Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials

Pretreatment and Posttreatment Factors Associated with Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

BACKGROUND

Hydrocephalus is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to evaluate novel preoperative and postoperative risk factors for shunt-dependent hydrocephalus (SDHC) after aSAH via a systematic review and meta-analysis.

METHODS

A systematic search was conducted using PubMed and Embase databases for studies pertaining to aSAH and SDHC. Articles were assessed by meta-analysis if the number of risk factors for SDHC was reported by >4 studies and could be extracted separately for patients who did or did not develop SDHC.

RESULTS

Thirty-seven studies were included, comprising 12,667 patients with aSAH (SDHC 2214 vs. non-SDHC 10,453). In a primary analysis of 15 novel potential risk factors, 8 were identified to be significantly associated with increased prevalence of SDHC after aSAH, including high World Federation of Neurological Surgeons grades (odds ratio [OR], 2.43), hypertension (OR, 1.33), anterior cerebral artery (OR, 1.36), middle cerebral artery (OR, 0.65), and vertebrobasilar artery (2.21) involvement, decompressive craniectomy (OR, 3.27), delayed cerebral ischemia (OR, 1.65), and intracerebral hematoma (OR, 3.91).

CONCLUSIONS

Several new factors associated with increased odds of developing SDHC after aSAH were found to be significant. By providing evidence-based risk factors for shunt dependency, we describe an identifiable list of preoperative and postoperative prognosticators that may influence how surgeons recognize, treat, and manage patients with aSAH at high risk for developing SDHC.

Clinical Analysis of Microvascular Reconstruction Combined With Decompressive Craniectomy in Patients With Malignant Middle Cerebral Artery Infarctions

PURPOSE

This study aimed to evaluate the safety and efficacy of microvascular reconstruction combined with decompressive craniectomy (DHC) in patients with malignant middle cerebral artery infarctions (MMCA).

METHODS

We searched for patients with MMCA and aged＜60 years old, postoperative survival of more than 3 months, consistent with decompression of bone flap removal. Patients were divided into experimental group and control group according to whether they underwent emergency vascular revascularization within 5 days after onset of ischemic stroke.

RESULTS

A total of sixpatients were included in the treatment group and 12 patients in the control group. The National Institutes of Health Stroke Scale (NIHSS) score of the treatment group was lower than that of the control group seven days after operation, but the difference was not statistically significant; 3 months after surgery, modified ranking scale (mRs) score in the treatment group was lower than that in the control group, the difference was statistically significant (P = 0.002); mRs scores of the treatment group 3 months after surgery were significantly different from those before surgery (P < 0.05), but no such difference was found in the control group.

CONCLUSION

Compared with decompressive craniectomy, open surgical revascularization can improve early cerebral perfusion in MMCA patients, and neurological recovery is better at 3 months after operation. By ensuring that surgeons are properly trained and hospitals are equipped, open surgical revascularization can be a treatment option for patients with MMCA.

Surgery for Malignant Acute Ischemic Stroke: A Narrative Review of the Knowns and Unknowns

Malignant acute ischemic stroke (AIS) is characterized by acute neurological deterioration caused by progressive space-occupying brain edema, often occurring in the first hours to days after symptom onset. Without any treatment, the result is often fatal. Despite advances in treatment for AIS, up to 80% of patients with a large hemispheric stroke or cerebellar stroke are at risk of poor outcome. Decompressive surgery can be life-saving in a subgroup of patients with malignant AIS, but uncertainties exist on patient selection, predictors of malignant infarction, perioperative management, and timing of intervention. Although survivors are left disabled, most agree with the original decision to undergo surgery and would make the same decision again. In this narrative review, we focus on the clinical and radiological predictors of malignant infarction in AIS and outline the technical aspects of decompressive surgery as well as duraplasty and cranioplasty. We discuss the current evidence and recommendations for surgery in AIS, highlighting gaps in knowledge, and suggest directions for future studies. KEY POINTS: · Acute ischemic stroke from occlusion of a proximal intracranial artery can progress quickly to malignant edema, which can be fatal in 80% of patients despite medical management.. · Decompression surgery is life-saving within 48 hours of stroke onset, but the benefits beyond this time and in the elderly are unknown.. · Decompressive surgery is associated with high morbidity, particularly in the elderly. The decision to operate must be made after considering the individual's preference and expectations of quality of life in the context of the clinical condition.. · Further studies are needed to refine surgical technique including value of duraplasty and understand the role monitoring intracranial pressure during and after decompressive surgery.. · More studies are needed on the pathophysiology of malignant cerebral edema, prediction models including imaging and biomarkers to identify which subgroup of patients will benefit from decompressive surgery.. · More research is needed on factors associated with morbidity and mortality after cranioplasty, safety and efficacy of implants, and comparisons between them.. · Further studies are needed to assess the long-term effects of physical disability and quality of life of survivors after surgery, particularly those with severe neurological deficits..

Towards a core outcome set for cranioplasty following traumatic brain injury and stroke 'A systematic review of reported outcomes'

Background

There is wide-ranging published literature around cranioplasty following traumatic brain injury (TBI) and stroke, but the heterogeneity of outcomes limits the ability for meta-analysis. Consensus on appropriate outcome measures has not been reached, and given the clinical and research interest, a core outcome set (COS) would be beneficial.

Objectives

To collate outcomes currently reported across the cranioplasty literature which will subsequently be used in developing a cranioplasty COS.

Methods

This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. All full-text English studies with more than ten patients (prospective) or more than 20 patients (retrospective) published after 1990 examining outcomes in CP were eligible for inclusion.

Results

The review included 205 studies from which 202 verbatim outcomes were extracted, grouped into 52 domains, and categorised into one or more of the OMERACT 2.0 framework core area(s). The total numbers of studies that reported outcomes in the core areas are 192 (94%) pathophysiological manifestations/ 114 (56%) resource use/economic impact/ 94 (46%) life impact/mortality 20 (10%). In addition, there are 61 outcome measures used in the 205 studies across all domains.

Conclusion

This study shows considerable heterogeneity in the types of outcomes used across the cranioplasty literature, demonstrating the importance and necessity of developing a COS to help standardise reporting across the literature.

Large diameter hemicraniectomy does not improve long-term outcome in malignant infarction

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).

A Novel Nomogram for Predicting Malignant Cerebral Edema After Endovascular Thrombectomy in Acute Ischemic Stroke: A Retrospective Cohort Study

BACKGROUND

Malignant cerebral edema (MCE) is a common and feared complication after endovascular thrombectomy (EVT) in acute ischemic stroke (AIS). This study aimed to establish a nomogram to predict MCE in anterior circulation large vessel occlusion stroke (LVOS) patients receiving EVT in order to guide the postoperative medical care in the acute phase.

METHODS

In this retrospective cohort study, 381 patients with anterior circulation LVOS receiving EVT were screened from 636 hospitalized patients with LVOS at 2 stroke medical centers. Clinical baseline data and imaging data were collected within 2-5 days of admission to the hospital. The patients were divided into 2 groups based on whether MCE occurred after EVT. Multivariate logistic regression analysis was used to evaluate the independent risk factors for MCE and to establish a nomogram.

RESULTS

Sixty-six patients out of 381 (17.32%) developed MCE. The independent risk factors for MCE included admission National Institutes of Health Stroke Scale (NIHSS) ≥16 (odds ratio [OR] 1.851; 95% CI 1.029-3.329; P = 0.038), ASPECT score (OR 0.621; 95% CI 0.519-0.744; P < 0.001), right hemisphere (OR 1.636; 95% CI 0.941-2.843; P = 0.079), collateral circulation (OR 0.155; 95% CI 0.074-0.324; P < 0.001), recanalization (OR 0.223; 95% CI 0.109-0.457; P < 0.001), hematocrit (OR, 0.937; 95% CI: 0.892-0.985; P =0.010), and glucose (OR 1.118; 95% CI 1.023-1.223; P = 0.036), which were adopted as parameters of the nomogram. The receiver operating characteristic curve analysis showed that the area under the curve of the nomogram in predicting MCE was 0.901(95% CI 0.848-0.940; P < 0.001). The Hosmer-Lemeshow test results were not significant (P = 0.685), demonstrating a good calibration of the nomogram.

CONCLUSIONS

The novel nomogram composed of admission NIHSS, ASPECT scores, right hemisphere, collateral circulation, recanalization, hematocrit, and serum glucose provide a potential predictor for MCE in patients with AIS after EVT.

Functional and Mortality Outcomes with Medical and Surgical Therapy in Malignant Posterior Circulation Infarcts: A Systematic Review

BACKGROUND

There remains uncertainty regarding optimal definitive management for malignant posterior circulation infarcts (MPCI). While guidelines recommend neurosurgery for malignant cerebellar infarcts that are refractory to medical therapy, concerns exist about the functional outcome and quality of life after decompressive surgery.

OBJECTIVE

This study aims to evaluate the outcomes of surgical intervention compared to medical therapy in MPCI.

METHODS

In this systematic review, MEDLINE, Embase and Cochrane databases were searched from inception until 2 April 2021. Studies were included if they involved posterior circulation strokes treated with neurosurgical intervention and reported mortality and functional outcome data. Data were collected according to PRISMA guidelines.

RESULTS

The search yielded 6677 studies, of which 31 studies (comprising 723 patients) were included for analysis. From the included studies, we found that surgical therapy led to significant differences in mortality and functional outcomes in patients with severe disease. Neurological decline and radiological criteria were often used to decide the timing for surgical intervention, as there is currently limited evidence for preventative neurosurgery. There is also limited evidence for the superiority of one surgical modality over another.

CONCLUSION

For patients with MPCI who are clinically stable at the time of presentation, in terms of mortality and functional outcome, surgical therapy appears to be equivocal to medical therapy. Reliable evidence is lacking, and further prospective studies are rendered.

Predictors and outcome of malignant cerebral edema after successful reperfusion in anterior circulation stroke

BACKGROUND AND OBJECTIVE

Risk factors and predictors of malignant cerebral edema (MCE) after successful endovascular thrombectomy (EVT) were not fully explored. This study aimed to evaluate the incidence and risk factors of MCE after successful reperfusion.

METHODS

We retrospectively analyzed consecutive ischemic stroke patients who underwent EVT in our institution from November 2015 to April 2022. Patients who failed to achieve successful reperfusion (modified thrombolysis in cerebral infarction [mTICI]<2b) were excluded. Based on multivariate logistic models, the best-fit monogram was established. The discriminative performance was assessed by the receiver operating characteristics curve (ROC).

RESULTS

A total of 307 patients were included and 48 (15.6%) were diagnosed with MCE after successful reperfusion. Patients with MCE after successful reperfusion had a lower 3-month favorable outcome (15.2% versus 59.6%; p<0.001), a lower 3-month good outcome (17.4% versus 68.4%; p<0.001), and a higher rate of mortality at 3-month (54.3% versus 8.8%; p<0.001) compared with patients without MCE. Predictors of MCE after successful reperfusion included admission glucose level, baseline National Institutes of Health Stroke Scale (NIHSS) score, stroke etiology, occlusion site and puncture-to-reperfusion (PTR) time>120 min. The area under the curve (AUC) of the nomogram was 0.805 (95% CI, 0.756-0.847).

CONCLUSIONS

MCE after successful reperfusion is associated with poor outcome and mortality. A nomogram containing admission glucose level, baseline NIHSS score, stroke etiology, occlusion site and PTR time>120 min may predict the risk of MCE after successful reperfusion in patients with acute ischemic stroke and treated successfully with EVT.

Neuroworsening in the Emergency Department Is a Predictor of Traumatic Brain Injury Intervention and Outcome: A TRACK-TBI Pilot Study

INTRODUCTION

Neuroworsening may be a sign of progressive brain injury and is a factor for treatment of traumatic brain injury (TBI) in intensive care settings. The implications of neuroworsening for clinical management and long-term sequelae of TBI in the emergency department (ED) require characterization.

METHODS

Adult TBI subjects from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot Study with ED admission and disposition Glasgow Coma Scale (GCS) scores were extracted. All patients received head computed tomography (CT) scan <24 h post-injury. Neuroworsening was defined as a decline in motor GCS at ED disposition (vs. ED admission). Clinical and CT characteristics, neurosurgical intervention, in-hospital mortality, and 3- and 6-month Glasgow Outcome Scale-Extended (GOS-E) scores were compared by neuroworsening status. Multivariable regressions were performed for neurosurgical intervention and unfavorable outcome (GOS-E ≤ 3). Multivariable odds ratios (mOR) with [95% confidence intervals] were reported.

RESULTS

In 481 subjects, 91.1% had ED admission GCS 13-15 and 3.3% had neuroworsening. All neuroworsening subjects were admitted to intensive care unit (vs. non-neuroworsening: 26.2%) and were CT-positive for structural injury (vs. 45.4%). Neuroworsening was associated with subdural (75.0%/22.2%), subarachnoid (81.3%/31.2%), and intraventricular hemorrhage (18.8%/2.2%), contusion (68.8%/20.4%), midline shift (50.0%/2.6%), cisternal compression (56.3%/5.6%), and cerebral edema (68.8%/12.3%; all p < 0.001). Neuroworsening subjects had higher likelihoods of cranial surgery (56.3%/3.5%), intracranial pressure (ICP) monitoring (62.5%/2.6%), in-hospital mortality (37.5%/0.6%), and unfavorable 3- and 6-month outcome (58.3%/4.9%; 53.8%/6.2%; all p < 0.001). On multivariable analysis, neuroworsening predicted surgery (mOR = 4.65 [1.02-21.19]), ICP monitoring (mOR = 15.48 [2.92-81.85], and unfavorable 3- and 6-month outcome (mOR = 5.36 [1.13-25.36]; mOR = 5.68 [1.18-27.35]).

CONCLUSIONS

Neuroworsening in the ED is an early indicator of TBI severity, and a predictor of neurosurgical intervention and unfavorable outcome. Clinicians must be vigilant in detecting neuroworsening, as affected patients are at increased risk for poor outcomes and may benefit from immediate therapeutic interventions.

Machine learning prediction of malignant middle cerebral artery infarction after mechanical thrombectomy for anterior circulation large vessel occlusion

OBJECTIVE

Prediction of malignant middle cerebral artery infarction (MMI) could identify patients for early intervention. We trained and internally validated a ML model that predicts MMI following mechanical thrombectomy (MT) for ACLVO.

METHODS

All patients who underwent MT for ACLVO between 2015 - 2021 at a single institution were reviewed. Data was divided into 80% training and 20% test sets. 10 models were evaluated on the training set. The top 3 models underwent hyperparameter tuning using grid search with nested 5-fold CV to optimize the area under the receiver operating curve (AUROC). Tuned models were evaluated on the test set and compared to logistic regression.

RESULTS

A total of 381 patients met the inclusion criteria. There were 50 (13.1%) patients who developed MMI. Out of the 10 ML models screened on the training set, the top 3 performing were neural network (median AUROC 0.78, IQR 0.72 - 0.83), support vector machine ([SVM] median AUROC 0.77, IQR 0.72 - 0.83), and random forest (median AUROC 0.75, IQR 0.68 - 0.81). On the test set, random forest (median AUROC 0.78, IQR 0.73 - 0.83) and neural network (median AUROC 0.78, IQR 0.73 - 0.83) were the top performing models, followed by SVM (median AUROC 0.77, IQR 0.70 - 0.83). These scores were significantly better than those for logistic regression (AUROC 0.72, IQR 0.66 - 0.78), individual risk factors, and the Malignant Brain Edema score (p < 0.001 for all).

CONCLUSION

ML models predicted MMI with good discriminative ability. They outperformed standard statistical techniques and individual risk factors.

Perioperative Management of the Acute Stroke Patient: From Door to Needle to NeuroICU

Acute ischemic stroke is a neurologic emergency that requires precise care due to high likelihood of morbidity and mortality. Current guidelines recommend thrombolytic therapy with alteplase within the first 3 to 4.5 hours of initial stroke symptoms and endovascular mechanical thrombectomy within the first 16 to 24 hours. Anesthesiologists may be involved in the care of these patients perioperatively and in the intensive care unit. Although the optimal anesthetic for these procedures remains under investigation, this article will review how to best optimize and treat these patients to achieve the best outcomes.

Ischemic brain edema: Emerging cellular mechanisms and therapeutic approaches

Brain edema is one of the most devastating consequences of ischemic stroke. Malignant cerebral edema is the main reason accounting for the high mortality rate of large hemispheric strokes. Despite decades of tremendous efforts to elucidate mechanisms underlying the formation of ischemic brain edema and search for therapeutic targets, current treatments for ischemic brain edema remain largely symptom-relieving rather than aiming to stop the formation and progression of edema. Recent preclinical research reveals novel cellular mechanisms underlying edema formation after brain ischemia and reperfusion. Advancement in neuroimaging techniques also offers opportunities for early diagnosis and prediction of malignant brain edema in stroke patients to rapidly adopt life-saving surgical interventions. As reperfusion therapies become increasingly used in clinical practice, understanding how therapeutic reperfusion influences the formation of cerebral edema after ischemic stroke is critical for decision-making and post-reperfusion management. In this review, we summarize these research advances in the past decade on the cellular mechanisms, and evaluation, prediction, and intervention of ischemic brain edema in clinical settings, aiming to provide insight into future preclinical and clinical research on the diagnosis and treatment of brain edema after stroke.

Decompressive Hemicraniectomy in the Stroke Patient

Decompressive hemicraniectomy (DHC) is a life-saving procedure involving removal of large portions of the skull to relieve intracranial pressure in patients with space occupying cerebral edema such as traumatic brain injury (TBI) and stroke. Although the procedure has been shown to decrease mortality in patients, the risk of severe disability is significant. Quality of life, not just survival, following DHC has emerged as an important consideration when the decision is made to perform a DHC.

Outcomes of decompressive craniectomy for large territory cerebral infarction with and without prior reperfusion: a multicentre retrospective review

PURPOSE

Reperfusion therapy has greatly improved outcomes of ischaemic stroke but remains associated with haemorrhagic conversion and early deterioration in a significant proportion of patients. Outcomes in terms of function and mortality are mixed and the evidence for decompressive craniectomies (DC) in this context remains sparse. We aim to investigate the clinical efficacy of DC in this group of patients compared to those without prior reperfusion therapy.

METHODS

A multicentre retrospective study was conducted between 2005 and 2020, and all patients with DC for large territory infarctions were included. Outcomes in terms of inpatient and long-term modified Rankin scale (mRS) and mortality were assessed at various time points and compared using both univariable and multivariable analyses. Favourable mRS was defined as 0-3.

RESULTS

There were 152 patients included in the final analysis. The cohort had a mean age of 57.5 years and median Charlson comorbidity index of 2. The proportion of preoperative anisocoria was 15.1%, median preoperative Glasgow coma scale was 9, the ratio of left-sided stroke was 40.1%, and ICA infarction was 42.8%. There were 79 patients with prior reperfusion and 73 patients without. After multivariable analysis, the proportion of favourable 6-month mRS (reperfusion, 8.2%; no reperfusion, 5.4%) and 1-year mortality (reperfusion, 26.7%; no reperfusion, 27.3%) were similar in both groups. Subgroup analysis of thrombolysis and/or thrombectomy against no reperfusion was also unremarkable.

CONCLUSION

Reperfusion therapy prior to DC performed for large territory cerebral infarctions does not affect the functional outcome and mortality in a well-selected patient population.

Complications of Decompressive Craniectomy: A Case-Based Review

Background Decompressive craniectomy (DC) is a frequently performed procedure to treat intracranial hypertension following traumatic brain injury (TBI) and stroke. DC is a salvage procedure that reduces mortality at the expense of severe disability and compromises the quality of life. The procedure is not without serious complications.

Methods We describe the complications following DC and its management in a case-based review in this article.

Results Complications after DC are classified as early or late complications based on the time of occurrence. Early complication includes hemorrhage, external cerebral herniation, wound complications, CSF leak/fistula, and seizures/epilepsy. Contusion expansion, new contralateral epidural, and subdural hematoma in the immediate postoperative period mandate surgical intervention. It is necessary to repeat non-contrast CT head at 24 hours and 48 hours following DC. Late complication includes subdural hygroma, hydrocephalus, syndrome of the trephined, bone resorption, and falls on the unprotected cranium. An early cranioplasty is an effective strategy to mitigate most of the late complications.

Conclusions DC can be associated with a number of complications. One should be aware of the possible complications, and timely intervention is required.

Rates of operative intervention for infection after synthetic or autologous cranioplasty: a National Readmissions Database analysis

OBJECTIVE

The aim of this study was to characterize the clinical utilization and associated charges of autologous bone flap (ABF) versus synthetic flap (SF) cranioplasty and to characterize the postoperative infection risk of SF versus ABF using the National Readmissions Database (NRD).

METHODS

The authors used the publicly available NRD to identify index hospitalizations from October 2015 to December 2018 involving elective ABF or SF cranioplasty after traumatic brain injury (TBI) or stroke. Subsequent readmissions were further characterized if patients underwent neurosurgical intervention for treatment of infection or suspected infection. Survey Cox proportional hazards models were used to assess risk of readmission.

RESULTS

An estimated 2295 SF and 2072 ABF cranioplasties were performed from October 2015 to December 2018 in the United States. While the total number of cranioplasty operations decreased during the study period, the proportion of cranioplasties utilizing SF increased (p < 0.001), particularly in male patients (p = 0.011) and those with TBI (vs stroke, p = 0.012). The median total hospital charge for SF cranioplasty was $31,200 more costly than ABF cranioplasty (p < 0.001). Of all first-time readmissions, 20% involved surgical treatment for infectious reasons. Overall, 122 SF patients (5.3%) underwent surgical treatment of infection compared with 70 ABF patients (3.4%) on readmission. After accounting for confounders using a multivariable Cox model, female patients (vs male, p = 0.003), those discharged nonroutinely (vs discharge to home or self-care, p < 0.001), and patients who underwent SF cranioplasty (vs ABF, p = 0.011) were more likely to be readmitted for reoperation. Patients undergoing cranioplasty during more recent years (e.g., 2018 vs 2015) were less likely to be readmitted for reoperation because of infection (p = 0.024).

CONCLUSIONS

SFs are increasingly replacing ABFs as the material of choice for cranioplasty, despite their association with increased hospital charges. Female sex, nonroutine discharge, and SF cranioplasty are associated with increased risk for reoperation after cranioplasty.

Cerebrospinal fluid volume improves prediction of malignant edema after endovascular treatment of stroke

BACKGROUND

The ratio of intracranial cerebrospinal fluid (CSF) volume to intracranial volume (ICV) has been identified as a potential predictor of malignant edema formation in patients with acute ischemic stroke.

AIMS

We aimed to evaluate the added value of the CSF/ICV ratio in a model to predict malignant edema formation in patients who underwent endovascular treatment.

METHODS

We included patients from the MR CLEAN Registry, a prospective national multicenter registry of patients who were treated with endovascular treatment between 2014 and 2017 because of acute ischemic stroke caused by large vessel occlusion. The CSF/ICV ratio was automatically measured on baseline thin-slice noncontrast CT. The primary outcome was the occurrence of malignant edema based on clinical and imaging features. The basic model included the following predictors: age, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT score, occlusion of the internal carotid artery, collateral score, time between symptom onset and groin puncture, and unsuccessful reperfusion. The extended model included the basic model and the CSF/ICV ratio. The performance of the basic and the extended model was compared with the likelihood ratio test.

RESULTS

Malignant edema occurred in 40 (6%) of 683 patients. In the extended model, a lower CSF/ICV ratio was associated with the occurrence of malignant edema (odds ratio (OR) per percentage point, 1.2; 95% confidence interval (CI) 1.1-1.3, p < 0.001). Age lost predictive value for malignant edema in the extended model (OR 1.1; 95% CI 0.9-1.5, p = 0.372). The performance of the extended model was higher than that of the basic model (p < 0.001).

CONCLUSIONS

Adding the CSF/ICV ratio improves a multimodal prediction model for the occurrence of malignant edema after endovascular treatment.

Comparative Study of Cerebral Perfusion in Different Types of Decompressive Surgery for Traumatic Brain Injury

Introduction Computed tomography perfusion (CTP) brain usefulness in the treatment of traumatic brain injury (TBI) is still being investigated. Comparative research of CTP in the various forms of decompressive surgery has not yet been reported to our knowledge. Patients with TBI who underwent decompressive surgery were studied using pre- and postoperative CTP. CTP findings were compared with patient's outcome.

Materials and Methods This was a single-center, prospective cohort study. A prospective analysis of patients who were investigated with CTP from admission between 2019 and 2021 was undertaken. The patients in whom decompressive surgery was required for TBI, were included in our study after applying inclusion and exclusion criteria. CTP imaging was performed preoperatively and 5 days after decompressive surgery to measure cerebral perfusion. Numbers of cases included in the study were 75. Statistical analysis was done.

Results In our study, cerebral perfusion were improved postoperatively in the all types of decompressive surgery (p-value < 0.05). But association between type of surgery with improvement in cerebral perfusion, Glasgow Coma Scale at discharge, and Glasgow Outcome Scale-extended at 3 months were found to be statistically insignificant (p-value > 0.05).

Conclusion CTP brain may play a role as a prognostic tool in TBI patients undergoing decompressive surgery.

Malignant Middle Cerebral Artery Infarction during Early versus Late Endovascular Treatment in Acute Ischemic Stroke

INTRODUCTION

Endovascular treatment (EVT) performed in the early time window has been shown to decrease the incidence of malignant middle cerebral artery infarction (MMI). However, the incidence of MMI in patients undergoing EVT during the late time window is unclear. This study aimed to investigate the prevalence of MMI in patients undergoing late EVT and compare it with that in patients undergoing early EVT.

METHODS

We retrospectively analyzed consecutive patients with anterior large vessel occlusion stroke who underwent EVT at Xuanwu Hospital between January 2013 and June 2021. Eligible patients were divided into early EVT (within 6 h) and late EVT (6-24 h) groups according to the time from their stroke onset to puncture and compared. The occurrence of MMI post-EVT was the primary outcome.

RESULTS

A total of 605 patients were recruited, of whom 300 (50.4%) underwent EVT within 6 h and 305 (49.6%) underwent EVT within 6-24 h. A total of 119 patients (19.7%) developed MMI. 68 patients (22.7%) in the early EVT group and 51 patients (16.7 %) in the late EVT group developed MMI (p = 0.066). After adjusting for covariate variables, late EVT was independently associated with a lower incidence of MMI (odds ratio, 0.404; 95% confidence interval, 0.242-0.675; p = 0.001).

CONCLUSION

MMI is not an uncommon phenomenon in the modern thrombectomy era. Compared with the early time window, patients selected by stricter radiological criteria to undergo EVT in the late time window are independently associated with a lower incidence of MMI.

Impact of Decompressive Craniectomy on Hemorrhagic Transformation in Malignant Ischemic Stroke in Mice

BACKGROUND

Endovascular thrombectomy has changed the management of ischemic stroke. The reperfusion can however lead to a hemorrhagic transformation (HT). Decompressive craniectomy (DC) is a surgical procedure used for malignant ischemic stroke. However, its efficacy was demonstrated before the era of endovascular thrombectomy trials. Here, we hypothesized that DC for ischemic stroke after thrombectomy could lead to a higher risk of HT. We thus evaluated this hypothesis in a mouse model of stroke induced by occlusion of the middle cerebral artery (MCAO) with or without mechanical reperfusion.

METHODS

Ninety mice subjected to MCAO were divided into 6 groups: permanent MCAO with or without DC; MCAO followed by a mechanical reperfusion with or without DC and MCAO with a mechanical reperfusion followed by r-tPA (recombinant tissue-type plasminogen activator)-induced reperfusion with or without DC. Mice were evaluated by magnetic resonance imaging 24 hours after the MCAO to assess ischemic lesion volumes, and the rate, type, and volume of HTs.

RESULTS

The ischemic volume was higher in the 2 groups without reperfusion than in the 4 groups with reperfusion independently of r-tPA treatment and DC. The distribution of HT types was different between the 6 groups. The HT volumes and HT scores was smaller in the 2 groups without reperfusion and in the reperfusion group without r-tPA and without DC. In mice having reperfusion, the mean HT score was higher in mice who had DC without r-tPA (HT score 5; P=0.048) or with r-tPA (HT score 8; P=0.02), than in mice without DC (HT score 1).

CONCLUSIONS

DC for a malignant stroke, after reperfusion, corresponding to an endovascular thrombectomy failure, increases the risk of severe hemorrhagic transformations in a model of ischemic stroke in mice. This result support the need of clinical studies to evaluate the added value of DC at the era of endovascular thrombectomy.

Decompressive Hemicraniectomies as a Damage Control Approach for Multilobar Firearm Projectile Injuries: A Single-Center Experience

BACKGROUND

While firearms projectile injuries to the head carry a high rate of morbidity and mortality, current literature in clinical management remains controversial. Decompressive hemicraniectomy (DHC) has been previously described in the neurosurgical literature for traumatic brain injuries, with positive results in the reduction of mortality. Here we aim to assess DHC as a damage control approach for multilobar firearm injuries to the head and compare our results with what is present in the literature.

METHODS

A retrospective review of patients who sustained multilobar firearm injuries to the head admitted to our center from January 2009 to April 2021 was performed. Exclusion criteria were a Glasgow Coma Scale (GCS) score <5, and/or brain stem dysfunction that persisted despite stabilization and medical therapy for intracranial hypertension.

RESULTS

A total of 20 patients were analyzed, with an average GCS on admission of 8.35. The 60-day mortality rate for all 20 patients was 20% with a total of 4 deaths, 1 of which was due to pulmonary sepsis in the critical postoperative care unit. The mean hospital stay of surviving patients was 22 days.

CONCLUSIONS

DHC should be considered as a damage control strategy for young patients with multilobar firearm injuries and GCS >5, having yielded favorable results in this study when compared to current literature.

Dynamic Craniotomy With NuCrani Reversibly Expandable Cranial Bone Flap Fixation Plates: A Technical Report

BACKGROUND

Dynamic craniotomy provides cranial decompression without bone flap removal along with avoidance of cranioplasty and reduced risks for complications.

OBJECTIVE

To report the first clinical cases using a novel dynamic craniotomy bone flap fixation system. The NeuroVention NuCrani reversibly expandable cranial bone flap fixation plates provide dynamic bone flap movement to accommodate changes in intracranial pressure (ICP) after a craniotomy.

METHODS

The reversibly expandable cranial bone flap fixation plates were used for management of cerebral swelling in a patient with a subdural hemorrhage after severe traumatic brain injury and another patient with a hemorrhagic stroke.

RESULTS

Both cases had high ICP's which normalized immediately after the dynamic craniotomy. Progressive postoperative cerebral swelling was noted which was compensated by progressive outward bone flap migration thereby maintaining a normal ICP, and with resolution of the cerebral swelling, the plates retracted the bone flaps to an anatomic flush position.

CONCLUSION

The reversibly expandable plates provide an unhinged cranial bone flap outward migration with an increase in ICP and retract the bone flap after resolution of brain swelling while also preventing the bone flap from sinking inside the skull.

Cerebral Edema in Patients with severe Hemispheric Syndrome: Incidence, Risk Factors, and Outcomes-Data from SITS-ISTR

BACKGROUND AND PURPOSE

Cerebral edema (CED) in ischemic stroke can worsen prognosis and about 70% of patients who develop severe CED die if treated conservatively. We aimed to describe incidence, risk factors and outcomes of CED in patients with extensive ischemia.

METHODS

Oservational study based on Safe Implementation of Treatments in Stroke-International Stroke Treatment Registry (2003-2019). Severe hemispheric syndrome (SHS) at baseline and persistent SHS (pSHS) at 24 hours were defined as National Institutes of Health Stroke Score (NIHSS) >15. Outcomes were moderate/severe CED detected by neuroimaging, functional independence (modified Rankin Scale 0-2) and death at 90 days.

RESULTS

Patients (n=8,560) presented with SHS and developed pSHS at 24 hours; 82.2% received intravenous thrombolysis (IVT), 10.5% IVT+thrombectomy, and 7.3% thrombectomy alone. Median age was 77 and NIHSS 21. Of 7,949 patients with CED data, 3,780 (47.6%) had any CED and 2,297 (28.9%) moderate/severe CED. In the multivariable analysis, age <50 years (relative risk [RR], 1.56), signs of acute infarct (RR, 1.29), hyperdense artery sign (RR, 1.39), blood glucose >128.5 mg/dL (RR, 1.21), and decreased level of consciousness (RR, 1.14) were associated with moderate/severe CED (for all P<0.05). Patients with moderate/severe CED had lower odds to achieve functional Independence (adjusted odds ratio [aOR], 0.35; 95% confidence interval [CI], 0.23 to 0.55) and higher odds of death at 90 days (aOR, 2.54; 95% CI, 2.14 to 3.02).

CONCLUSIONS

In patients with extensive ischemia, the most important predictors for moderate/ severe CED were age <50, high blood glucose, signs of acute infarct, hyperdense artery on baseline scans, and decreased level of consciousness. CED was associated with worse functional outcome and a higher risk of death at 3 months.

PrImary decompressive Craniectomy in AneurySmal Subarachnoid hemOrrhage (PICASSO) trial: study protocol for a randomized controlled trial

BACKGROUND

Poor-grade aneurysmal subarachnoid hemorrhage (SAH) is associated with poor neurological outcome and high mortality. A major factor influencing morbidity and mortality is brain swelling in the acute phase. Decompressive craniectomy (DC) is currently used as an option in order to reduce intractably elevated intracranial pressure (ICP). However, execution and optimal timing of DC remain unclear.

METHODS

PICASSO resembles a multicentric, prospective, 1:1 randomized standard treatment-controlled trial which analyzes whether primary DC (pDC) performed within 24 h combined with the best medical treatment in patients with poor-grade SAH reduces mortality and severe disability in comparison to best medical treatment alone and secondary craniectomy as ultima ratio therapy for elevated ICP. Consecutive patients presenting with poor-grade SAH, defined as grade 4-5 according to the World Federation of Neurosurgical Societies (WFNS), will be screened for eligibility. Two hundred sixteen patients will be randomized to receive either pDC additional to best medical treatment or best medical treatment alone. The primary outcome is the clinical outcome according to the modified Rankin Scale (mRS) at 12 months, which is dichotomized to favorable (mRS 0-4) and unfavorable (mRS 5-6). Secondary outcomes include morbidity and mortality, time to death, length of intensive care unit (ICU) stay and hospital stay, quality of life, rate of secondary DC due to intractably elevated ICP, effect of size of DC on outcome, use of duraplasty, and complications of DC.

DISCUSSION

This multicenter trial aims to generate the first confirmatory data in a controlled randomized fashion that pDC improves the outcome in a clinically relevant endpoint in poor-grade SAH patients.

TRIAL REGISTRATION

DRKS DRKS00017650. Registered on 09 June 2019.

Decompressive craniectomy index: Does the size of decompressive craniectomy matter in malignant middle cerebral artery infarction?

Background

Malignant middle cerebral artery (MCA) infarction is associated with high mortality, mainly due to intracranial hypertension. This malignant course develops when two-thirds or more of MCA territory is infarcted. Randomized clinical trials demonstrated that in patients with malignant MCA infarction, decompressive craniectomy (DC) is associated with better prognosis. In these patients, some prognostic predictors are already known, including age and time between stroke and DC. The size of bone flap was not associated with long-term prognosis in the previous studies. Therefore, this paper aims to further expand the analysis of the bone removal toward a more precise quantification and verify the prognosis implication of the bone flap area/whole supratentorial hemicranium relation in patients treated with DC for malignant middle cerebral infarcts.

Methods

This study included 45 patients operated between 2015 and 2020. All patients had been diagnosed with a malignant MCA infarction and were submitted to DC to treat the ischemic event. The primary endpoint was dichotomized modified Rankin scale (mRS) 1 year after surgery (mRS≤4 or mRS>4).

Results

Patients with bad prognosis (mRS 5-6) were on average: older and with a smaller decompressive craniectomy index (DCI). In multivariate analysis, with adjustments for "age" and "time" from symptoms onset to DC, the association between DCI and prognosis remained.

Conclusion

In our series, the relation between bone flap size and theoretical maximum supratentorial hemicranium area (DCI) in patients with malignant MCA infarction was associated with prognosis. Further studies are necessary to confirm these findings.

Management of Pediatric Stroke - Challenges and Perspectives from Resource-limited Settings

Childhood stroke is not as common as adult stroke, but it is underrecognized the world over. Diagnosis is often delayed due to lack of awareness not only by the lay public but also by emergency and front-line health care workers. Despite the relative rarity of childhood stroke, the impact on morbidity, mortality and the economic burden for families and society is high, especially in poorly resourced settings. The risk factors for stroke in children differ from the adult population where lifestyle factors play a more important role. The developmental aspects of the pediatric cerebral vasculature and hematological maturational biology affects the clinical presentation, investigation, management and outcomes of childhood stroke in a different way compared to adults. The management of childhood stroke is currently based on expert guidelines and evidence extrapolated from adult studies. Hyperacute therapies that have revolutionized the treatment of stroke in adults cannot be easily applied to children at this stage due to the diagnostic delays, diverse risk factors and developmental considerations mentioned above. Much has been achieved in the understanding of genetic, acquired, preventable and recurrent stroke risk factors in the past decade through international collaborative efforts like the International Pediatric Stroke Study. Evidence for the prevention and treatment of childhood stroke remains elusive. Even more elusive are relevant and achievable management guidelines for pediatric stroke in resource-limited settings. This narrative review focusses on the current management practices globally, emphasizing the challenges, and gaps in knowledge of pediatric stroke in low- and middle-income countries and other areas with limited resources. Priorities and some potential solutions at national and local level are suggested for these settings.

Brain symmetry index predicts 3-month mortality in patients with acute large hemispheric infarction

Quantitative electroencephalography data are helpful to predict outcomes of cerebral infarction patients. The study was performed to evaluate the value of brain symmetry index by quantitative electroencephalography in predicting 3-month mortality of large hemispheric infarction. We studied a prospective, consecutive series of patients with large supratentorial cerebral infarction confirmed within 3 days from the onset in 2 intensive care units from August 2017 to February 2020. The electroencephalography was recorded once admission. The brain symmetry index (BSI) which is divided into BSIfast and BSIslow were calculated for each electrodes pair. The outcome was mortality at 3 months after the onset. A total of 38 patients were included. The subjects were divided into the mortality group (15 patients) and survival group (23 patients). Of the BSIfast and BSIslow at each electrodes pair, higher BSIfastC3-C4, higher BSIslowC3-C4, and higher BSIslowO1-O2 were noticed in the mortality group than that in the survival group at 3 months (P = .001; P = .010; P = .009). Multivariable analysis indicated that BSIfastC3-C4 was an independent predictor of 3-month mortality (odds ratio = 1.059, 95%CI 1.003, 1.119, P = .039). BSIfastC3-C4 could significant predict 3-month mortality (area under curve = 0.805, P = .005). And when we combined BSIfastC3-C4, Glasgow Coma Scale and infarct volume together to predict the 3-month mortality, the predicted value increased (area under curve = 0.840, P = .002). BSIfastC3-C4 could independently predict the 3-month mortality of large hemispheric infarction. The combination marker which includes Glasgow Coma Scale, infarct volume, and BSIfastC3-C4 has a better diagnostic value. Further clinical trials with a large sample size are still needed.

Surgical decompression for malignant cerebral oedema after ischaemic stroke

BACKGROUND

Large territory middle cerebral artery (MCA) ischaemic strokes account for around 10% of all ischaemic strokes and have a particularly devastating prognosis when associated with malignant oedema. Progressive cerebral oedema starts developing in the first 24 to 48 hours of stroke ictus with an associated rise in intracranial pressure. The rise in intracranial pressure may eventually overwhelm compensatory mechanisms leading to a cascading secondary damage to surrounding unaffected parenchyma. This downward spiral can rapidly progress to death or severe neurological disability. Early decompressive craniectomy to relieve intracranial pressure and associated tissue shift can help ameliorate this secondary damage and improve outcomes. Evidence has been accumulating of the benefit of early surgical decompression in stroke patients. Earlier studies have excluded people above the age of 60 due to associated poor outcomes; however, newer trials have included this patient subgroup. This review follows a Cochrane Review published in 2012.

OBJECTIVES

To assess the effectiveness of surgical decompression in people with malignant oedema after ischaemic stroke with regard to reduction in mortality and improved functional outcome. We also aimed to examine the adverse effects of surgical decompression in this patient cohort.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2022, Issue 7 of 12), MEDLINE Ovid, Embase Ovid, Web of Science Core Collection, Scopus databases, ClinicalTrials.gov, and the WHO ICTRP to July 2022. We also reviewed the reference lists of relevant articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing decompressive craniectomy with medical management to best medical management alone for people with malignant cerebral oedema after MCA ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results, assessed study eligibility, performed risk of bias assessment, and extracted the data. The primary outcomes were death and death or severe disability (modified Rankin Scale (mRS) > 4) at 6 to 12 months follow-up. Other outcomes included death or moderate disability (mRS > 3), severe disability (mRS = 5), and adverse events. We assessed the certainty of the evidence using the GRADE approach, categorising it as high, moderate, low, or very low.

MAIN RESULTS

We included nine RCTs with a total of 513 participants included in the final analysis. Three studies included patients younger than 60 years of age; two trials accepted patients up to 80 years of age; and one trial only included patients 60 years or older. The majority of included trials (six) mandated a time from stroke ictus to treatment of < 48 hours, whilst in two of them this was < 96 hours. Surgical decompression was associated with a reduction in death (odds ratio (OR) 0.18, 95% confidence interval (CI) 0.12 to 0.27, 9 trials, 513 participants, P < 0.001; high-certainty evidence); death or severe disability (mRS > 4, OR 0.22, 95% CI 0.15 to 0.32, 9 trials, 513 participants, P < 0.001; high-certainty evidence); and death or moderate disability (mRS > 3, OR 0.34, 95% CI 0.22 to 0.52, 9 trials, 513 participants, P < 0.001; moderate-certainty evidence). Subgroup analysis did not reveal any significant effect on treatment outcomes when analysing age (< 60 years versus ≥ 60 years); time from stroke ictus to intervention (< 48 hours versus ≥ 48 hours); or dysphasia. There was a significant subgroup effect of time at follow-up (6 versus 12 months, P = 0.02) on death as well as death or severe disability (mRS > 4); however, the validity of this finding was affected by fewer participant numbers in the six-month follow-up subgroup. There was no consistent reporting of per-participant adverse event rates in any of the included studies, which prevented further analysis.

AUTHORS' CONCLUSIONS

Surgical decompression improves outcomes in the management of malignant oedema after acute ischaemic stroke, including a considerable reduction in death or severe disability (mRS > 4) and a reduction in death or moderate disability (mRS > 3). Whilst there is evidence that this positive treatment effect is present in patients > 60 years old, it is important to take into account that these patients have a poorer prospect of functional survival independent of this treatment effect. In interpreting these results it must also be considered that the data demonstrating benefit are drawn from a unique patient subset with profound neurological deficit, reduced level of consciousness, and no pre-morbid disability or severe comorbidity.

Medical management of cerebral edema in large hemispheric infarcts

Acute ischemic stroke confers a high burden of morbidity and mortality globally. Occlusion of large vessels of the anterior circulation, namely the intracranial carotid artery and middle cerebral artery, can result in large hemispheric stroke in ~8% of these patients. Edema from stroke can result in a cascade effect leading to local compression of capillary perfusion, increased stroke burden, elevated intracranial pressure, herniation and death. Mortality from large hemispheric stroke is generally high and surgical intervention may reduce mortality and improve good outcomes in select patients. For those patients who are not eligible candidates for surgical decompression either due timing, medical co-morbidities, or patient and family preferences, the mainstay of medical management for cerebral edema is hyperosmolar therapy. Other neuroprotectants for cerebral edema such as glibenclamide are under investigation. This review will discuss current guidelines and evidence for medical management of cerebral edema in large hemispheric stroke as well as discuss important neuromonitoring and critical care management targeted at reducing morbidity and mortality for these patients.

Decompressive Craniectomy for the Treatment of Severe Diffuse Traumatic Brain Injury: A Randomized Controlled Trial

Background  Severe traumatic brain injury (TBI) is one of the leading public health problems across the world. TBI is associated with high economic costs to the healthcare system specially in developing countries. Decompressive craniectomy is a procedure in which an area of the skull is removed to increase the volume of intracranial compartment. There are various techniques of decompressive craniectomy used that include subtemporal and circular decompression, and unilateral or bilateral frontotemporoparietal decompression. Objective  The aim of this study was to compare the outcome of decompressive craniectomy for the management of severe TBI versus conservative management alone at the Department of Neurosurgery, Abbasi Shaheed Hospital, Karachi, Pakistan. Methods  The study (randomized controlled trial) was conducted from February 1, 2014, till June 30, 2017. Results  A total of 136 patients were included after following the inclusion criteria. They were randomly assigned to two groups, making it 68 patients in each study group. There were 89 males and 47 females. All the patients received standard care recommended by the Brain Trauma Foundation. The mortality rate observed at 6 months in decompressive craniectomy was 22.05%, while among conservative management group, it was 45.58%. Difference in mortality of both groups at 6 months was significant. Total 61.76% (42) of patients from decompressive craniectomy group had a favorable outcome (Glasgow outcome scale: 4-5) at 6 months. While among conservative management group, total 35.29% (24) had a favorable outcome (Glasgow outcome scale: 4-5). Difference in Glasgow outcome scale at 6 months of both groups was significant. Conclusion  In conclusion, decompressive craniectomy is simple, safe, and better than conservative management alone.

Acute Hospital Management of Pediatric Stroke

The field of pediatric stroke has historically been hampered by limited evidence and small patient cohorts. However the landscape of childhood stroke is rapidly changing due in part to increasing awareness of the importance of pediatric stroke and the emergence of dedicated pediatric stroke centers, care pathways, and alert systems. Acute pediatric stroke management hinges on timely diagnosis confirmed by neuroimaging, appropriate consideration of recanalization therapies, implementation of neuroprotective measures, and attention to secondary prevention. Because pediatric stroke is highly heterogenous in etiology, management strategies must be individualized. Determining a child's underlying stroke etiology is essential to appropriately tailoring hyperacute stroke management and determining best approach to secondary prevention. Herein, we review the methods of recognition, diagnosis, management, current knowledge gaps and promising research for pediatric stroke.

A nomogram for predicting malignant cerebral artery infarction in the modern thrombectomy era

Objective

This study aimed to develop and validate a nomogram to predict malignant cerebral artery infarction (MMI) after endovascular treatment (EVT) in patients with acute ischemic stroke (AIS) in the modern thrombectomy era.

Methods

We retrospectively analyzed data from a prospective cohort of consecutive patients with AIS who underwent EVT at Xuanwu hospital between January 2013 and June 2021. A multivariable logistic regression model was employed to construct the nomogram for predicting MMI after EVT. The discrimination and calibration of the nomogram were assessed both in the derivation and validation cohorts.

Results

A total of 605 patients were enrolled in this study, with 425 in the derivation cohort and 180 in the validation cohort. The nomogram was developed based on admission systolic blood pressure (SBP), the National Institute of Health Stroke Score (NIHSS), the Alberta Stroke Program Early Computed Tomography Score (ASPECTS), vessel occlusion site, EVT time window, and recanalization status. The nomogram displayed good discrimination with the area under the receiver operating characteristics (ROCs) curve (AUC) of 0.783 [95% confidence interval (CI), 0.726–0.840] in the derivation cohort and 0.806 (95% CI, 0.738–0.874) in the validation cohort. The calibration of the nomogram was good as well, with the Hosmer–Lemeshow test of p = 0.857 in the derivation cohort and p = 0.275 in the validation cohort.

Conclusion

In the modern thrombectomy era, a nomogram containing admission SBP, NIHSS, ASPECTS, vessel occlusion site, EVT time window, and recanalization status may predict the risk of MMI after EVT in patients with AIS.

Association between proteinuria and the development of malignant middle cerebral artery infarction: A retrospective cohort study

A disrupted blood-brain barrier (BBB) with extravasation of macromolecules plays a critical role in the development of malignant middle cerebral artery infarction (MMI). Proteinuria is considered a marker of generalized endothelial dysfunction, including BBB disruption. This study aimed to clarify whether proteinuria identified in the acute stage of stroke is associated with MMI development. Patients with infarctions involving the middle cerebral artery territory were reviewed. Urine samples collected within 8 hours after stroke were analyzed using urine dipsticks. Patients were divided into proteinuria (urine dipstick reading of 1 + to 4+) and nonproteinuria groups. MMI was present if either signs of uncal herniation or a progressive conscious disturbance were recorded along with a midline shift > 5 mm identified on follow-up computed tomography (CT). Among the 1261 patients identified between January 2010 and June 2019, 138 were eligible for final analyses. Patients in the MMI group had lower Alberta Stroke Program Early CT Scores (ASPECTS), higher National Institutes of Health Stroke Scale scores, and a greater proportion of proteinuria than those in the non-MMI group. Four multivariate logistic regression models were used to clarify the role of proteinuria in MMI development. In model 1, proteinuria was significantly associated with MMI after adjusting for age, sex, dyslipidemia and ASPECTS (OR = 2.987, 95% CI = 1.329-6.716, P = .0081). The risk of developing MMI in patients with proteinuria remained significant in model 2 (OR = 3.066, 95% CI = 1.349-6.968, P = .0075) after adjusting for estimated glomerular filtrate rate (eGFR) < 60ml/min/1.73 m2 in addition to variables in model 1. In model 3, proteinuria was still significantly associated with MMI after adjusting for age, sex, dyslipidemia, ASPECTS, hypertension, diabetes, and atrial fibrillation (OR = 2.521, 95% CI = 1.075-5.912, P = .0335). In model 4, the risk of developing MMI in patients with proteinuria remained significant (OR = 2.579, 95% CI = 1.094-6.079, P = .0304) after adjusting for eGFR < 60ml/min/1.73 m2 in addition to variables in model 3. Proteinuria is independently associated with MMI development. Proteinuria may be a clinically accessible predictor of MMI development.

Optic nerve sheath diameter and optic nerve sheath diameter/eyeball transverse diameter ratio in prediction of malignant progression in ischemic stroke

Background

The optic nerve sheath diameter (ONSD)/eyeball transverse diameter (ETD) ratio has been suggested in the evaluation of intracranial pressure (ICP). The aim of this study was to evaluate the predictive value of ONSD and ONSD/ETD in relation to risk for secondary malignant middle cerebral artery infarction (MMI).

Methods

A total of 91 patients with MCA occlusion were included in this study. Data were divided into two groups based on development of MMI or not. ONSD and ETD were measured by unenhanced computed tomography (CT). The differences in ONSD and the ONSD/ETD ratios between the MMI and non-MMI groups were compared. Receiver operating characteristic curve analyses were used to test the diagnostic value of ONSD and ONSD/ETD independently, to predict MMI.

Results

The ONSD in the MMI group and non-MMI group were 5.744 ± 0.140 mm and 5.443 ± 0.315 mm, respectively (P = 0.001). In addition, the ONSD/ETD ratios in the MMI group and non-MMI group were 0.258 ± 0.008 and 0.245 ± 0.006, respectively (P = 0.001). The receiver operating characteristic (ROC) curve demonstrated an area under the curve (AUC) for ONSD of 0.812 [95% confidence interval (CI): 0.718–0.906, P = 0.001], with a sensitivity of 97.4% and a specificity of 66.0% at the cut-off value of 5.520 mm. The AUC for ONSD/ETD ratio in predicting occurrence of MMI was 0.895 (95% CI: 0.823–0.968, P = 0.001), with a sensitivity of 84.2% and a specificity of 92.5% at a cut-off value of 0.250.

Conclusion

In acute stroke patients with massive cerebral infarction, an increased ONSD or ONSD/ETD ratio increases the odds of malignant progression and may be used as an indicator for emergent therapeutic interventions. In addition, the ONSD/ETD ratio may be more valuable than ONSD in predicting the malignant progression of acute stroke patients.

Comparison of Common Outcome Measures for Assessing Independence in Patients Diagnosed with Disorders of Consciousness: A Traumatic Brain Injury Model Systems Study

Patients with disorders of consciousness (DoC) after traumatic brain injury (TBI) recover to varying degrees of functional dependency. Dependency is difficult to measure but critical for interpreting clinical trial outcomes and prognostic counseling. In participants with DoC (i.e., not following commands) enrolled in the TBI Model Systems National Database (TBIMS NDB), we used the Functional Independence Measure (FIM^®) as the reference to evaluate how accurately the Glasgow Outcome Scale-Extended (GOSE) and Disability Rating Scale (DRS) assess dependency. Using the established FIM-dependency cut-point of <80, we measured the classification performance of literature-derived GOSE and DRS cut-points at 1-year post-injury. We compared the area under the receiver operating characteristic curve (AUROC) between the DRS_Depend, a DRS-derived marker of dependency, and the data-derived optimal GOSE and DRS cut-points. Of 18,486 TBIMS participants, 1483 met inclusion criteria (mean [standard deviation (SD)] age = 38 [18] years; 76% male). The sensitivity of GOSE cut-points of ≤3 and ≤4 (Lower Severe and Upper Severe Disability, respectively) for identifying FIM-dependency were 97% and 98%, but specificities were 73% and 51%, respectively. The sensitivity of the DRS cut-point of ≥12 (Severe Disability) for identifying FIM-dependency was 60%, but specificity was 100%. The DRS_Depend had a sensitivity of 83% and a specificity of 94% for classifying FIM-dependency, with a greater AUROC than the data-derived optimal GOSE (≤3, p = 0.01) and DRS (≥10, p = 0.008) cut-points. Commonly used GOSE and DRS cut-points have limited specificity or sensitivity for identifying functional dependency. The DRS_Depend identifies FIM-dependency more accurately than the GOSE and DRS cut-points, but requires further validation.

Spreading Depolarization as a Therapeutic Target in Severe Ischemic Stroke: Physiological and Pharmacological Strategies

BACKGROUND

Spreading depolarization (SD) occurs nearly ubiquitously in malignant hemispheric stroke (MHS) and is strongly implicated in edema progression and lesion expansion. Due to this high burden of SD after infarct, it is of great interest whether SD in MHS patients can be mitigated by physiologic or pharmacologic means and whether this intervention improves clinical outcomes. Here we describe the association between physiological variables and risk of SD in MHS patients who had undergone decompressive craniectomy and present an initial case of using ketamine to target SD in MHS.

METHODS

We recorded SD using subdural electrodes and time-linked with continuous physiological recordings in five subjects. We assessed physiologic variables in time bins preceding SD compared to those with no SD.

RESULTS

Using multivariable logistic regression, we found that increased ETCO2 (OR 0.772, 95% CI 0.655-0.910) and DBP (OR 0.958, 95% CI 0.941-0.991) were protective against SD, while elevated temperature (OR 2.048, 95% CI 1.442-2.909) and WBC (OR 1.113, 95% CI 1.081-1.922) were associated with increased risk of SD. In a subject with recurrent SD, ketamine at a dose of 2 mg/kg/h was found to completely inhibit SD.

CONCLUSION

Fluctuations in physiological variables can be associated with risk of SD after MHS. Ketamine was also found to completely inhibit SD in one subject. These data suggest that use of physiological optimization strategies and/or pharmacologic therapy could inhibit SD in MHS patients, and thereby limit edema and infarct progression. Clinical trials using individualized approaches to target this novel mechanism are warranted.

A multicenter cohort study of early complications after cranioplasty: results of the German Cranial Reconstruction Registry

OBJECTIVE

Cranioplasty (CP) is a crucial procedure after decompressive craniectomy and has a significant impact on neurological improvement. Although CP is considered a standard neurosurgical procedure, inconsistent data on surgery-related complications after CP are available. To address this topic, the authors analyzed 502 patients in a prospective multicenter database (German Cranial Reconstruction Registry) with regard to early surgery-related complications.

METHODS

Early complications within 30 days, medical history, mortality rates, and neurological outcome at discharge according to the modified Rankin Scale (mRS) were evaluated. The primary endpoint was death or surgical revision within the first 30 days after CP. Independent factors for the occurrence of complications with or without surgical revision were identified using a logistic regression model.

RESULTS

Traumatic brain injury (TBI) and ischemic stroke were the most common underlying diagnoses that required CP. In 230 patients (45.8%), an autologous bone flap was utilized for CP; the most common engineered materials were titanium (80 patients [15.9%]), polyetheretherketone (57 [11.4%]), and polymethylmethacrylate (57 [11.4%]). Surgical revision was necessary in 45 patients (9.0%), and the overall mortality rate was 0.8% (4 patients). The cause of death was related to ischemia in 2 patients, diffuse intraparenchymal hemorrhage in 1 patient, and cardiac complications in 1 patient. The most frequent causes of surgical revision were epidural hematoma (40.0% of all revisions), new hydrocephalus (22.0%), and subdural hematoma (13.3%). Preoperatively increased mRS score (OR 1.46, 95% CI 1.08-1.97, p = 0.014) and American Society of Anesthesiologists Physical Status Classification System score (OR 2.89, 95% CI 1.42-5.89, p = 0.003) were independent predictors of surgical revision. Ischemic stroke, as the underlying diagnosis, was associated with a minor rate of revisions compared with TBI (OR 0.18, 95% CI 0.06-0.57, p = 0.004).

CONCLUSIONS

The authors have presented class II evidence-based data on surgery-related complications after CP and have identified specific preexisting risk factors. These results may provide additional guidance for optimized treatment of these patients.

Outcomes of patients admitted to the ICU for acute stroke: a retrospective cohort

Background

Although acute stroke is a leading cause of morbidity and mortality worldwide, data on outcomes of stroke patients requiring ICU admission are limited. We aimed to identify factors associated with a good neurological outcome (defined as a modified Rankin Scale score [mRS] of 0–2) 6 months after ICU admission.

Methods

We retrospectively studied consecutive patients who were admitted to the ICU of a French university-affiliated hospital between January 2014 and December 2018 and whose ICD-10 code indicated acute stroke. Patients with isolated subarachnoid hemorrhage or posttraumatic stroke were excluded.

Results

The 323 identified patients had a median age of 67 [54.5–77] years; 173 (53.6%) were male. The main reasons for ICU admission were neurological failure (87%), hemodynamic instability (28.2%), acute respiratory failure (26%), and cardiac arrest (5.3%). At ICU admission, the Glasgow Coma Scale score was 6 [4–10] and the SAPSII was 54 [35–64]. The stroke was hemorrhagic in 248 (76.8%) patients and ischemic in 75 (23.2%). Mechanical ventilation was required in 257 patients (79.6%). Six months after ICU admission, 61 (19.5%) patients had a good neurological outcome (mRS, 0–2), 50 (16%) had significant disability (mRS, 3–5), and 202 (64.5%) had died; 10 were lost to follow-up. By multivariable analysis, factors independently associated with not having an mRS of 0–2 at 6 months were older age (odds ratio, 0.93/year; 95% confidence interval, 0.89–0.96; P < 0.01) and lower Glasgow Coma Scale score at ICU admission (odds ratio, 1.23/point; 95% confidence interval, 1.07–1.40; P < 0.01).

Conclusions

Acute stroke requiring ICU admission carried a poor prognosis, with less than a fifth of patients having a good neurological outcome at 6 months. Age and depth of coma independently predicted the outcome.

Predictors of malignant middle cerebral artery infarction after endovascular thrombectomy: results of DIRECT-MT trial

OBJECTIVES

Predictors of malignant middle cerebral artery infarction (mMCAi) in patients after intravenous thrombolysis were well documented, but the risk factors of mMCAi after endovascular thrombectomy (EVT) were not fully explored. Therefore, the present study aimed to investigate the predictors of mMCAi after EVT in stroke patients.

METHODS

This was a secondary analysis of the DIRECT-MT trial. Patients who underwent EVT for the occlusions of MCA and/or intracranial internal carotid artery were analyzed. Primary outcome was the occurrence of mMCAi after EVT. Demographic, clinical, imaging, and treatment data were recorded, and multivariate logistic regression analysis was used to identify independent predictors. All of the candidate predictors were included, and forward elimination was applied to establish the most effective predictive model. Predictive ability and calibration of the model were assessed using the area under the receiver operating characteristic curve (AUC) and Hosmer-Lemeshow test, respectively.

RESULTS

Of 559 enrolled patients, 74 (13.2%) patients developed mMCAi. Predictors of mMCAi included unsuccessful reperfusion, higher serum glucose, lower Alberta Stroke Project Early Computed Tomography Change Score (ASPECTS), higher clot burden score (CBS), lower collateral score, and higher pass number of thrombectomy device. AUC of predictive model integrating all independent variables was 0.836. The Hosmer-Lemeshow test showed appropriate calibration (p = 0.859).

CONCLUSIONS

Reperfusion, serum glucose, ASPECTS, CBS, collateral, and pass number of thrombectomy device were associated with the occurrence of mMCAi in stroke patients after EVT, while alteplase treatment was not. Our findings might facilitate the early identification and management of stroke patients at a high risk of mMCAi.

KEY POINTS

• A total of 13.2% of stroke patients with large vessel occlusion of anterior circulation developed mMCAi after EVT. • The occurrence of mMCAi had a definite negative impact on the outcome for stroke patients. • Reperfusion, serum glucose, ASPECTS, CBS, collateral score, and the pass number of thrombectomy device were associated with the occurrence of mMCAi after EVT in stroke patients.

Current Status and Outcomes of Critical Traumatic Brain Injury (GCS = 3-5) in a Developing Country: A Retrospective, Registry-Based Study

BACKGROUND

Patients sustaining critical TBI [initial Glasgow Coma Scale (GCS) ≤ 5] generally have poor outcomes. Little is known about the frequency, mortality rate, and functional outcomes of such patients in Iran.

METHODS

In this retrospective, registry-based cohort study, the demographic and clinicoradiological findings of TBI patients were queried from March 21, 2017, to March 21, 2020. We included TBI patients with initial GCS of 3-5. The functional outcome was assessed using the Glasgow Outcome Score-extended 6 (GOSE-6) months after the hospital discharge. Patients were classified as having unfavorable (GOSE-6 ≤ 4) and favorable (GOSE-6 > 4) outcomes. Gathered data were compared between groups. Multivariable logistic regression analysis was done to find factors affecting the outcome.

RESULTS

Four hundred ninety-seven patients (mean age = 37.59 ± 17.89) were enrolled, and 69.2% had unfavorable outcomes. Elderly patients (age ≥ 65 years) were highly overrepresented among the unfavorable group. 48.9% had bilateral fixed dilated pupils (BDFP), who mostly attained unfavorable outcomes. The overall in-hospital mortality rate was 50.3%. The in-hospital mortality rate was appalling among elderly patients with BFDP and GCS 3( 90%) and GCS 4(100%). Age ≥ 65 years [odds ratio (OR) 3.45, 95% confidence interval (CI) 1.19-10.04], and BFDP (OR 4.48, 95% CI 2.60-7.73) increase the odds of unfavorable outcomes according to the regression analysis.

CONCLUSION

The survival rate and favorable outcomes of critical TBI patients are generally poor. However, we believe that the neurotrauma surgeons should discuss with patients' proxies and explain the clinical conditions and possible outcomes.

Elevation of neutrophil carcinoembryonic antigen-related cell adhesion molecule 1 associated with multiple inflammatory mediators was related to different clinical stages in ischemic stroke patients

BACKGROUND

We aimed to analyze the level of carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1) in neutrophils of ischemic stroke (IS) patients at different stages, together with its roles in neutrophils.

PATIENTS AND METHODS

Sixty-seven patients were classified into acute phase group (n = 19), subacute phase group (n = 28), and stable phase group (n = 20), and 20 healthy individuals who had received physical examination at the same time period as healthy control. We then analyzed the expression level of CEACAM1 and cell viability in CEACAM1 positive and CEACAM1 negative neutrophils by flow cytometry and the content of plasma CEACAM1, neutrophil gelatinase-associated lipocalin (NGAL), matrix metalloproteinases-9 (MMP-9) was measured using enzyme-linked immunosorbent assay (ELISA), while that of interleukin-10 (IL-10) and tumor necrosis factor (TNF) was determined using a Human Enhanced Sensitivity Flex set.

RESULTS

Compared with healthy control, the percentage of CEACAM1 positive neutrophils in IS patients showed a significant increase, and a significant increase was also noticed in the content of plasma CEACAM1 at the subacute stage. Reduction in cell viability was observed in CEACAM1 positive neutrophils compared with CEACAM1 negative counterparts. There was a positive correlation between CEACAM1 expression rate in neutrophils and plasma CEACAM1 and IL-10 content in the subacute group. Compared with acute group and healthy control group, there was an instinct increase in the level of plasma MMP-9 and NGAL in subacute group.

CONCLUSIONS

Our data showed that there was a rapid increase of CEACAM1 in neutrophils at the acute stage of IS. We speculated that CEACAM1 may serve as an inhibitory regulator involving in the progression of IS.

Prognosis of Ischemic Stroke Patients Undergoing Endovascular Thrombectomy is Influenced by Systemic Inflammatory Index Through Malignant Brain Edema

Purpose

Patients and Methods

Results

Conclusion