. Event rates were calculated for both of these outcomes. A risk of bias assessment was performed to determine the quality of the included studies. RESULTS From an initial 1117 articles, 12 were included following full-text screening. All were of retrospective design. The 12 included studies reported on 677 patients, with the proportion experiencing hydrocephalus/ventriculomegaly being 0.38 (95% CI: 0.24, 0.53). Ten studies incorporating 523 patients provided data on the need for permanent CSF diversion, with 0.10 (95% CI: 0.07, 0.13) requiring a shunt. The included studies were overall of high methodological quality and rigour. CONCLUSION Though hydrocephalus is relatively common following DC in this clinical setting, only a minority of patients are deemed to require permanent CSF diversion. Clinicians should be aware of the incidence of this complication and counsel patients and families appropriately.
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Affiliation(s)
- Christopher Dillon Ovenden
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Australia; Discipline of Surgery, University of Adelaide, Adelaide, Australia
| | | | - Aashray Gupta
- Discipline of Surgery, University of Adelaide, Adelaide, Australia; Gold Coast University Hospital, Southport, Australia
| | - Nidhi Aujayeb
- Discipline of Surgery, University of Adelaide, Adelaide, Australia
| | - Kayla Nathin
- Discipline of Surgery, University of Adelaide, Adelaide, Australia
| | - Joseph Hewitt
- Discipline of Surgery, University of Adelaide, Adelaide, Australia
| | - Joshua Kovoor
- Discipline of Surgery, University of Adelaide, Adelaide, Australia
| | - Brandon Stretton
- Discipline of Surgery, University of Adelaide, Adelaide, Australia
| | - Stephen Bacchi
- Discipline of Surgery, University of Adelaide, Adelaide, Australia
| | - Suzanne Edwards
- Discipline of Surgery, University of Adelaide, Adelaide, Australia
| | - Lola Kaukas
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Adam J Wells
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Australia; Discipline of Surgery, University of Adelaide, Adelaide, Australia
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Pershin ME, Yenaldiev GK, Shagal LV, Timchenko LV, Muzlaev GG, Tkachev VV. [Staged treatment of a patient with malignant ischemic cerebral infarction]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:85-93. [PMID: 37830473 DOI: 10.17116/neiro20238705185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
The authors discuss surgical decompression of the brain in patients with malignant ischemic cerebral infarcts. Successful staged treatment of a middle-aged patient with malignant ischemic stroke in the middle cerebral artery basin is presented.
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Affiliation(s)
- M E Pershin
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russia
| | - G K Yenaldiev
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russia
| | - L V Shagal
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russia
| | - L V Timchenko
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russia
| | - G G Muzlaev
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russia
| | - V V Tkachev
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russia
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Moughal S, Trippier S, AL-Mousa A, Hainsworth AH, Pereira AC, Minhas PS, Shtaya A. Strokectomy for malignant middle cerebral artery infarction: experience and meta-analysis of current evidence. J Neurol 2022; 269:149-158. [PMID: 33340332 PMCID: PMC8739160 DOI: 10.1007/s00415-020-10358-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/25/2020] [Accepted: 12/04/2020] [Indexed: 11/05/2022]
Abstract
Strokectomy means surgical excision of infarcted brain tissue post-stroke with preservation of skull integrity, distinguishing it from decompressive hemicraniectomy. Both can mitigate malignant middle cerebral artery (MCA) syndrome but evidence regarding strokectomy is sparse. Here, we report our data and meta-analysis of strokectomy compared to hemicraniectomy for malignant MCA infarction. All malignant MCA stroke cases requiring surgical intervention in a large tertiary centre (January 2012-December 2017, N = 24) were analysed for craniotomy diameter, complications, length of follow-up and outcome measured using the modified Rankin score (mRS). Good outcome was defined as mRS 0-3 at 12 months. In a meta-analysis, outcome from strokectomy (pooled from our cohort and published strokectomy studies) was compared with hemicraniectomy (our cohort pooled with published DECIMAL, DESTINY and HAMLET clinical trial data). In our series (N = 24, 12/12 F/M; mean age: 45.83 ± 8.91, range 29-63 years), 4 patients underwent strokectomy (SC) and 20 hemicraniectomy (HC). Among SC patients, craniotomy diameter was smaller, relative to HC patients (86 ± 13.10 mm, 120 ± 4.10 mm, respectively; p = 0.003), complications were less common (25%, 55%) and poor outcomes were less common (25%, 70%). In the pooled data (N = 41 SC, 71 HC), strokectomy tended towards good outcome more than hemicraniectomy (OR 2.2, 95% CI 0.99-4.7; p = 0.051). In conclusion, strokectomy may be non-inferior, lower risk and cost saving relative to hemicraniectomy sufficiently to be worthy of further investigation and maybe a randomised trial.
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Affiliation(s)
- Saad Moughal
- grid.264200.20000 0000 8546 682XNeurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, SW17 0RE UK ,grid.451349.eAtkinson Morley Neurosurgery Centre, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Sarah Trippier
- grid.451349.eNeurology Department, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Alaa AL-Mousa
- grid.33801.390000 0004 0528 1681Department of Surgery, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Atticus H. Hainsworth
- grid.264200.20000 0000 8546 682XNeurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George’s, University of London, London, SW17 0RE UK ,grid.451349.eNeurology Department, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Anthony C. Pereira
- grid.451349.eNeurology Department, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Pawanjit S Minhas
- grid.451349.eAtkinson Morley Neurosurgery Centre, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Anan Shtaya
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, SW17 0RE, UK. .,Atkinson Morley Neurosurgery Centre, St George's University Hospitals NHS Foundation Trust, London, UK.
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Maïer B, Delvoye F, Labreuche J, Escalard S, Desilles JP, Redjem H, Hébert S, Smajda S, Ciccio G, Lapergue B, Blanc R, Piotin M, Mazighi M. Impact of Blood Pressure After Successful Endovascular Therapy for Anterior Acute Ischemic Stroke: A Systematic Review. Front Neurol 2020; 11:573382. [PMID: 33193021 PMCID: PMC7659685 DOI: 10.3389/fneur.2020.573382] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/30/2020] [Indexed: 12/11/2022] Open
Abstract
Background and Purpose: Optimal blood pressure (BP) targets after endovascular therapy (EVT) for acute ischemic stroke (AIS) still need to be assessed, especially according to the recanalization status. Facing the lack of randomized controlled trials addressing this question, we performed a systematic review of studies assessing the post-EVT BP impact on functional outcome and symptomatic intracranial hemorrhage (sICH). Methods: Studies published after January 1, 2012 were included in the systematic review. The PRISMA checklist and flow diagram were followed for the design and reporting of this work. Results: Five studies were included in the present analysis. Despite a significant heterogeneity among studies which precluded a meta-analysis, systolic BP (SBP) was the most frequently used parameter to describe BP. BP variability (standard deviation, successive variability) after EVT was associated with worse functional outcome, especially in studies without specific BP targets after successful EVT. Lower BP values after successful EVT were associated with lower odds of sICH. Four studies evaluated the post-EVT BP impact on recanalized patients solely, with only one specifically addressing the impact of a TICI 2B vs. 2C. Interestingly, SBP reduction was inversely associated with worse outcomes in TICI 3 patients but not in TICI 2B patients, pointing to the potential value of BP management according to the exact TICI. Conclusions: BP post-EVT seems to be associated with worse functional outcomes and sICH. However, given the important heterogeneity depicted among the included studies, no decisive conclusion can be made from this systematic review, thus underlying the urgent need of randomized controlled trials evaluating this question.
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Affiliation(s)
- Benjamin Maïer
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France.,Université de Paris, Paris, France
| | - François Delvoye
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Julien Labreuche
- University Lille, CHU Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, Lille, France
| | - Simon Escalard
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Jean-Philippe Desilles
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France.,Université de Paris, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Hocine Redjem
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Solène Hébert
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Stanislas Smajda
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | - Gabriele Ciccio
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France
| | | | - Raphaël Blanc
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Mikael Mazighi
- Interventional Neuroradiology Department, Fondation Rothschild, Paris, France.,Université de Paris, Paris, France.,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France.,FHU Neurovasc, Paris, France
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Beez T, Munoz-Bendix C, Steiger HJ, Beseoglu K. Decompressive craniectomy for acute ischemic stroke. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:209. [PMID: 31174580 PMCID: PMC6556035 DOI: 10.1186/s13054-019-2490-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/26/2019] [Indexed: 12/21/2022]
Abstract
Malignant stroke occurs in a subgroup of patients suffering from ischemic cerebral infarction and is characterized by neurological deterioration due to progressive edema, raised intracranial pressure, and cerebral herniation. Decompressive craniectomy (DC) is a surgical technique aiming to open the “closed box” represented by the non-expandable skull in cases of refractory intracranial hypertension. It is a valuable modality in the armamentarium to treat patients with malignant stroke: the life-saving effect has been proven for both supratentorial and infratentorial DC in virtually all age groups. This leaves physicians with the difficult task to decide who will require early or preemptive surgery and who might benefit from postponing surgery until clear evidence of deterioration evolves. Together with the patient’s relatives, physicians also have to ascertain whether the patient will have acceptable disability and quality of life in his or her presumed perception, based on preoperative predictions. This complex decision-making process can only be managed with interdisciplinary efforts and should be supported by continued research in the age of personalized medicine.
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Affiliation(s)
- Thomas Beez
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - Christopher Munoz-Bendix
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Hans-Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
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