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Legros V, Lefour S, Bard M, Giordano-Orsini G, Jolly D, Kanagaratnam L. Optic Nerve and Perioptic Sheath Diameter (ONSD), Eyeball Transverse Diameter (ETD) and ONSD/ETD Ratio on MRI in Large Middle Cerebral Artery Infarcts: A Case-Control Study. J Stroke Cerebrovasc Dis 2020; 30:105500. [PMID: 33360251 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/03/2020] [Accepted: 11/22/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Despite recent progress in the multidisciplinary management of large middle cerebral artery infarcts, the neurological prognosis remains worrying in a non-negligible number of cases. The objective of this study is to analyze the contribution of optic nerve and perioptic sheath measurement on MRI to the acute phase of large middle cerebral artery infarcts. METHODS A retrospective case-control study between January 2008 and December 2019 in a single academic medical center was performed. Cases and controls were selected by interrogation of International Classification of Diseases (ICD), 10th edition, with ischemic stroke as criterion (code I64). Decompressive hemicraniectomy was a criterion for large middle cerebral artery infarcts (cases). Cases were matched with controls (1:3) based on age (± 5 years), sex, and year of hospitalization (± 2 years) The examinations were performed on 3T MRI (Siemens IRM 3T Magnetom).Optic nerve and perioptic sheath diameter was calculated using electronic calipers, 3 mm behind retina and in a perpendicular vector with reference to the orbit in axial 3D TOF sequence. RESULTS Of 2612 patients, 22 patients met all the criteria of large middle cerebral artery infarcts and they were paired with 44 controls. Patients were mainly women, mean age of 53.6 years. There is a significant difference in the size of the optic nerve and perioptic sheath diameter measured on MRI at patient's admission (right: 5.13 ± 0.2 mm vs. 4.80 mm ± 0.18, p <0. 0001, left: 5.16 ± 0.17 vs 4.78 ± 0.20, p<0.0001). The AUC of optic nerve and perioptic sheath diameter was 0.93 (95%IC [0.85-1.00]), for a threshold at 5.03 mm, the sensitivity was 0.82 (95%IC [0.6-0.93]), specificity 0.94 (95%IC [0.85-0.98]). The Odds Ratio of large middle cerebral artery infarcts was 46.4 for optic nerve and perioptic sheath diameter the (95%IC [6.15-350.1] p=0.0002). CONCLUSION Optic nerve and perioptic sheath diameter in the first MRI can predict the risk of developing large middle cerebral artery infarcts requiring a decompressive hemicraniectomy.
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Affiliation(s)
- Vincent Legros
- Surgical and Trauma Intensive Care Unit, Trauma Center, Hopital Maison Blanche, Reims University Hospital, 45 rue Cognacq Jay, 51092 Reims Cedex, France.
| | - Sophie Lefour
- Department of Neurology, Hopital Maison Blanche, Reims University Hospital, 45 rue Cognacq Jay, 51092 Reims Cedex, France.
| | - Mathieu Bard
- Department of Anesthesiology and Critical Care, Hopital Maison Blanche, Reims University Hospital, 45 rue Cognacq Jay, 51092 Reims Cedex, France; University of Medicine of Reims Champagne-Ardennes, 51 rue Cognacq Jay, 51092 Reims Cedex, France.
| | - Guillaume Giordano-Orsini
- Department of emergency medicine, Hopital Maison Blanche, Reims University Hospital, 45 rue Cognacq Jay, 51092 Reims Cedex, France; University of Medicine of Reims Champagne-Ardennes, France.
| | - Damien Jolly
- University of Medicine of Reims Champagne-Ardennes, 51 rue Cognacq Jay, 51092 Reims Cedex, France; Department of clinical research, Hopital Robert Debré, Reims University Hospital, 51 avenue du General Koenig, 51092 Reims Cedex, France.
| | - Lukshe Kanagaratnam
- University of Medicine of Reims Champagne-Ardennes, 51 rue Cognacq Jay, 51092 Reims Cedex, France; Department of clinical research, Hopital Robert Debré, Reims University Hospital, 51 avenue du General Koenig, 51092 Reims Cedex, France.
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202
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Mohamed MWF, Aung SS, Mereddy N, Ramanan SP, Hamid P. Role, Effectiveness, and Outcome of Decompressive Craniectomy for Cerebral Venous and Dural Sinus Thrombosis (CVST): Is Surgery Really an Option? Cureus 2020; 12:e12135. [PMID: 33489547 PMCID: PMC7811578 DOI: 10.7759/cureus.12135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Cerebral venous and dural sinus thrombosis (CVST) is predominantly a disease of young people. It accounts for 0.5% of all strokes, and patients usually have good outcomes. However, a minority of patients may present with elevated intracranial pressure characteristics in a serious illness type and may die from brain herniation if not treated promptly. Decompressive craniectomy (DC) is the only treatment modality that can prevent death in such cases of imminent brain herniation. Unfortunately, due to the condition's rarity and ethical concerns, randomized controlled trials are not available. This review assessed the available literature on cerebral venous and dural sinus thrombosis in different age groups and decompressive craniectomy in cerebral venous and dural sinus thrombosis. It revealed that decompressive surgery is extremely effective when done early and for the correct indications with patients achieving excellent functional outcomes post-surgery. Decompressive surgery is recommended in rapidly deteriorating patients with computed tomography (CT) scan evidence of basal cisterns effacement, a mass effect from haemorrhage and/or infarction, and significant midline shift.
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Affiliation(s)
| | - Su Sandi Aung
- Medicine and Surgery, University of Medicine 1, Yangon, MMR
| | - Nakul Mereddy
- Medicine and Surgery, Bhaskar Medical College, Hyderabad, IND
| | | | - Pousette Hamid
- Neurology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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203
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Alzayiani M, Schmidt T, Veldeman M, Riabikin A, Brockmann MA, Schiefer J, Clusmann H, Schubert GA, Albanna W. Risk profile of decompressive hemicraniectomy for malignant stroke after revascularization treatment. J Neurol Sci 2020; 420:117275. [PMID: 33352507 DOI: 10.1016/j.jns.2020.117275] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 12/10/2020] [Accepted: 12/12/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Revascularization by pharmacological and/or endovascular treatment is an effective therapy for acute ischemic stroke caused by artery occlusion. In the context of malignant middle cerebral artery infarction (MMI), decompressive hemicraniectomy (DHC) can be life-saving. However, its effectiveness and safety after revascularization have not been thoroughly assessed. This retrospective study aimed to determine the risk profile of pre-surgical revascularization treatment (RT) for subsequent DHC. METHODS A total of 152 consecutive patients treated by DHC after MMI were identified between 2012 and 2015. After elimination of cases with previous stroke and cases pre-treated with antiplatelets or anticoagulants (increased postoperative bleeding), twenty-four out of fifty patients (n = 24/50, 48%) received pre-surgical revascularization treatment by intravenous thrombolysis (TL), mechanical thrombectomy (MT) or a combination of both. Demographic data was compared alongside perioperative, postoperative complications (intra-/extracerebral hemorrhage, revision surgery due to hemorrhage or infection, and overall mortality) and economic parameters. RESULTS Comparing patients with and without prior RT, there was no statistically significant difference in duration of surgery (RT: 83 [57-116] min vs. no-RT: 96 [69-119] min, p = 0.308), intraoperative blood loss (RT: 300 [225-375] ml vs. no-RT: 300 [250-400] ml, p = 0.763), intraoperative transfusion requirement (RT: 12.5% vs. no-RT: 26.9%, p = 0.294), or need for volume substitution (RT: 1300 [1200-1400] ml vs. no-RT: 1200 [1100-1400] ml, p = 0.359). The rate of postoperative complications was also comparable in both groups, including intra-/extracerebral hemorrhage, revision due to hemorrhage or infections, and mortality (p = 0.814, p = 0.520, p = 0.697, and p = 0.769). Health economic parameters were not affected (ventilation time: RT: 309 [12-527] hrs. vs. no-RT: 444 [171-605] hrs., p = 0.120, length of stay: RT: 23 [13-32] days vs. no-RT: 28 [19-41], p = 0.156, and stay costs: RT: 27768 [13044-60,248] € vs. no-RT: 35422 [21225-49,585] €, p = 0.312). CONCLUSION DHC for patients with MMI who previously received revascularization therapy appears to be safe and not associated with a higher complication rate or increased health economic burden.
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Affiliation(s)
| | - Tobias Schmidt
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Alexander Riabikin
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Marc A Brockmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany; Department of Neuroradiology, University Medical Center Mainz, Mainz, Germany
| | | | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | | | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
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204
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Hecht N, Schrammel M, Neumann K, Müller MM, Dreier JP, Vajkoczy P, Woitzik J. Perfusion-Dependent Cerebral Autoregulation Impairment in Hemispheric Stroke. Ann Neurol 2020; 89:358-368. [PMID: 33219550 DOI: 10.1002/ana.25963] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/18/2020] [Accepted: 11/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Loss of cerebral autoregulation (CA) plays a key role in secondary neurologic injury. However, the regional distribution of CA impairment after acute cerebral injury remains unclear because, in clinical practice, CA is only assessed within a limited compartment. Here, we performed large-scale regional mapping of cortical perfusion and CA in patients undergoing decompressive surgery for malignant hemispheric stroke. METHODS In 24 patients, autoregulation over the affected hemisphere was calculated based on direct, 15 to 20-minute cortical perfusion measurement with intraoperative laser speckle imaging and mean arterial blood pressure (MAP) recording. Cortical perfusion was normalized against noninfarcted tissue and 6 perfusion categories from 0% to >100% were defined. The interaction between cortical perfusion and MAP was estimated using a linear random slope model and Pearson correlation. RESULTS Cortical perfusion and CA impairment were heterogeneously distributed across the entire hemisphere. The degree of CA impairment was significantly greater in areas with critical hypoperfusion (40-60%: 0.42% per mmHg and 60-80%: 0.46% per mmHg) than in noninfarcted (> 100%: 0.22% per mmHg) or infarcted (0-20%: 0.29% per mmHg) areas (*p < 0.001). Pearson correlation confirmed greater CA impairment at critically reduced perfusion (20-40%: r = 0.67; 40-60%: r = 0.68; and 60-80%: r = 0.68) compared to perfusion > 100% (r = 0.36; *p < 0.05). Tissue integrity had no impact on the degree of CA impairment. INTERPRETATION In hemispheric stroke, CA is impaired across the entire hemisphere to a variable extent. Autoregulation impairment was greatest in hypoperfused and potentially viable tissue, suggesting that precise localization of such regions is essential for effective tailoring of perfusion pressure-based treatment strategies. ANN NEUROL 2021;89:358-368.
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Affiliation(s)
- Nils Hecht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Max Schrammel
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurosurgery, University of Oldenburg, Oldenburg, Germany
| | - Konrad Neumann
- Institute for Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Marc-Michael Müller
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Anesthesiology, University of Schleswig-Holstein, Kiel, Germany
| | - Jens P Dreier
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany.,Einstein Center for Neurosciences Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurosurgery, University of Oldenburg, Oldenburg, Germany
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205
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Hernández-Durán S, Meinen L, Rohde V, von der Brelie C. Invasive Monitoring of Intracranial Pressure After Decompressive Craniectomy in Malignant Stroke. Stroke 2020; 52:707-711. [PMID: 33272130 DOI: 10.1161/strokeaha.120.032390] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The role of decompressive hemicraniectomy (DC) in malignant cerebral infarction (MCI) has clearly been established, but little is known about the course of intracranial pressure (ICP) in patients undergoing this surgical measure. In this study, we investigated the role of invasive ICP monitoring in patients after DC for MCI, postulating that postoperative ICP predicts mortality. METHODS In this retrospective observational study of MCI patients undergoing DC, ICP were recorded continuously in hourly intervals for the first 72 hours after DC. For every hour, mean ICP was calculated, pooling ICP of every patient. A receiver operating characteristic analysis was performed for hourly mean ICP. A subgroup analysis by age (≥60 years and <60 years) was also performed. RESULTS A total of 111 patients were analyzed, with 29% mortality rate in patients <60 years, and 41% in patients ≥60 years. A threshold of 10 mm Hg within the first 72 postoperative hours was a reliable predictor of mortality in MCI, with an acceptable sensitivity of 70% and high specificity of 97%. Established predictors of mortality failed to predict mortality. CONCLUSIONS Our study suggests the need to reevaluate postoperative ICP after DC in MCI and calls for a redefinition of ICP thresholds in these patients to indicate further therapy.
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Affiliation(s)
| | - Leonie Meinen
- Department of Neurological Surgery, Universitätsmedizin Göttingen, Germany
| | - Veit Rohde
- Department of Neurological Surgery, Universitätsmedizin Göttingen, Germany
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206
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Pedro KM, Roberto KT, Chua AE. Safety and Outcome of Decompressive Hemicraniectomy After Recombinant Tissue Plasminogen Activator Thrombolysis for Acute Ischemic Stroke: A Systematic Review. World Neurosurg 2020; 144:50-58. [DOI: 10.1016/j.wneu.2020.08.088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/10/2020] [Accepted: 08/12/2020] [Indexed: 10/23/2022]
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207
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Decompressive craniectomy in aneurysmal subarachnoid hemorrhage: Who and when? – A systematic review and meta-analysis. Clin Neurol Neurosurg 2020; 199:106252. [DOI: 10.1016/j.clineuro.2020.106252] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022]
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208
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Decompressive craniectomy in malignant MCA infarction in times of mechanical thrombectomy. Acta Neurochir (Wien) 2020; 162:3147-3152. [PMID: 31879817 DOI: 10.1007/s00701-019-04180-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Mechanical thrombectomies (MT) in stroke have changed the standard treatment regimen with a continuous increase of MTs during the last years. A subsequent reduction in the rates of decompressive craniectomies (DC) as well as a change in clinical characteristics of patients undergoing an additional DC after MT may be assumed. Therefore, objective of this study was to investigate the influence of nowadays regularly performed MT on patients undergoing DC. METHODS Patients with DC due to cerebral infarctions between January 2009 and January 2018 were included. Patients' clinical presentation and surgical parameters were collected retrospectively. Initial GCS and NIHSS, extent of the stroke, time interval from symptom onset to DC, and neurological outcome were compared between patients with and without thrombectomy. RESULTS A total of 5469 ischemic strokes were treated in the investigated period, leading to DC in 119 cases (2.2%). A decrease in the rate of performed DCs was recorded: in 2009, 2.8% of ischemic stroke patients underwent surgery compared to 1.9% in 2017. In the meantime, the number of MTs in our center has increased from 84 in 2014 to 160 in 2017. MT was performed in 32 patients prior to DC. No significant differences could be seen between the groups regarding age, initial NIHSS (median 18 in both groups, p = 0.81), extent of the infarctions prior to DC (median ASPECTS 0 in both groups, p = 0.87), time interval from symptom onset to DC, and neurological outcome. CONCLUSIONS The introduction of routinely performed MT as part of the standard treatment regimen for ischemic stroke has led to a decrease in DCs. However, DC patients with and without MT showed no differences regarding their initial clinical criteria and outcome. These results suggest that earlier DC studies in patients with MCA infarction also apply for the collective of thrombectomized patients.
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209
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Mrosk F, Hecht N, Vajkoczy P. Decompressive hemicraniectomy in ischemic stroke. J Neurosurg Sci 2020; 65:249-258. [PMID: 33252206 DOI: 10.23736/s0390-5616.20.05103-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Malignant hemispheric stroke (MHS) is a life-threatening event, associated with high morbidity and mortality. Decompressive hemicraniectomy (DHS) is the treatment of choice to relieve the emerging space-occupying brain edema. This review details the pathophysiological and scientific background, considerations for clinical decision making, surgical treatment and impact on the patients' outcome. Although surgery reduces mortality significantly, the probability for unfavorable outcome is still high in selected cases. While former randomized controlled studies aimed for the prevention of the primary cause, the current research focuses on the treatment and prevention of secondary neurological injury.
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Affiliation(s)
- Friedrich Mrosk
- Department of Neurosurgery, Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany -
| | - Peter Vajkoczy
- Department of Neurosurgery, Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
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210
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Mourand I, Mahmoudi M, Dargazanli C, Pavillard F, Arquizan C, Labreuche J, Derraz I, Gaillard N, Blanchet-Fourcade G, Lefevre PH, Boukriche Y, Gascou G, Corti L, Costalat V, Le Bars E, Cagnazzo F. DWI cerebellar infarct volume as predictor of outcomes after endovascular treatment of acute basilar artery occlusion. J Neurointerv Surg 2020; 13:995-1001. [PMID: 33243771 DOI: 10.1136/neurintsurg-2020-016804] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/27/2020] [Accepted: 11/06/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Preprocedural predictors of outcome in patients with acute basilar artery occlusion (ABAO) who have undergone endovascular treatment (EVT) remain controversial. Our aim was to determine if pre-EVT diffusion-weighted imaging cerebellar infarct volume (CIV) is a predictor of 90-day outcomes. METHODS We analyzed consecutive MRI-selected endovascularly treated patients with ABAO within the first 24 hours after symptom onset. Successful reperfusion was defined as a modified Thrombolysis in Cerebral Infarction score of 2b-3. Using the initial MRI, baseline CIV was calculated in mL on an apparent diffusion coefficient map reconstruction (Olea Sphere software). CIV was analyzed in univariate and multivariable models as a predictor of 90-day functional independence (modified Rankin Scale (mRS) 0-2) and mortality. According to receiver operating characteristic (ROC) analysis, the optimal cut-off was determined by maximizing the Youden index to evaluate the prognostic value of CIV. RESULTS Of the 110 MRI-selected patients with ABAO, 64 (58.18%) had a cerebellar infarct. The median CIV was 9.6 mL (IQR 2.7-31.4). Successful reperfusion was achieved in 81.8% of the cases. At 90 days the proportion of patients with mRS ≤2 was 31.8% and the overall mortality rate was 40.9%. Baseline CIV was significantly associated with 90-day mRS 0-2 (p=0.008) in the univariate analysis and was an independent predictor of 90-day mortality (adjusted OR 1.79, 95% CI 1.25 to 2.54, p=0.001). The ROC analysis showed that a CIV ≥4.7 mL at the initial MRI was the optimal cut-off to discriminate patients with a higher risk of death at 90 days (area under the ROC curve (AUC)=0.74, 95% CI 0.61 to 0.87, sensitivity and specificity of 87.9% and 58.1%, respectively). CONCLUSIONS In our series of MRI-selected patients with ABAO, pre-EVT CIV was an independent predictor of 90-day mortality. The risk of death was increased for baseline CIV ≥4.7 mL.
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Affiliation(s)
- Isabelle Mourand
- Neurology, University Hospital Centre Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Mehdi Mahmoudi
- Neuroradiology, University Hospital Center Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Cyril Dargazanli
- Neuroradiology, University Hospital Center Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Frederique Pavillard
- Reanimation, University Hospital Centre Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Caroline Arquizan
- Neurology, University Hospital Centre Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Julien Labreuche
- Biostatistics, University Hospital Center Lilles, Lilles, France
| | - Imad Derraz
- Neuroradiology, University Hospital Center Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Nicolas Gaillard
- Neurology, University Hospital Centre Montpellier, Montpellier, Languedoc-Roussillon, France
| | | | - Pierre Henri Lefevre
- Neuroradiology, University Hospital Center Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Yassine Boukriche
- Neurology, Hospital Center Beziers, Beziers, Languedoc-Roussillon, France
| | - Gregory Gascou
- Neuroradiology, University Hospital Center Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Lucas Corti
- Neurology, University Hospital Centre Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Vincent Costalat
- Neuroradiology, University Hospital Center Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Emmanuelle Le Bars
- Neuroradiology, University Hospital Center Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Federico Cagnazzo
- Neuroradiology, University Hospital Center Montpellier, Montpellier, Languedoc-Roussillon, France
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211
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Bath PM, Appleton JP, England T. The Hazard of Negative (Not Neutral) Trials on Treatment of Acute Stroke: A Review. JAMA Neurol 2020; 77:114-124. [PMID: 31790551 DOI: 10.1001/jamaneurol.2019.4107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance While there are a limited number of beneficial treatments for acute stroke (eg, stroke units, reperfusion, aspirin, hemicraniectomy), there are more negative (as opposed to neutral) interventions spanning multiple different mechanisms of action. To reduce the risk of future negative studies, it is vital to understand why previous interventions appeared to cause harm. Observations The limited number of beneficial treatments for acute ischemic stroke are far outnumbered by negative (not neutral) interventions that worsened outcomes in randomized clinical trials (RCTs), including those with putative neuroprotectant, anticoagulant, anti-inflammatory, free radical-scavenging, hemorrhagic, or vasoactive activity. Other agents reduced thrombolytic efficiency or exhibited neuropsychiatric or cardiac toxicity. In intracerebral hemorrhage, platelet transfusion was hazardous. Although reperfusion treatments should be given as soon as possible, very early intervention with other strategies may instead be hazardous, as has been seen with physical therapy and vasodepressors. Conclusions and Relevance The lessons learned from negative stroke RCTs are vital for designing future studies. Multicenter preclinical studies are necessary, and animals that die must be included in analyses. Randomized clinical trials must assess multiple neurological, vascular, cardiac, and general safety effects, whether these are on target or off target. All preclinical trials and RCTs must be published in full. Learning from the past will help to reduce the number of negative stroke RCTs in the future.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, England.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, England
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, England.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, England
| | - Timothy England
- Vascular Medicine, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, England
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212
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Lammy S, Taylor A, Willetts S, St George EJ. In Reply to the Letter to the Editor Regarding "15-Year Institutional Retrospective Case Series of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction (mMCAI)". World Neurosurg 2020; 143:640. [PMID: 33167161 DOI: 10.1016/j.wneu.2020.08.155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 08/21/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Simon Lammy
- SpR Neurological Surgery, Department of Neurosurgery, Institute of Neurological Sciences, Glasgow, United Kingdom.
| | - Aaron Taylor
- SHO Neurological Surgery, Department of Neurosurgery, Institute of Neurological Sciences, Glasgow, United Kingdom
| | - Sarah Willetts
- FY2 Neurological Surgery, Department of Neurosurgery, Institute of Neurological Sciences, Glasgow, United Kingdom
| | - Edward J St George
- Consultant Neurological Surgeon, Department of Neurosurgery, Institute of Neurological Sciences, Glasgow, United Kingdom
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213
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Keni RR, Florez-Perdomo WA, Rahman MM, Moscote-Salazar LR, Agrawal A. Letter to the Editor Regarding "15-Year Institutional Retrospective Case Series of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction (mMCAI)". World Neurosurg 2020; 143:639. [PMID: 33167160 DOI: 10.1016/j.wneu.2020.08.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 08/18/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Ravish R Keni
- Department of Neurology, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India
| | - William Andres Florez-Perdomo
- Medicina General-Universidad Surcolombiana, Medico Investigador Concejo Latinoamericano de Neurointensivismo-CLaNi, Clinica Sahagún IPS SA, Córdoba, Colombia
| | - Md Moshiur Rahman
- Department of Neurosurgery, Holy Family Red Crescent, Medical College, Dhaka, Bangladesh
| | | | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India.
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214
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Siket MS, Cadena R. Novel Treatments for Transient Ischemic Attack and Acute Ischemic Stroke. Emerg Med Clin North Am 2020; 39:227-242. [PMID: 33218660 DOI: 10.1016/j.emc.2020.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The treatment of acute ischemic stroke is one of the most rapidly evolving areas in medicine. Like all ischemic vascular emergencies, the priority is reperfusion before irreversible infarction. The central nervous system is sensitive to brief periods of hypoperfusion, making stroke a golden hour diagnosis. Although the phrase "time is brain" is relevant today, emerging treatment strategies use more specific markers for consideration of reperfusion than time alone. Innovations in early stroke detection and individualized patient selection for reperfusion therapies have equipped the emergency medicine clinician with more opportunities to help stroke patients and minimize the impact of this disease.
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Affiliation(s)
- Matthew S Siket
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine at the University of Vermont, 111 Colchester Avenue, EC2-216, Burlington, VT 05401, USA; Department of Neurological Sciences, Larner College of Medicine at the University of Vermont, 111 Colchester Avenue, EC2-216, Burlington, VT 05401, USA.
| | - Rhonda Cadena
- Division of Neurocritical Care, Department of Neurology, University of North Carolina, 170 Manning Drive, CB#7025, Chapel Hill, NC 27517, USA; Department of Neurosurgery, University of North Carolina, 170 Manning Drive, CB#7025, Chapel Hill, NC 27517, USA; Department of Emergency Medicine, University of North Carolina, 170 Manning Drive, CB#7025, Chapel Hill, NC 27517, USA
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215
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Lilja-Cyron A, Andresen M, Kelsen J, Andreasen TH, Petersen LG, Fugleholm K, Juhler M. Intracranial pressure before and after cranioplasty: insights into intracranial physiology. J Neurosurg 2020; 133:1548-1558. [PMID: 31628275 DOI: 10.3171/2019.7.jns191077] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/24/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Decompressive craniectomy (DC) is an emergency neurosurgical procedure used in cases of severe intracranial hypertension or impending intracranial herniation. The procedure is often lifesaving, but it exposes the brain to atmospheric pressure in the subsequent rehabilitation period, which changes intracranial physiology and probably leads to complications such as hydrocephalus, hygromas, and "syndrome of the trephined." The objective of the study was to study the effect of cranioplasty on intracranial pressure (ICP), postural ICP changes, and intracranial pulse wave amplitude (PWA). METHODS The authors performed a prospective observational study including patients who underwent DC during a 12-month period. Telemetric ICP sensors were implanted in all patients at the time of DC. ICP was evaluated before and after cranioplasty during weekly measurement sessions including a standardized postural change program. RESULTS Twelve of the 17 patients enrolled in the study had cranioplasty performed and were included in the present investigation. Their mean ICP in the supine position increased from -0.5 ± 4.8 mm Hg the week before cranioplasty to 6.3 ± 2.5 mm Hg the week after cranioplasty (p < 0.0001), whereas the mean ICP in the sitting position was unchanged (-1.2 ± 4.8 vs -1.1 ± 3.6 mm Hg, p = 0.90). The difference in ICP between the supine and sitting positions was minimal before cranioplasty (1.1 ± 1.8 mm Hg) and increased to 7.4 ± 3.6 mm Hg in the week following cranioplasty (p < 0.0001). During the succeeding 2 weeks of the follow-up period, the mean ICP in the supine and sitting positions decreased in parallel to, respectively, 4.6 ± 3.0 mm Hg (p = 0.0003) and -3.9 ± 2.7 mm Hg (p = 0.040), meaning that the postural ICP difference remained constant at around 8 mm Hg. The mean intracranial PWA increased from 0.7 ± 0.7 mm Hg to 2.9 ± 0.8 mm Hg after cranioplasty (p < 0.0001) and remained around 3 mm Hg throughout the following weeks. CONCLUSIONS Cranioplasty restores normal intracranial physiology regarding postural ICP changes and intracranial PWA. These findings complement those of previous investigations on cerebral blood flow and cerebral metabolism in patients after decompressive craniectomy.
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Affiliation(s)
| | | | - Jesper Kelsen
- 2Orthopaedic Surgery (Spine Section), Rigshospitalet; and
| | | | - Lonnie Grove Petersen
- 3Department of Biomedical Sciences, Faculty of Health Services, University of Copenhagen, Copenhagen, Denmark
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216
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Parish JM, Asher AM, Pfortmiller D, Smith MD, Clemente JD, Stetler WR, Bernard JD. Outcomes After Decompressive Craniectomy for Ischemic Stroke: A Volumetric Analysis. World Neurosurg 2020; 145:e267-e273. [PMID: 33065347 DOI: 10.1016/j.wneu.2020.10.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Decompressive hemicraniectomy (DHC) is a treatment of space-occupying hemispheric infarct. Current surgical guidelines use criteria of age <60 years and surgery within 48 hours of stroke onset. OBJECTIVE The purpose of this study was to evaluate the neurologic outcome after DHC and evaluate the relationship of stroke volume and outcomes. METHODS A retrospective review was performed of patients undergoing DHC for cerebral infarct from 2016 to 2019. Unfavorable outcome was defined as modified Rankin Scale (mRS) score >3. Patients with precraniectomy magnetic resonance imaging were selected as a subset for volumetric stroke volume analysis using RAPID software (iSchemaView, Redwood City, California), with stroke volume defined as apparent diffusion coefficient <620 on diffusion-weighted imaging. RESULTS Fifty-two patients met the inclusion criteria. At 90 days, favorable outcome was achieved in 11 patients (21.2%), and 41 patients (78.8%) had unfavorable outcomes (15 [29%] died). Surgery after 48 hours, age >60 years, and multivessel distribution did not significantly affect 90-day mRS score (P = 0.091, 0.111, and 0.664, respectively). In volumetric subset analysis, 10 patients of 41 (31.3%) achieved favorable outcomes, and no patients with volume of infarct >280 mL had a favorable outcome. There was a trend of lower volumes associated with favorable outcomes, but this did not meet significance (favorable 207 ± 68.7 vs. unfavorable 262 ± 117.1; P = 0.163). CONCLUSIONS Outcomes after DHC for malignant hemispheric infarct were not affected by current accepted guidelines. Volume of infarct may have an effect on outcome after DHC. Further research to aid in predicting which patients benefit from decompressive craniectomy is warranted.
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Affiliation(s)
- Jonathan M Parish
- Department of Neurological Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA.
| | - Anthony M Asher
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | | | - Mark D Smith
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
| | | | - William R Stetler
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
| | - Joe D Bernard
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
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217
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Effect of Recanalization on Cerebral Edema, Long-Term Outcome, and Quality of Life in Patients with Large Hemispheric Infarctions. J Stroke Cerebrovasc Dis 2020; 29:105358. [PMID: 33035882 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 09/20/2020] [Accepted: 09/22/2020] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Space-occupying cerebral edema is the main cause of mortality and poor functional outcome in patients with large cerebral artery occlusion (LVO). We aimed to determine whether recanalization of LVO would augment cerebral edema volume and the impact on functional outcome and quality of life (QoL). MATERIALS AND METHODS Prospectively, 43 patients with large middle cerebral artery territory infarction or NIHSS ≥ 12 on admission were enrolled. The degree of recanalization (partial and complete versus no recanalization) was assessed by computed tomography (CT)-angiography or Duplex ultrasound more than 24 h after symptom onset. Cerebral edema volume was measured on follow up CTs by computer-based planimetry. Mortality, functional outcome (by modified Ranking Scale (mRS) and Barthel Index (BI)) were assessed at discharge and 12 months, and QoL (by SF-36 and EQ-5D-3L) at 12 months. RESULTS Mean cerebral edema volume was 333±141 ml without recanalization (n=13, group 1) and 276±140 ml with partial or complete recanalization (n=30, group 2, p= 0.23). There were no significant differences in mortality at discharge (38% versus 23%), at 12 months (58% versus 48%), in functional outcome at discharge (mRS 0-3: 0% both; mRS 4-5: 62% versus 77%) and at 12 months (mRS 0-3: 0% versus 11%; mRS 4-5: 42% versus 41%). The BI improved significantly from discharge to 12 months only in group 2 (p=0.001). Mean physical component score in SF-36 was 25.6±6.4, psychological component score was 41.9±14.1. In the EQ-5D-3L, most patients reported problems with activities of daily living, reduced mobility, and selfcare. CONCLUSIONS Recanalization of a large cerebral artery occlusion in the anterior circulation territories is not associated with amplification of post-ischemic cerebral edema but may be correlated with better long-term functional outcome. QoL was low and mainly dependent on physical disability. The association between recanalization, collateral status and development of cerebral edema after LVO and the effect on functional outcome and quality of life should be explored in a larger patient population.
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218
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Schizodimos T, Soulountsi V, Iasonidou C, Kapravelos N. An overview of management of intracranial hypertension in the intensive care unit. J Anesth 2020; 34:741-757. [PMID: 32440802 PMCID: PMC7241587 DOI: 10.1007/s00540-020-02795-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 05/09/2020] [Indexed: 12/29/2022]
Abstract
Intracranial hypertension (IH) is a clinical condition commonly encountered in the intensive care unit, which requires immediate treatment. The maintenance of normal intracranial pressure (ICP) and cerebral perfusion pressure in order to prevent secondary brain injury (SBI) is the central focus of management. SBI can be detected through clinical examination and invasive and non-invasive ICP monitoring. Progress in monitoring and understanding the pathophysiological mechanisms of IH allows the implementation of targeted interventions in order to improve the outcome of these patients. Initially, general prophylactic measures such as patient's head elevation, fever control, adequate analgesia and sedation depth should be applied immediately to all patients with suspected IH. Based on specific indications and conditions, surgical resection of mass lesions and cerebrospinal fluid drainage should be considered as an initial treatment for lowering ICP. Hyperosmolar therapy (mannitol or hypertonic saline) represents the cornerstone of medical treatment of acute IH while hyperventilation should be limited to emergency management of life-threatening raised ICP. Therapeutic hypothermia could have a possible benefit on outcome. To control elevated ICP refractory to maximum standard medical and surgical treatment, at first, high-dose barbiturate administration and then decompressive craniectomy as a last step are recommended with unclear and probable benefit on outcomes, respectively. The therapeutic strategy should be based on a staircase approach and be individualized for each patient. Since most therapeutic interventions have an uncertain effect on neurological outcome and mortality, future research should focus on both studying the long-term benefits of current strategies and developing new ones.
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Affiliation(s)
- Theodoros Schizodimos
- 2nd Department of Intensive Care Medicine, George Papanikolaou General Hospital, G. Papanikolaou Avenue, 57010, Exochi, Thessaloniki, Greece.
| | - Vasiliki Soulountsi
- 1st Department of Intensive Care Medicine, George Papanikolaou General Hospital, Thessaloniki, Greece
| | - Christina Iasonidou
- 2nd Department of Intensive Care Medicine, George Papanikolaou General Hospital, G. Papanikolaou Avenue, 57010, Exochi, Thessaloniki, Greece
| | - Nikos Kapravelos
- 2nd Department of Intensive Care Medicine, George Papanikolaou General Hospital, G. Papanikolaou Avenue, 57010, Exochi, Thessaloniki, Greece
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Peng G, Huang C, Chen W, Xu C, Liu M, Xu H, Cai C. Risk factors for decompressive craniectomy after endovascular treatment in acute ischemic stroke. Neurosurg Rev 2020; 43:1357-1364. [PMID: 31485788 DOI: 10.1007/s10143-019-01167-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/07/2019] [Accepted: 08/20/2019] [Indexed: 02/05/2023]
Abstract
Endovascular treatment (EVT) is safe and effective for acute ischemic stroke (AIS) caused by large artery occlusion in the anterior circulation. However, some patients require decompressive craniectomy (DC), despite having undergone a timely EVT. This study aimed to evaluate the risk factors for subsequent DC after EVT. This retrospective cohort study comprised 138 patients who received EVT between April 2015 and June 2019 at our center. The need for subsequent DC was defined as cerebral edema or/and hemorrhagic transformation caused by large ischemic infarction, with a ≥ 5-mm midline shift and clinical deterioration after EVT. The relationship between risk factors and DC after EVT was assessed via univariate and multivariable logistic regression. Thirty (21.7%) patients required DC. These patients tended to have atrial fibrillation (P = 0.037), sedation (P = 0.049), mechanical ventilation (P = 0.008), poorer collateral circulation (P = 0.003), a higher baseline National Institutes of Health Stroke Scale (NIHSS) score (P < 0.001), heavier thrombus burden (P < 0.001), a lower baseline Alberta Stroke Program Early Computed Tomography Score (ASPECTS) (P < 0.001), and unsuccessful recanalization (P < 0.001). In the multivariate analysis, higher baseline NIHSS score [odds ratio (OR), 1.17; 95% confidence interval (CI), 1.03-1.32], heavier thrombus burden [OR, 1.35; 95% CI, 1.02-1.79], baseline ASPECTS ≤ 8 [OR, 7.41; 95% CI, 2.43-22.66], and unsuccessful recanalization [OR, 7.49; 95% CI, 2.13-26.36] were independent risk factors for DC after EVT. DC remains an essential treatment for some AIS patients after EVT, especially those with higher baseline NIHSS scores, heavier thrombus burden, baseline ASPECTS ≤ 8, and unsuccessful recanalization.
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Affiliation(s)
- Guoyi Peng
- Department of Neurosurgery, Shantou Central Hospital, Affiliated Shantou Hospital of Sun Yat-Sen University, 114 Waima Road, Shantou, 515041, Guangdong, China
| | - Chuming Huang
- Department of Neurology, Shantou Central Hospital, Affiliated Shantou Hospital of Sun Yat-Sen University, 114 Waima Road, Shantou, 515041, Guangdong, China
| | - Weiqiang Chen
- Department of Neurosurgery, First Affiliated Hospital, Shantou University Medical College, 57 Changping Road, Shantou, 515041, Guangdong, China
| | - Chukai Xu
- Department of Neurology, Shantou Central Hospital, Affiliated Shantou Hospital of Sun Yat-Sen University, 114 Waima Road, Shantou, 515041, Guangdong, China
| | - Mingfa Liu
- Department of Neurosurgery, Shantou Central Hospital, Affiliated Shantou Hospital of Sun Yat-Sen University, 114 Waima Road, Shantou, 515041, Guangdong, China
| | - Haixiong Xu
- Department of Neurosurgery, Shantou Central Hospital, Affiliated Shantou Hospital of Sun Yat-Sen University, 114 Waima Road, Shantou, 515041, Guangdong, China.
| | - Chuwei Cai
- Department of Neurosurgery, Shantou Central Hospital, Affiliated Shantou Hospital of Sun Yat-Sen University, 114 Waima Road, Shantou, 515041, Guangdong, China.
- Department of Intervention Neuroradiology, Shantou Central Hospital, Affiliated Shantou Hospital of Sun Yat-Sen University, 114 Waima Road, Shantou, 515041, Guangdong, China.
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220
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Sueiras M, Thonon V, Santamarina E, Sánchez-Guerrero Á, Riveiro M, Poca MA, Quintana M, Gándara D, Sahuquillo J. Is Spreading Depolarization a Risk Factor for Late Epilepsy? A Prospective Study in Patients with Traumatic Brain Injury and Malignant Ischemic Stroke Undergoing Decompressive Craniectomy. Neurocrit Care 2020; 34:876-888. [PMID: 33000378 DOI: 10.1007/s12028-020-01107-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 09/05/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Spreading depolarizations (SDs) have been described in patients with ischemic and haemorrhagic stroke, traumatic brain injury, and migraine with aura, among other conditions. The exact pathophysiological mechanism of SDs is not yet fully established. Our aim in this study was to evaluate the relationship between the electrocorticography (ECoG) findings of SDs and/or epileptiform activity and subsequent epilepsy and electroclinical outcome. METHODS This was a prospective observational study of 39 adults, 17 with malignant middle cerebral artery infarction (MMCAI) and 22 with traumatic brain injury, who underwent decompressive craniectomy and multimodal neuromonitoring including ECoG in penumbral tissue. Serial electroencephalography (EEG) recordings were obtained for all surviving patients. Functional disability at 6 and 12 months after injury were assessed using the Barthel, modified Rankin (mRS), and Extended Glasgow Outcome (GOS-E) scales. RESULTS SDs were recorded in 58.9% of patients, being more common-particularly those of isoelectric type-in patients with MMCAI (p < 0.04). At follow-up, 74.7% of patients had epileptiform abnormalities on EEG and/or seizures. A significant correlation was observed between the degree of preserved brain activity on EEG and disability severity (R [mRS]: + 0.7, R [GOS-E, Barthel]: - 0.6, p < 0.001), and between the presence of multifocal epileptiform abnormalities on EEG and more severe disability on the GOS-E at 6 months (R: - 0.3, p = 0.03) and 12 months (R: - 0.3, p = 0.05). Patients with more SDs and higher depression ratios scored worse on the GOS-E (R: - 0.4 at 6 and 12 months) and Barthel (R: - 0.4 at 6 and 12 months) disability scales (p < 0.05). The number of SDs (p = 0.064) and the depression ratio (p = 0.1) on ECoG did not show a statistically significant correlation with late epilepsy. CONCLUSIONS SDs are common in the cortex of ischemic or traumatic penumbra. Our study suggests an association between the presence of SDs in the acute phase and worse long-term outcome, although no association with subsequent epilepsy was found. More comprehensive studies, involving ECoG and EEG could help determine their association with epileptogenesis.
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Affiliation(s)
- Maria Sueiras
- Department of Clinical Neurophysiology, Vall d'Hebron University Hospital, Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain. .,Neurotrauma and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR), Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain. .,Universitat Autònoma de Barcelona (UAB), Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Vanessa Thonon
- Department of Clinical Neurophysiology, Vall d'Hebron University Hospital, Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Estevo Santamarina
- Epilepsy Unit, Department of Neurology, Vall d'Hebron University Hospital, Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Ángela Sánchez-Guerrero
- Neurotrauma and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR), Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Marilyn Riveiro
- Neurotrauma Intensive Care Unit, Vall d'Hebron University Hospital, Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Maria-Antonia Poca
- Neurotrauma and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR), Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Universitat Autònoma de Barcelona (UAB), Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Department of Neurosurgery, Vall d'Hebron University Hospital, Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Manuel Quintana
- Epilepsy Unit, Department of Neurology, Vall d'Hebron University Hospital, Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Dario Gándara
- Neurotrauma and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR), Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Department of Neurosurgery, Vall d'Hebron University Hospital, Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Juan Sahuquillo
- Neurotrauma and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR), Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Universitat Autònoma de Barcelona (UAB), Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Department of Neurosurgery, Vall d'Hebron University Hospital, Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain
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221
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Sun W, Li G, Song Y, Zhu Z, Yang Z, Chen Y, Miao J, Song X, Lan Y, Qiu X, Zhu S, Fan Y. A web based dynamic MANA Nomogram for predicting the malignant cerebral edema in patients with large hemispheric infarction. BMC Neurol 2020; 20:360. [PMID: 32993551 PMCID: PMC7523347 DOI: 10.1186/s12883-020-01935-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 09/17/2020] [Indexed: 12/04/2022] Open
Abstract
Background For large hemispheric infarction (LHI), malignant cerebral edema (MCE) is a life-threatening complication with a mortality rate approaching 80%. Establishing a convenient prediction model of MCE after LHI is vital for the rapid identification of high-risk patients as well as for a better understanding of the potential mechanism underlying MCE. Methods One hundred forty-two consecutive patients with LHI within 24 h of onset between January 1, 2016 and August 31, 2019 were retrospectively reviewed. MCE was defined as patient death or received decompressive hemicraniectomy (DHC) with obvious mass effect (≥ 5 mm midline shift or Basal cistern effacement). Binary logistic regression was performed to identify independent predictors of MCE. Independent prognostic factors were incorporated to build a dynamic nomogram for MCE prediction. Results After adjusting for confounders, four independent factors were identified, including previously known atrial fibrillation (KAF), midline shift (MLS), National Institutes of Health Stroke Scale (NIHSS) and anterior cerebral artery (ACA) territory involvement. To facilitate the nomogram use for clinicians, we used the “Dynnom” package to build a dynamic MANA (acronym for MLS, ACA territory involvement, NIHSS and KAF) nomogram on web (http://www.MANA-nom.com) to calculate the exact probability of developing MCE. The MANA nomogram’s C-statistic was up to 0.887 ± 0.041 and the AUC-ROC value in this cohort was 0.887 (95%CI, 0.828 ~ 0.934). Conclusions Independent MCE predictors included KAF, MLS, NIHSS, and ACA territory involvement. The dynamic MANA nomogram is a convenient, practical and effective clinical decision-making tool for predicting MCE after LHI in Chinese patients.
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Affiliation(s)
- Wenzhe Sun
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Guo Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Yang Song
- School of Medicine and Health Management; Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Zhou Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Zhaoxia Yang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Yuxi Chen
- The Solomon H. Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - Jinfeng Miao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Xiaoyan Song
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Yan Lan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Xiuli Qiu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Suiqiang Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China.
| | - Yebin Fan
- School of Computer Science and Technology, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China.
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222
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Zaed I, Rossini Z, Faedo F, Fontanella MM, Cardia A, Servadei F. Long-term follow-up of custom-made porous hydroxyapatite cranioplasty in adult patients: a multicenter European study. Can we trust self-reported complications? J Neurosurg Sci 2020; 66:335-341. [PMID: 32989979 DOI: 10.23736/s0390-5616.20.05138-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cranioplasty is a surgical intervention aiming to re-establish the integrity of skull defects. Autologous bone and different heterologous materials are used for this purpose, with various reported related complications. The aim of the study was to evaluate the complication rate in a multicentric cohort of patients underwent porous hydroxyapatite (PHA) cranioplasty implantation and to assess the validity of company post-market clinical analysis. METHODS Authors analyzed a company based register of 6279 PHA cranioplasty implanted all over the world. In these adult patients only self-reported complications were available. We then obtained the data of adult patients treated with custom-made porous HA prostheses (CustomBone Service) in 20 institutions from different European countries through an on-site interview with the physicians in charge of the patients (494 patients). The endpoints were the incidence of adverse events and of related implant removal. RESULTS The groups of patients had similar demographics characteristics. The average follow-up was 26.7 months. A significantly higher number of complications was recorded in the group of patients underwent onsite interview. Thirty-nine complications were reported (7.89%) with an explantation rate of 4.25% (21 cases) in the series, compared to the data reported from the Company (complications rate of 3.3% and explantation rate of 3.1%). The most common complications were infection (4.86%), hematomas (1.22%), fractures (1.01%), mobilization (0.4%) and scar retraction (0.4%). CONCLUSIONS Our data confirm that porous HA cranioplasty is at least as effective as other heterologous materials to repair cranial defects. Another interesting finding is that self-reporting complicantions by surgeons does not give a precise picture of the real rate of complications of the devices. These data in future studies need to be re-confirmed with on-site interviews.
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Affiliation(s)
- Ismail Zaed
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy - .,Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy -
| | - Zefferino Rossini
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Francesca Faedo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Marco M Fontanella
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Andrea Cardia
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Franco Servadei
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
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Specificities of acute phase stroke management in the elderly. Rev Neurol (Paris) 2020; 176:684-691. [PMID: 32980154 DOI: 10.1016/j.neurol.2020.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 06/22/2020] [Accepted: 07/06/2020] [Indexed: 11/21/2022]
Abstract
Health professionals are currently facing the challenge of managing an increasing number of old patients presenting with acute stroke, due to rapid aging of the population. Compared to their younger counterparts, elderly patients differ in many ways in the setting of acute stroke. Apart from a striking high stroke incidence, which increases exponentially as age increases, cardioembolism also becomes, as patients age, the main cause of ischemic stroke. Delirium, which can challenge the diagnosis, is frequent at the acute phase of stroke, and may be related to an underlying dementia, which is almost exclusively observed in the elderly during stroke. At all levels, management of elderly stroke patients is suboptimal, especially when they are cognitively impaired, with insufficiencies including admission to stroke units, applying standards of care and investigation, reperfusion therapy for ischemic stroke, and finally transfer to rehabilitation centers. A paradigm shift must take place to limit age-related discrimination for acute-phase management of stroke.
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224
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Cerebellar Necrosectomy Instead of Suboccipital Decompression: A Suitable Alternative for Patients with Space-Occupying Cerebellar Infarction. World Neurosurg 2020; 144:e723-e733. [PMID: 32977029 DOI: 10.1016/j.wneu.2020.09.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/11/2020] [Accepted: 09/12/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Space-occupying cerebellar ischemic strokes (SOCSs) often lead to neurological deterioration and require surgical intervention to release pressure from the posterior fossa. Current guidelines recommend suboccipital decompressive craniectomy (SDC) with dural expansion when medical therapy is not sufficient. However, no good-quality evidence is available to support this surgical practice, and the surgical timing and technique both remain controversial. We have described an alternative to SDC, surgical evacuation of infarcted tissue (necrosectomy) and its clinical outcomes. METHODS In the present retrospective, single-center study, 34 consecutive patients with SOCS undergoing necrosectomy via osteoplastic craniotomy were included. The patient characteristics and radiological findings were evaluated. To differentiate the effects of age on the functional outcomes, the patients were divided into 2 groups (group I, age ≤60 years; and group II, age >60 years). Functional outcomes were assessed using the Glasgow outcome scale, modified Rankin scale, and Barthel index at discharge and 30 days postoperatively. RESULTS In our cohort, we observed overall mortality of 21%, with good functional outcomes (Glasgow outcome scale score ≥4) for 76% of the patients. No statistically significant differences in mortality or functional outcomes were observed between the 2 patient groups. Comparing our data with a recent meta-analysis of SDC, the number of adverse events and unfavorable outcome showed equipoise between the 2 treatment modalities. CONCLUSIONS Necrosectomy appears to be a suitable alternative to SDC for SOCS, achieving comparable mortality and functional outcomes. Further trials are necessary to evaluate which surgical technique is more beneficial in the setting of SOCSs.
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225
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Lee SJ, Choi MH, Lee SE, Park JH, Park B, Lee JS, Hong JM. Optic nerve sheath diameter change in prediction of malignant cerebral edema in ischemic stroke: an observational study. BMC Neurol 2020; 20:354. [PMID: 32962645 PMCID: PMC7510108 DOI: 10.1186/s12883-020-01931-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 09/14/2020] [Indexed: 12/28/2022] Open
Abstract
Background In acute large anterior circulation infarct patients with large core volume, we evaluated the role of optic nerve sheath diameter (ONSD) change rates in prediction of malignant progression. Methods We performed a retrospective observational study including patients with anterior circulation acute ischemic stroke with large ischemic cores from January 2010 to October 2017. Primary outcome was defined as undergoing decompressive surgery or death due to severe cerebral edema, and termed malignant progression. Patients were divided into malignant progressors and nonprogressors. Malignant progression was divided into early progression that occurred before D1 CT, and late progression that occurred afterwards. Retrospective analysis of changes in mean ONSD/eyeball transverse diameter (ETD) ratio, and midline shifting (MLS) were evaluated on serial computed tomography (CT). Through analysis of CT at baseline, postprocedure, and at D1, the predictive ability of time based change in ONSD/ETD ratio in predicting malignant progression was evaluated. Results A total of 58 patients were included. Nineteen (32.8%) were classified as malignant; 12 early, and 7 late progressions. In analysis of CTpostprocedure, A 1 mm/hr. rate of change in MLS during the CTbaseline-CTpostprocedure time phase lead to a 6.7 fold increased odds of early malignant progression (p < 0.05). For ONSD/ETD, 1%/hr. change lead to a 1.6 fold increased odds, but this association was trending (p = 0.249). In the CTD1, 1%/day change of ONSD/ETD in the CTbaseline-CTD1 time phase lead to a 1.4 fold increased odds of late malignant progression (p = 0.021) while 1 mm/day rate of change in MLS lead to a 1.5 fold increased odds (p = 0.014). Conclusions The rate of ONSD/ETD changes compared to baseline at D1 CT can be a predictor of late malignant progression along with MLS. ONSD/ETD change rates evaluated at postprocedure did not predict early malignant progression.
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Affiliation(s)
- Seong-Joon Lee
- Department of Neurology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Mun Hee Choi
- Department of Neurology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Sung Eun Lee
- Department of Neurology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Ji Hyun Park
- Office of Biostatistics, Medical Research Collaborating Center, Ajou Research Institute for Innovative Medicine, Ajou University Medical Center, Suwon, Republic of Korea
| | - Bumhee Park
- Office of Biostatistics, Medical Research Collaborating Center, Ajou Research Institute for Innovative Medicine, Ajou University Medical Center, Suwon, Republic of Korea.,Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea.
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226
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Yu H, Guo L, He J, Kong J, Yang M. Role of decompressive craniectomy in the management of poor-grade aneurysmal subarachnoid hemorrhage: short- and long-term outcomes in a matched-pair study. Br J Neurosurg 2020; 35:785-791. [PMID: 32945182 DOI: 10.1080/02688697.2020.1817851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the short- and long-term therapeutic effect and possibility of decompressive craniectomy (DC) for patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). METHODS Patients suffering from aSAH (Hunt-Hess grades IV, V) who underwent DC from January 2008 to April 2016 were enrolled in this study, and a sample-matched control group was set up. Information regarding participants' demography, clinical characteristics, and neuroimaging findings was systematically established. The outcome of a 6-month to 3-year follow-up was assessed according to the Glasgow outcome scale (GOS), modified Rankin Scale (mRS) and Barthel Index (BI). RESULTS Patients who had DC (21) experienced a statistically significant decrease in short-term mortality compared with those without DC (24, p < 0.05) and showed a decrease in intracranial pressure (ICP) after surgery. However, there was no significant difference in the long-term assessment (GOS/mRS/BI) between the two groups. CONCLUSIONS Some critical patients who have refractory ICP after poor-grade aSAH would benefit from DC for prolonging life in the short term if performed early. Nevertheless, the overall outcome for the long term remains disappointing, larger and longer prospective studies are urgently needed to investigate this issue.
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Affiliation(s)
- Hai Yu
- Department of Neurosurgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Liang Guo
- Department of Neurosurgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Junhua He
- Department of Neurosurgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Jun Kong
- Department of Neurosurgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Min Yang
- Department of Neurosurgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
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227
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Primary decompressive craniectomy in poor-grade aneurysmal subarachnoid hemorrhage: long-term outcome in a single-center study and systematic review of literature. Neurosurg Rev 2020; 44:2153-2162. [PMID: 32920754 PMCID: PMC8338868 DOI: 10.1007/s10143-020-01383-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/16/2020] [Accepted: 09/01/2020] [Indexed: 11/16/2022]
Abstract
Primary decompressive craniectomy (PDC) in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) in order to decrease elevated intracranial pressure (ICP) is controversially discussed. The aim of this study was to analyze the effect of PDC on long-term clinical outcome in these patients in a single-center cohort and to perform a systematic review of literature. Eighty-seven consecutive poor-grade SAH patients (World Federation of Neurosurgical Societies (WFNS) grades IV and V) were analyzed between October 2012 and August 2017 at the author’s institution. PDC was performed due to clinical signs of herniation or brain swelling according to the treating surgeon. Outcome was analyzed according to the modified Rankin Scale (mRS). Literature was systematically reviewed up to August 2019, and data of poor-grade aSAH patients who underwent PDC was extracted for statistical analyses. Of 87 patients with poor-grade aSAH in the single-center cohort, 38 underwent PDC and 49 did not. Favorable outcome at 2 years post-hemorrhage did not differ significantly between the two groups (26% versus 20%). Systematic literature review revealed 9 studies: Overall, a favorable outcome could be achieved in nearly half of the patients (49%), with an overall mortality of 24% (median follow-up 11 months). Despite a worse clinical status at presentation (significantly higher rate of mydriasis and additional ICH), poor-grade aSAH patients with PDC achieve favorable outcome in a significant number of patients. Therefore, treatment and PDC should not be omitted in this severely ill patient collective. Prospective controlled studies are warranted.
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228
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Abstract
A 24-year-old primigravid woman at 29-weeks gestation presented with headache, hypertension and proteinuria. A diagnosis of pre-eclampsia was made. Later that day she developed a left hemiparesis and neuroimaging demonstrated an intracerebral haemorrhage in the right frontal lobe as well as thrombosis of the superior sagittal sinus. She was commenced on an IV heparin infusion to manage the sinus thrombosis, and nifedipine and labetalol to treat the hypertension. GCS remained 15/15. However, 12 hours later, she became progressively agitated. Her GCS decreased to 10/15 (E3V2M5). Repeat imaging demonstrated enlargement of the haematoma, causing significant mass effect and midline shift. A decision was made to perform decompressive hemicraniectomy to save the life of the mother, and caesarean section to protect the foetus as well as providing definitive treatment of pre-eclampsia. Due to further neurological deterioration of the mother it became necessary to perform the two procedures simultaneously. We present the first reported case of decompressive craniectomy and caesarean section performed simultaneously. After discussing the case, we consider why this clinical scenario is rare and why it became necessary in this patient to perform the two procedures simultaneously.
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Affiliation(s)
- Bennett Choy
- University of Sheffield Medical School, Sheffield, United Kingdom of Great Britain and Northern Ireland
| | - Kenneth Burns
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom of Great Britain and Northern Ireland
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Baatiema L, Abimbola S, de-Graft Aikins A, Damasceno A, Kengne AP, Sarfo FS, Charway-Felli A, Somerset S. Towards evidence-based policies to strengthen acute stroke care in low-middle-income countries. J Neurol Sci 2020; 418:117117. [PMID: 32919367 DOI: 10.1016/j.jns.2020.117117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/30/2020] [Accepted: 09/01/2020] [Indexed: 12/31/2022]
Abstract
Stroke is a major public health issue in many low- and middle-income countries (LMICs). Despite the emergence of new effective interventions for acute stroke care, uptake remains slow and largely inaccessible to patients in LMICs, where health systems response has been inadequate. In this paper, we propose a policy framework to optimise access to acute stroke care in LMICs. We draw on evidence from relevant primary studies, such as availability of evidence-based acute stroke care interventions, barriers to uptake of interventions for stroke care and insights on stroke mortality and morbidity burden in LMICs. Insights from review of secondary studies, principally systematic reviews on evidence-based acute stroke care; and the accounts and experiences of some regional experts on stroke and other NCDs have been taken into consideration. In LMICs, there is limited availability and access to emergency medical transport services, brain imaging services and best practice interventions for acute stroke care. Availability of specialist acute stroke workforce and low awareness of early stroke signs and symptoms are also major challenges impeding the delivery of quality stroke care services. As a result, stroke care in LMICs is patchy, fragmented and often results in poor patient outcomes. Reconfiguration of LMIC health systems is thus required to optimise access to quality acute stroke care. We therefore propose a ten-point framework to be adapted to country-specific health system capacity, needs and resources: Emergency medical transport and treatment services, scaling-up interventions and services for acute stroke care, clinical guidelines for acute stroke treatment and management, access to brain imaging services, human resource capacity development strategies, centralisation of stroke services, tele-stroke care, public awareness campaigns on early stroke symptoms, establish stroke registers and financing of stroke care in LMICs. While we recognise the challenges of implementing the recommendations in low resource settings, this list can provide a platform as well serve as the starting point for advocacy and prioritisation of interventions depending on context.
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Affiliation(s)
- Leonard Baatiema
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana.
| | - Seye Abimbola
- School of Public Health, University of Sydney, Australia.
| | | | | | - Andre Pascal Kengne
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa.
| | - Fred S Sarfo
- Kwame Nkrumah University of Science & Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Department of Medicine, Kumasi, Ghana.
| | | | - Shawn Somerset
- Faculty of Health, University of Canberra, Canberra, Australia.
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Mitchell KAS, Anderson W, Shay T, Huang J, Luciano M, Suarez JI, Manson P, Brem H, Gordon CR. First-In-Human Experience With Integration of Wireless Intracranial Pressure Monitoring Device Within a Customized Cranial Implant. Oper Neurosurg (Hagerstown) 2020; 19:341-350. [PMID: 31993644 PMCID: PMC7594174 DOI: 10.1093/ons/opz431] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/01/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Decompressive craniectomy is a lifesaving treatment for intractable intracranial hypertension. For patients who survive, a second surgery for cranial reconstruction (cranioplasty) is required. The effect of cranioplasty on intracranial pressure (ICP) is unknown. OBJECTIVE To integrate the recently Food and Drug Administration-approved, fully implantable, noninvasive ICP sensor within a customized cranial implant (CCI) for postoperative monitoring in patients at high risk for intracranial hypertension. METHODS A 16-yr-old female presented for cranioplasty 4-mo after decompressive hemicraniectomy for craniocerebral gunshot wound. Given the persistent transcranial herniation with concomitant subdural hygroma, there was concern for intracranial hypertension following cranioplasty. Thus, cranial reconstruction was performed utilizing a CCI with an integrated wireless ICP sensor, and noninvasive postoperative monitoring was performed. RESULTS Intermittent ICP measurements were obtained twice daily using a wireless, handheld monitor. The ICP ranged from 2 to 10 mmHg in the supine position and from -5 to 4 mmHg in the sitting position. Interestingly, an average of 7 mmHg difference was consistently noted between the sitting and supine measurements. CONCLUSION This first-in-human experience demonstrates several notable findings, including (1) newfound safety and efficacy of integrating a wireless ICP sensor within a CCI for perioperative neuromonitoring; (2) proven restoration of normal ICP postcranioplasty despite severe preoperative transcranial herniation; and (3) proven restoration of postural ICP adaptations following cranioplasty. To the best of our knowledge, this is the first case demonstrating these intriguing findings with the potential to fundamentally alter the paradigm of cranial reconstruction.
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Affiliation(s)
- Kerry-Ann S Mitchell
- Section of Neuroplastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - William Anderson
- Section of Neuroplastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tamir Shay
- Section of Neuroplastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark Luciano
- Section of Neuroplastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose I Suarez
- Division of Neurocritical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Paul Manson
- Section of Neuroplastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Henry Brem
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chad R Gordon
- Section of Neuroplastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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231
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Therapeutic Hypothermia in Patients with Malignant Ischemic Stroke and Hemicraniectomy—A Systematic Review and Meta-analysis. World Neurosurg 2020; 141:e677-e685. [DOI: 10.1016/j.wneu.2020.05.277] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 05/28/2020] [Accepted: 05/30/2020] [Indexed: 02/02/2023]
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232
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Le Roy L, Amara A, Le Roux C, Bocher O, Létondor A, Benz N, Timsit S. Principal component analysis, a useful tool to study cyclin-dependent kinase-inhibitor's effect on cerebral ischaemia. Brain Commun 2020; 2:fcaa136. [PMID: 33094284 PMCID: PMC7566348 DOI: 10.1093/braincomms/fcaa136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/30/2020] [Accepted: 07/06/2020] [Indexed: 12/22/2022] Open
Abstract
Stroke is a leading cause of acute death related in part to brain oedema, blood-brain barrier disruption and glial inflammation. A cyclin-dependant kinase inhibitor, (S)-roscovitine, was administered 90 min after onset on a model of rat focal cerebral ischaemia. Brain swelling and Evans Blue tissue extravasation were quantified after Evans Blue injection. Combined tissue Evans Blue fluorescence and immunofluorescence of endothelial cells (RECA1), microglia (isolectin-IB4) and astrocytes (glial fibrillary acidic protein) were analysed. Using a Student's t-test or Mann-Whitney test, (S)-roscovitine improved recovery by more than 50% compared to vehicle (Mann-Whitney, P < 0.001), decreased significantly brain swelling by 50% (t-test, P = 0.0128) mostly in the rostral part of the brain. Main analysis was therefore performed on rostral cut for immunofluorescence to maximize biological observations (cut B). Evans Blue fluorescence decreased in (S)-roscovitine group compared to vehicle (60%, t-test, P = 0.049) and was further supported by spectrophotometer analysis (Mann-Whitney, P = 0.0002) and Evans Blue macroscopic photonic analysis (t-test, P = 0.07). An increase of RECA-1 intensity was observed in the ischaemic hemisphere compared to non-ischaemic hemisphere. Further study showed, in the ischaemic hemisphere that (S)-roscovitine treated group compared to vehicle, showed a decrease of: (i) endothelial RECA-1 intensity of about 20% globally, mainly located in the cortex (-28.5%, t-test, P = 0.03); (ii) Microglia's number by 55% (t-test, P = 0.006) and modulated reactive astrocytes through a trend toward less astrocytes number (15%, t-test, P = 0.05) and astrogliosis (21%, t-test, P = 0.076). To decipher the complex relationship of these components, we analysed the six biological quantitative variables of our study by principal component analysis from immunofluorescence studies of the same animals. Principal component analysis differentiated treated from non-treated animals on dimension 1 with negative values in the treated animals, and positive values in the non-treated animals. Interestingly, stroke recovery presented a negative correlation with this dimension, while all other biological variables showed a positive correlation. Dimensions 1 and 2 allowed the identification of two groups of co-varying variables: endothelial cells, microglia number and Evans Blue with positive values on both dimensions, and astrocyte number, astrogliosis and brain swelling with negative values on dimension 2. This partition suggests different mechanisms. Correlation matrix analysis was concordant with principal component analysis results. Because of its pleiotropic complex action on different elements of the NeuroVascular Unit response, (S)-roscovitine may represent an effective treatment against oedema in stroke.
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Affiliation(s)
- Lucas Le Roy
- Univ Brest, Inserm, EFS, UMR 1078, Genetics, functional genomics and biotechnology (GGB), F-29200, Brest, France
| | - Ahmed Amara
- Univ Brest, Inserm, EFS, UMR 1078, Genetics, functional genomics and biotechnology (GGB), F-29200, Brest, France
| | - Cloé Le Roux
- Univ Brest, Inserm, EFS, UMR 1078, Genetics, functional genomics and biotechnology (GGB), F-29200, Brest, France
| | - Ozvan Bocher
- Univ Brest, Inserm, EFS, UMR 1078, Genetics, functional genomics and biotechnology (GGB), F-29200, Brest, France
| | - Anne Létondor
- Univ Brest, Inserm, EFS, UMR 1078, Genetics, functional genomics and biotechnology (GGB), F-29200, Brest, France
| | - Nathalie Benz
- Univ Brest, Inserm, EFS, UMR 1078, Genetics, functional genomics and biotechnology (GGB), F-29200, Brest, France
| | - Serge Timsit
- Univ Brest, Inserm, EFS, UMR 1078, Genetics, functional genomics and biotechnology (GGB), F-29200, Brest, France
- Neurology and Stroke Unit Department, CHRU de Brest, Université de Bretagne Occidentale, Inserm 1078, France
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Hamamoto Filho PT, Gonçalves LB, Koetz NF, Silvestrin AML, Alves Júnior AC, Rocha LA, Módolo GP, de Avila MAG, Martin LC, Neugebauer H, Zanini MA, Bazan R. Long-term follow-up of patients undergoing decompressive hemicraniectomy for malignant stroke: Quality of life and caregiver's burden in a real-world setting. Clin Neurol Neurosurg 2020; 197:106168. [PMID: 32861040 DOI: 10.1016/j.clineuro.2020.106168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND PURPOSE Decompressive hemicraniectomy is a life-saving procedure for the treatment of space-occupying middle cerebral artery infarctions (malignant stroke); however, patients may survive severely disabled. Comprehensive data on long-term sequelae outside randomized controlled trials are scarce. METHODS We retrospectively evaluated the survival rates, quality of life, ability to perform activities of daily living, and caregiver burden of 61 patients (aged from 37 to 83) who had previously undergone decompressive hemicraniectomy for malignant stroke between 2012 and 2017. RESULTS The mortality rate was higher among patients older than 60 years than among younger patients (71.0 % vs 36.7 %, p = 0.007; odds ratio 4.222, 95 % confidence interval 1.443-12.355). The mean survival time was 37.9 ± 6.0 months for 19 survivors of the younger group and 22.6 ± 5.7 months for 9 survivors of the older group. Among the 28 surviving patients, 22 (78.6 %) were interviewed, and we found that age was a determining factor for functional outcome (Barthel indices of 65.7 ± 10.6 for younger patients vs 48.0 ± 9.3 for older patients, p < 0.001), but not for quality of life. The caregiver burden was significantly correlated (R = -0.53, p < 0.01) with the severity of disability and age (R = 0.544, p = 0.011) of the patients. CONCLUSION Our findings show that the degree of impairment, as well as caregiver burden, is higher in patients older than 60 years than in younger patients.
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Affiliation(s)
- Pedro Tadao Hamamoto Filho
- UNESP - Univ Estadual Paulista, Botucatu Medical School, Department of Neurology, Psychology and Psychiatry, Brazil.
| | - Lucas Braz Gonçalves
- UNESP - Univ Estadual Paulista, Botucatu Medical School, Department of Neurology, Psychology and Psychiatry, Brazil
| | - Nicholas Falcomer Koetz
- UNESP - Univ Estadual Paulista, Botucatu Medical School, Department of Neurology, Psychology and Psychiatry, Brazil
| | | | - Aderaldo Costa Alves Júnior
- UNESP - Univ Estadual Paulista, Botucatu Medical School, Department of Neurology, Psychology and Psychiatry, Brazil
| | - Lilian Aline Rocha
- UNESP - Univ Estadual Paulista, Botucatu Medical School, Department of Neurology, Psychology and Psychiatry, Brazil
| | - Gabriel Pinheiro Módolo
- UNESP - Univ Estadual Paulista, Botucatu Medical School, Department of Neurology, Psychology and Psychiatry, Brazil
| | | | - Luis Cuadrado Martin
- UNESP - Univ Estadual Paulista, Botucatu Medical School, Department of Internal Medicine, Brazil
| | | | - Marco Antônio Zanini
- UNESP - Univ Estadual Paulista, Botucatu Medical School, Department of Neurology, Psychology and Psychiatry, Brazil
| | - Rodrigo Bazan
- UNESP - Univ Estadual Paulista, Botucatu Medical School, Department of Neurology, Psychology and Psychiatry, Brazil
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Lilja-Cyron A, Andresen M, Kelsen J, Andreasen TH, Fugleholm K, Juhler M. Long-Term Effect of Decompressive Craniectomy on Intracranial Pressure and Possible Implications for Intracranial Fluid Movements. Neurosurgery 2020; 86:231-240. [PMID: 30768137 DOI: 10.1093/neuros/nyz049] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 01/29/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Decompressive craniectomy (DC) is used in cases of severe intracranial hypertension or impending intracranial herniation. DC effectively lowers intracranial pressure (ICP) but carries a risk of severe complications related to abnormal ICP and/or cerebrospinal fluid (CSF) circulation, eg, hygroma formation, hydrocephalus, and "syndrome of the trephined." OBJECTIVE To study the long-term effect of DC on ICP, postural ICP regulation, and intracranial pulse wave amplitude (PWA). METHODS Prospective observational study including patients undergoing DC during a 12-mo period. Telemetric ICP sensors (Neurovent-P-tel; Raumedic, Helmbrechts, Germany) were implanted in all patients. Following discharge from the neuro intensive care unit (NICU), scheduled weekly ICP monitoring sessions were performed during the rehabilitation phase. RESULTS A total of 16 patients (traumatic brain injury: 7, stroke: 9) were included (median age: 55 yr, range: 19-71 yr). Median time from NICU discharge to cranioplasty was 48 d (range: 16-98 d) and during this period, mean ICP gradually decreased from 7.8 ± 2.0 mm Hg to -1.8 ± 3.3 mm Hg (P = .02). The most pronounced decrease occurred during the first month. Normal postural ICP change was abolished after DC for the entire follow-up period, ie, there was no difference between ICP in supine and sitting position (P = .67). PWA was markedly reduced and decreased from initially 1.2 ± 0.7 mm Hg to 0.4 ± 0.3 mm Hg (P = .05). CONCLUSION Following NICU discharge, ICP decreases to negative values within 4 wk, normal postural ICP regulation is lost and intracranial PWA is diminished significantly. These abnormalities might have implications for intracranial fluid movements (eg, CSF and/or glymphatic flow) following DC and warrants further investigations.
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Affiliation(s)
| | - Morten Andresen
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Jesper Kelsen
- Department of Orthopedic Surgery (Spine Section), Rigshospitalet, Copenhagen, Denmark
| | | | - Kåre Fugleholm
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
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235
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Li J, Zhang P, Wu S, Yuan R, Liu J, Tao W, Wang D, Liu M. Impaired consciousness at stroke onset in large hemisphere infarction: incidence, risk factors and outcome. Sci Rep 2020; 10:13170. [PMID: 32759986 PMCID: PMC7406648 DOI: 10.1038/s41598-020-70172-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 07/23/2020] [Indexed: 02/05/2023] Open
Abstract
Impaired consciousness (IC) at stroke onset in large hemispheric infarctions (LHI) patients is common in clinical practice. However, little is known about the incidence and risk factors of IC at stroke onset in LHI. Besides, stroke-related complications and clinical outcomes in relation to the development of IC has not been systematically examined. Data of 256 consecutive patients with LHI were collected. IC at stroke onset was retrospectively collected from the initial emergency department and/or admission records. Of the 256 LHI patients enrolled, 93 (36.3%) had IC at stroke onset. LHI patients with IC at stroke onset were older (median age 66 vs. 61, p = 0.041), had shorter prehospital delay (24 vs. 26 h, p < 0.001and higher baseline National Institutes of Health Stroke Scale (NIHSS) score (19 vs. 12, p < 0.001). Independent risk factors of IC at stroke onset were high NIHSS score (odds ratio, OR 1.17, 95% confidence interval [CI] 1.12 to 1.23) and atrial fibrillation (OR 1.93, 95% CI 1.07 to 3.47). Dyslipidemia appeared to protect against IC at stroke onset (adjusted OR 0.416, 95% CI 0.175 to 0.988). IC at stroke onset was associated with higher frequency of stroke-related complications (90.32% vs. 67.48%, p < 0.001), especially brain edema (45.16% vs. 23.31%, p < 0.001) and pneumonia (63.44% vs. 47.82%, p = 0.019). The IC group had higher rates of in-hospital death (23.66% vs. 11.66%, p = 0.012), 3-month mortality (49.46% vs. 24.87%, p = 0.002), and 3-month unfavorable outcome (64.51% vs. 49.07%, p = 0.017). However, after adjusting for age, baseline NIHSS score and other confounders, IC at stroke onset was not an independent predictor of in-hospital death (adjusted OR 0.56, 95% CI 0.22 to 1.47), 3-month mortality (adjusted OR 0.54, 95% CI 0.25 to 1.14) and 3-month unfavorable outcome (adjusted OR 0.64, 95% CI 0.31 to 1.33) in LHI patients (all p > 0.05). Our results suggested that IC occur in 1 out of every 3 LHI patients at stroke onset and was associated with initial stroke severity and atrial fibrillation. LHI patients with IC at stroke onset more frequently had stroke-related complications, 3-month mortality and unfavorable outcome, whereas IC was not an independent predictor of poor outcomes.
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Affiliation(s)
- Jie Li
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China. .,Department of Neurology, People's Hospital of Deyang City, No. 173, North Taishan Road, Deyang, 618000, Sichuan Province, People's Republic of China.
| | - Ping Zhang
- Department of Neurology, People's Hospital of Deyang City, No. 173, North Taishan Road, Deyang, 618000, Sichuan Province, People's Republic of China
| | - Simiao Wu
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Ruozhen Yuan
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Junfeng Liu
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Wendan Tao
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Deren Wang
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Ming Liu
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China.
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Lammy S, Taylor A, Willetts S, St George EJ. Fifteen-Year Institutional Retrospective Case Series of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction. World Neurosurg 2020; 143:e456-e463. [PMID: 32750513 DOI: 10.1016/j.wneu.2020.07.185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/23/2020] [Accepted: 07/26/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE In the present study, we updated our previously reported case series of patients who had undergone decompressive craniectomy for malignant middle cerebral artery infarction (mMCAI) (2005-2020). To the best of our knowledge, the present case series constitutes the largest reported series from a UK neurosurgical unit of decompressive craniectomy for mMCAI. METHODS We extracted data regarding the clinical discriminators, surgical timescales, and functional outcomes of patients. RESULTS A total of 67 patients had undergone decompressive craniectomy. The 30-day mortality was 17.9% (n = 12). Of the 67 patients, 31 were male (46.3%) and 36 were female (53.7%). Their mean age was 45 years (range, 16-64 years). The mean age of the survivors was 43 years (range, 16-62 years) compared with 50 years (range, 38-64 years) for those who had died. The median ictal and preoperative Glasgow coma scale score was 14 (range, 7-15) and 8 (range, 3-15), respectively. The corresponding motor scores were 6 and 5. The mean interval from ictus to neurosurgical unit admission was 18.25 hours (range, 0.5-66 hours) and from admission to decompressive craniotomy was 7.30 hours (range, 0.5-46 hours). Of the 67 patients, 63% had undergone "early" craniectomy (<48 hours from mMCAI evolution), with 89% of these patients having undergone craniectomy <24 hours after neurosurgical unit admission. The mean maximum anteroposterior craniectomy diameter was 13.01 cm (range, 10.29-15.56 cm), and mean surface area was 94.38 cm2 (range, 74.75-132.32 cm2). Overall, 46% of patients had had a modified Rankin scale score of <3 (range, 0-6) from discharge to 12 months postoperatively. The median neurosurgical unit length of stay was 15 days (range, 6 hours to 365 days). CONCLUSIONS The findings from the present update have confirmed that local practice has remained consistent with current evidence. However, patient selection might be optimized if diffusion-weighted magnetic resonance imaging and computed tomography perfusion were used at the original middle cerebral artery infarct admission.
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Affiliation(s)
- Simon Lammy
- Department of Neurosurgery, Institute of Neurological Sciences, Glasgow, United Kingdom.
| | - Aaron Taylor
- Department of Neurosurgery, Institute of Neurological Sciences, Glasgow, United Kingdom
| | - Sarah Willetts
- Department of Neurosurgery, Institute of Neurological Sciences, Glasgow, United Kingdom
| | - Edward J St George
- Department of Neurosurgery, Institute of Neurological Sciences, Glasgow, United Kingdom
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237
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Pedicelli A, Valente I, Pilato F, Distefano M, Colosimo C. Stroke priorities during COVID-19 outbreak: acting both fast and safe. J Stroke Cerebrovasc Dis 2020; 29:104922. [PMID: 32417235 PMCID: PMC7200390 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104922] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/27/2020] [Indexed: 12/13/2022] Open
Abstract
While the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) spreads all over the world, the healthcare systems are facing the dramatic challenge of simultaneously fight against the outbreak and life-threating emergencies. In this biological setting, emergency departments and neurovascular teams are exposed to high risk of infection and should therefore be prepared to deal with neurological emergencies safely. The purpose of this article is to analyze the current evidence on COVID-19 in the context of acute ischemic stroke and to describe the model of behavior we are putting into action to maintain the stroke pathway both rapid for the patient and safe for the healthcare professionals. We reserve a specific focus on personal protection equipment, dress code and healthcare professional behavior.
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Affiliation(s)
- Alessandro Pedicelli
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Area Diagnostica per Immagini, UOC Radiologia e Neuroradiologia, Roma, Italia.
| | - Iacopo Valente
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Area Diagnostica per Immagini, UOC Radiologia e Neuroradiologia, Roma, Italia.
| | - Fabio Pilato
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento di scienze dell'invecchiamento, neurologiche ortopediche e della testa-collo, Area Neuroscienze, UOC Neurologia, 00168 Roma, Italia.
| | - Marisa Distefano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento di scienze dell'invecchiamento, neurologiche ortopediche e della testa-collo, Area Neuroscienze, UOC Neurologia, 00168 Roma, Italia.
| | - Cesare Colosimo
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Area Diagnostica per Immagini, UOC Radiologia e Neuroradiologia, Roma, Italia; Università Cattolica del Sacro Cuore, Roma, Italia.
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238
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Casolla B, Kuchcinski G, Kyheng M, Hanafi R, Lejeune JP, Leys D, Cordonnier C, Hénon H. Infarct Volume Before Hemicraniectomy in Large Middle Cerebral Artery Infarcts Poorly Predicts Catastrophic Outcome. Stroke 2020; 51:2404-2410. [DOI: 10.1161/strokeaha.120.029920] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Infarct volumes predict malignant infarcts in patients undergoing decompressive hemicraniectomy (DH) for large middle cerebral artery territory infarcts. The aim of the study was to determine the optimal magnetic resonance imaging infarct volume threshold that predicts a catastrophic outcome at 1 year (modified Rankin Scale score of 5 or death).
Methods:
We included consecutive patients who underwent DH for large middle cerebral artery infarcts. We analyzed infarct volumes before DH with semi-automated methods on b1000 diffusion-weighted imaging sequences and apparent diffusion coefficient maps. We studied infarct volume thresholds for prediction of catastrophic outcomes, and analyzed sensitivity, specificity, and the area under the curve, a value ≥0.70 indicating an acceptable prediction.
Results:
Of 173 patients (109 men, 63%; median age 53 years), 42 (24.3%) had catastrophic outcomes. Magnetic resonance imaging b1000 diffusion-weighted imaging and apparent diffusion coefficient infarct volumes were associated to the occurrence of 1-year catastrophic outcome (adjusted odds ratio, 9.17 [95% CI, 2.00–42.04] and odds ratio, 4.18 [95% CI, 1.33–13.19], respectively, per 1 log increase). The optimal volume cutoff of were 211 mL on b1000 diffusion-weighted imaging and 181 mL on apparent diffusion coefficient maps. The 2 methods showed similar sensitivities and specificities and overlapping area under the curve of 0.64 (95% CI, 0.54–0.74).
Conclusions:
In patients with large middle cerebral artery infarcts, optimal magnetic resonance imaging infarct volume thresholds showed poor accuracy and low specificity to predict 1-year catastrophic outcome, with different b1000 diffusion-weighted imaging and apparent diffusion coefficient thresholds. In the setting of DH, optimal infarct volumes alone should not be used to deny DH, irrespectively of the method used.
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Affiliation(s)
- Barbara Casolla
- Department of Neurology, Stroke Unit (B.C., D.L., C.C., H.H.), University of Lille, Inserm U1172, CHU Lille, France
| | - Gregory Kuchcinski
- Department of Neuroradiology (G.K., R.H.), University of Lille, Inserm U1172, CHU Lille, France
| | - Maéva Kyheng
- University of Lille, CHU Lille, ULR 2694 - METRICS: évaluation des technologies de santé et des pratiques médicales, France (M.K.)
- CHU Lille, Département de Biostatistiques, France (M.K.)
| | - Riyad Hanafi
- Department of Neuroradiology (G.K., R.H.), University of Lille, Inserm U1172, CHU Lille, France
| | - Jean-Paul Lejeune
- Department of Neurosurgery, University of Lille, Inserm, U1189, CHU Lille, France (J.-P.L.)
| | - Didier Leys
- Department of Neurology, Stroke Unit (B.C., D.L., C.C., H.H.), University of Lille, Inserm U1172, CHU Lille, France
| | - Charlotte Cordonnier
- Department of Neurology, Stroke Unit (B.C., D.L., C.C., H.H.), University of Lille, Inserm U1172, CHU Lille, France
| | - Hilde Hénon
- Department of Neurology, Stroke Unit (B.C., D.L., C.C., H.H.), University of Lille, Inserm U1172, CHU Lille, France
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Quantitative Serial CT Imaging-Derived Features Improve Prediction of Malignant Cerebral Edema after Ischemic Stroke. Neurocrit Care 2020; 33:785-792. [PMID: 32729090 DOI: 10.1007/s12028-020-01056-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/16/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Malignant cerebral edema develops in a small subset of patients with hemispheric strokes, precipitating deterioration and death if decompressive hemicraniectomy (DHC) is not performed in a timely manner. Predicting which stroke patients will develop malignant edema is imprecise based on clinical data alone. Head computed tomography (CT) imaging is often performed at baseline and 24-h. We determined the incremental value of incorporating imaging-derived features from serial CTs to enhance prediction of malignant edema. METHODS We identified hemispheric stroke patients at three sites with NIHSS ≥ 7 who had baseline as well as 24-h clinical and CT imaging data. We extracted quantitative imaging features from baseline and follow-up CTs, including CSF volume, intracranial reserve (CSF/cranial volume), as well as midline shift (MLS) and infarct-related hypodensity volume. Potentially lethal malignant edema was defined as requiring DHC or dying with MLS over 5-mm. We built machine-learning models using logistic regression first with baseline data and then adding 24-h data including reduction in CSF volume (ΔCSF). Model performance was evaluated with cross-validation using metrics of recall (sensitivity), precision (predictive value), as well as area under receiver-operating-characteristic and precision-recall curves (AUROC, AUPRC). RESULTS Twenty of 361 patients (6%) died or underwent DHC. Baseline clinical variables alone had recall of 60% with low precision (7%), AUROC 0.59, AUPRC 0.15. Adding baseline intracranial reserve improved recall to 80% and AUROC to 0.82 but precision remained only 16% (AUPRC 0.28). Incorporating ΔCSF improved AUPRC to 0.53 (AUROC 0.91) while all imaging features further improved prediction (recall 90%, precision 38%, AUROC 0.96, AUPRC 0.66). CONCLUSION Incorporating quantitative CT-based imaging features from baseline and 24-h CT enhances identification of patients with malignant edema needing DHC. Further refinements and external validation of such imaging-based machine-learning models are required.
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240
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Abstract
Stroke is a major cause of death and disability globally. Diagnosis depends on clinical features and brain imaging to differentiate between ischaemic stroke and intracerebral haemorrhage. Non-contrast CT can exclude haemorrhage, but the addition of CT perfusion imaging and angiography allows a positive diagnosis of ischaemic stroke versus mimics and can identify a large vessel occlusion target for endovascular thrombectomy. Management of ischaemic stroke has greatly advanced, with rapid reperfusion by use of intravenous thrombolysis and endovascular thrombectomy shown to reduce disability. These therapies can now be applied in selected patients who present late to medical care if there is imaging evidence of salvageable brain tissue. Both haemostatic agents and surgical interventions are investigational for intracerebral haemorrhage. Prevention of recurrent stroke requires an understanding of the mechanism of stroke to target interventions, such as carotid endarterectomy, anticoagulation for atrial fibrillation, and patent foramen ovale closure. However, interventions such as lowering blood pressure, smoking cessation, and lifestyle optimisation are common to all stroke subtypes.
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Affiliation(s)
- Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital and The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
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241
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Wen X, Li Y, He X, Xu Y, Shu Z, Hu X, Chen J, Jiang H, Gong X. Prediction of Malignant Acute Middle Cerebral Artery Infarction via Computed Tomography Radiomics. Front Neurosci 2020; 14:708. [PMID: 32733197 PMCID: PMC7358521 DOI: 10.3389/fnins.2020.00708] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/11/2020] [Indexed: 12/23/2022] Open
Abstract
Malignant middle cerebral artery infarction (mMCAi) is a serious complication of cerebral infarction usually associated with poor patient prognosis. In this retrospective study, we analyzed clinical information as well as non-contrast computed tomography (NCCT) and computed tomography angiography (CTA) data from patients with cerebral infarction in the middle cerebral artery (MCA) territory acquired within 24 h from symptoms onset. Then, we aimed to develop a model based on the radiomics signature to predict the development of mMCAi in cerebral infarction patients. Patients were divided randomly into training (n = 87) and validation (n = 39) sets. A total of 396 texture features were extracted from each NCCT image from the 126 patients. The least absolute shrinkage and selection operator regression analysis was used to reduce the feature dimension and construct an accurate radiomics signature based on the remaining texture features. Subsequently, we developed a model based on the radiomics signature and Alberta Stroke Program Early CT Score (ASPECTS) based on NCCT to predict mMCAi. Our prediction model showed a good predictive performance with an AUC of 0.917 [95% confidence interval (CI), 0.863-0.972] and 0.913 [95% CI, 0.795-1] in the training and validation sets, respectively. Additionally, the decision curve analysis (DCA) validated the clinical efficacy of the combined risk factors of radiomics signature and ASPECTS based on NCCT in the prediction of mMCAi development in patients with acute stroke across a wide range of threshold probabilities. Our research indicates that radiomics signature can be an instrumental tool to predict the risk of mMCAi.
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Affiliation(s)
- Xuehua Wen
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Yumei Li
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xiaodong He
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Yuyun Xu
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Zhenyu Shu
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xingfei Hu
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Junfa Chen
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Hongyang Jiang
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xiangyang Gong
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China.,Institute of Artificial Intelligence and Remote Imaging, Hangzhou Medical College, Hangzhou, China
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Tracol C, Vannier S, Hurel C, Tuffier S, Eugene F, Le Reste PJ. Predictors of malignant middle cerebral artery infarction after mechanical thrombectomy. Rev Neurol (Paris) 2020; 176:619-625. [PMID: 32624178 DOI: 10.1016/j.neurol.2020.01.352] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 01/05/2020] [Accepted: 01/10/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Several predictors have been described to early diagnose malignant middle cerebral artery infarction (MMI) and select patient for hemicraniectomy. Nevertheless, few studies have assessed them among patients with acute ischemic stroke undergoing mechanical endovascular thrombectomy (MET). The overall objective in this study was to evaluate these predictors in patients undergoing MET in the purpose to guide the medical care in the acute phase. METHODS We selected patients from a prospective local database which reference all patients eligible for treatment with Alteplase thrombolysis and/or mechanical endovascular thrombectomy in acute stroke. We investigated demographic, clinical, and radiological data. Multivariate regression analysis was used to identify clinical and imaging predictors of MMI. RESULTS In 32 months, 66 patients were included. Eighteen (27.3%) developed MMI. Malignant evolution was associated with: severity of neurological deficit and level of consciousness at admission, infarct size in DWI sequence and involvement of other vascular territories. Study groups didn't differ in terms of successful reperfusion. Two variables were identified as independent predictors of MMI: DWI infarct volume (p<0.001) and time to thrombectomy (p=0.018). A decision tree based on these two factors was able to predict malignant evolution with high specificity (100%) and sensibility (73%). CONCLUSION Our study proposes a practical decision tree including DWI lesion volume and delay before thrombectomy to early and accurately predict MMI in a subgroup of patients with MCA infarction undergoing MET regardless to the status of reperfusion.
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Affiliation(s)
- C Tracol
- Neurology, university hospital, 37, quai de la Prevalaye, 35000 Rennes, France.
| | - S Vannier
- Neurology, university hospital, Rennes, France
| | - C Hurel
- Department of epidemiology, university hospital, Rennes, France
| | - S Tuffier
- Department of epidemiology, university hospital, Rennes, France
| | - F Eugene
- Radiology, university hospital, Rennes, France
| | - P J Le Reste
- Neurosurgery, university hospital, Rennes, France
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243
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Barrel Stave Osteotomy Decompression for Acute Brain Injury in Infants: Technical Note. J Craniofac Surg 2020; 31:e707-e710. [PMID: 32604285 DOI: 10.1097/scs.0000000000006637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Decompressive craniectomy (DC) is rarely required in infants, but when performed several aspects should be considered: These youngest patients are vulnerable to blood loss and cranial reconstruction can be challenging due to skull growth and bone flap resorption. On the other hand, infants have thin and flexible bone and osteogenic potential. The authors propose a technique which makes use of these unique aspects by achieving decompression with the craniofacial method of barrel stave osteotomy, aiming to achieve adequate DC, limit perioperative risks and facilitate subsequent cranial reconstruction.
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Pattankar S, Misra BK. Protocol-Based Early Decompressive Craniectomy in a Resource-Constrained Environment: A Tertiary Care Hospital Experience. Asian J Neurosurg 2020; 15:634-639. [PMID: 33145218 PMCID: PMC7591208 DOI: 10.4103/ajns.ajns_41_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/05/2020] [Accepted: 05/05/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Decompressive craniectomy (DC) is an emergency life-saving procedure used to treat refractory intracranial hypertension (RICH). The authors aim to analyze their experience with protocol-based early DC (<24 h) in RICH cases diagnosed based on clinical and radiological evidence, without preoperative intracranial pressure monitoring done over 10 years. MATERIALS AND METHODS This is a retrospective, observational study which includes 58 consecutive patients who underwent protocol-based early DC by the senior author at a single institution between 2007 and 2017. Background variables and outcome in the form of Glasgow Outcome Score-Extended (GOS-E) at 6 months and 1 year were analyzed. RESULTS Fourteen patients had traumatic brain injury (TBI), 17 had intracranial hemorrhage (ICH), 14 had malignant cerebral infarcts (MCI), and the reminder 13 patients had other causes. At 6 months, the mortality rate was 22.4%. Good recovery, moderate disability, and severe disability were seen in 13.8%, 17.2%, and 43.1% of patients, respectively. Two patients were in vegetative state. The cutoff for favorable/unfavorable outcome was defined as GOS-E 4-8/1-3. By this application, 63.8% of patients had favorable outcome at 6 months. The favorable outcome in patients of TBI, ICH, and MCI was 57.1%, 58.8%, and 85.7%, respectively. CONCLUSIONS DC helps in obtaining a favorable outcome in selected patients with a defined pathology. The diagnosis of RICH based on clinical and radiological parameters, and protocol-based early DC, is reasonably justified as the way forward for resource-constrained environments. The risk of vegetative state is small.
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Affiliation(s)
- Sanjeev Pattankar
- Department of Neurosurgery, P. D. Hinduja National Hospital and MRC, Mumbai, Maharashtra, India
| | - Basant Kumar Misra
- Department of Neurosurgery, P. D. Hinduja National Hospital and MRC, Mumbai, Maharashtra, India
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Mohamed W, Zaheer A, Deshpande R. Early aortic repair and decompressive hemicraniectomy in aortic dissection with ischaemic stroke. Perfusion 2020; 36:113-117. [PMID: 32580636 DOI: 10.1177/0267659120932413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The presence of stroke in patients with type A acute aortic dissection confers worse clinical outcomes and represents a therapeutic dilemma. While emergency surgical repair is the ideal management strategy, the risk of further cerebral insult is a cause of concern, especially in the elderly moribund patient, where delayed repair or a conservative approach may be considered. A 67-year-old female presented with chest pain and left-sided hemiparesis and was diagnosed with extensive type A acute aortic dissection and ischaemic stroke secondary to right common carotid artery stenosis. She underwent two major operations (emergency dissection repair and hemicraniectomy) and sustained several complications. Despite her eventful postoperative recovery, she was discharged after 6 weeks to a neurorehabilitation unit with a mild neurological deficit. Due to subsequent pulmonary complications, the patient died 5 weeks later. The present report appraises the current evidence on the management of patients with type A acute aortic dissection presenting with neurological sequelae.
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Affiliation(s)
- Walid Mohamed
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, UK
| | - Aneel Zaheer
- Department of Cardiac Surgery, King's College Hospital, London, UK
| | - Ranjit Deshpande
- Department of Cardiac Surgery, King's College Hospital, London, UK
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246
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Sabben C, Desilles JP, Charbonneau F, Savatovsky J, Morvan E, Obadia A, Raynouard I, Fela F, Escalard S, Redjem H, Smajda S, Ciccio G, Blanc R, Fahed R, Le Guerinel C, Engrand N, Ben Maacha M, Labreuche J, Mazighi M, Piotin M, Obadia M. Early successful reperfusion after endovascular therapy reduces malignant middle cerebral artery infarction occurrence in young patients with large diffusion-weighted imaging lesions. Eur J Neurol 2020; 27:1988-1995. [PMID: 32431009 DOI: 10.1111/ene.14330] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/08/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Malignant middle cerebral artery infarction (MMI) is a severe complication of acute ischaemic stroke (AIS). The aim of our study was to assess whether successful reperfusion after endovascular therapy (EVT) in AIS with clinical and imaging predictors of MMI decreased its occurrence. METHODS Data were collected between January 2014 and July 2018 in a monocentric prospective AIS registry of patients treated with EVT. Patients selected were <65 years old with severe anterior circulation AIS with a National Institutes of Health Stroke Scale score >15, baseline Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Score ≤ 6 and baseline diffusion-weighted imaging lesion volume >82 mL within 6 h of symptom onset. Successful reperfusion was defined as a Thrombolysis in Cerebral Ischemia score ≥ 2b. Occurrence of MMI was the primary endpoint. RESULTS A total of 66 EVT-treated patients were included in our study. MMI occurred in 27 patients (41%). In unadjusted analysis, successful reperfusion was associated with fewer MMIs (31.8% vs. 65.0%; P = 0.015) and with more favorable outcome at 3 months (50% vs. 20%; P = 0.023). In multivariate analysis, successful reperfusion was associated with an adjusted odds ratio (95% confidence intervals) of 0.35 (0.10-1.12) for MMI and 2.77 (0.84-10.43) for 3-month favorable outcome occurrence. CONCLUSIONS Early successful reperfusion performed in patients with AIS with clinical and imaging predictors of MMI was associated with decreased MMI occurrence. Reperfusion status might be considered in evaluating the need for craniectomy in patients with early predictors of MMI.
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Affiliation(s)
- C Sabben
- Department of Neurology, Rothschild Foundation Hospital, Paris
| | - J P Desilles
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris.,Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Paris, Paris
| | - F Charbonneau
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris
| | - J Savatovsky
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris
| | - E Morvan
- Department of Neurology, Rothschild Foundation Hospital, Paris
| | - A Obadia
- Department of Neurology, Rothschild Foundation Hospital, Paris
| | - I Raynouard
- Department of Neurology, Rothschild Foundation Hospital, Paris
| | - F Fela
- Department of Neurology, Rothschild Foundation Hospital, Paris
| | - S Escalard
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris
| | - H Redjem
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris
| | - S Smajda
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris
| | - G Ciccio
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris
| | - R Blanc
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris.,Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Paris, Paris
| | - R Fahed
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris
| | - C Le Guerinel
- Department of Neurosurgery, Rothschild Foundation Hospital, Paris
| | - N Engrand
- Neuro Intensive Care Unit, Rothschild Foundation Hospital, Paris
| | - M Ben Maacha
- Research and Biostatistics Unit, Rothschild Foundation Hospital, Paris
| | - J Labreuche
- ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, CHU Lille, Université de Lille, Lille, France
| | - M Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris.,Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Paris, Paris
| | - M Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris.,Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Paris, Paris
| | - M Obadia
- Department of Neurology, Rothschild Foundation Hospital, Paris
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Qureshi AI, Lobanova I, Huang W, Saeed O, Suarez JI. Rate and Predictors of Unanticipated Surgical Evacuation in Patients with Intracerebral Hemorrhage: Post Hoc Analysis of ATACH 2 Trial. World Neurosurg 2020; 141:e935-e940. [PMID: 32561489 DOI: 10.1016/j.wneu.2020.06.089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND We performed this analysis to identify the rates, predictors, and associated outcomes of unexpected neurosurgical evacuation in a multicenter randomized clinical trial, Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) 2. METHODS The ATACH 2 trial determined the efficacy of antihypertensive treatment in patients with spontaneous supratentorial intracerebral hemorrhages (ICHs) with a Glasgow Coma Scale (GCS) score of ≥5 and intraparenchymal hematoma volume of <60 cm3 on initial computed tomographic scan. We determined the proportion of ICH patients requiring unanticipated surgical evacuation and identified baseline factors associated with evacuation. RESULTS Among the 992 subjects analyzed, 44 (4.4%) subjects required unanticipated surgical evacuation of hematoma. The proportion of subjects with initial GCS score of 13 or less was significantly higher among those who required surgical evacuation (43.2% vs. 26.8%, P < 0.001). In the logistics regression analysis, hematoma volume ≥18 cm3 (odds ratio, 4.3; 95% confidence interval, 2.1-8.8) and right-sided hematoma (odds ratio, 2.8; 95% confidence interval, 1.3-5.9) were significantly associated with surgical evacuation. Age, location, GCS score strata, and allocated treatment (intensive vs. standard systolic blood pressure reduction) were not associated with surgical evacuation. Among the 44 patients who underwent surgical evacuation, death or disability at 3 months postrandomization was seen in 32 (73%) of 44 subjects. CONCLUSIONS In the large cohort of ATACH 2 subjects with good grade ICH, the rates of unanticipated surgical evacuation were low and were associated with relatively high rates of death or disability at 3 months.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Iryna Lobanova
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri-Columbia, Columbia, Missouri, USA.
| | - Wei Huang
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Omar Saeed
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Jose I Suarez
- Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine Baltimore, Maryland, USA
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248
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Huang K, Ji Z, Wu Y, Huang Y, Li G, Zhou S, Yang Z, Huang W, Yang G, Weng G, Chen P, Pan S. Safety and efficacy of glibenclamide combined with rtPA in acute cerebral ischemia with occlusion/stenosis of anterior circulation (SE-GRACE): study protocol for a randomized controlled trial. BMC Neurol 2020; 20:239. [PMID: 32527232 PMCID: PMC7291425 DOI: 10.1186/s12883-020-01823-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 06/05/2020] [Indexed: 12/11/2022] Open
Abstract
Background Thrombolysis with recombinant tissue plasminogen activator (rtPA) improves outcome for patients with acute ischemic stroke (AIS), but many of them still have substantial disability. Glibenclamide (US adopted name, glyburide), a long-acting sulfonylurea, shows promising result in treating AIS from both preclinical and clinical studies. This study investigates the safety and efficacy of glibenclamide combined with rtPA in treating AIS patients. Methods This is a prospective, randomized, double-blind, placebo-controlled, multicenter trial with an estimated sample size of 306 cases, starting in January 2018. Patients aged 18 to 74 years, presented with a symptomatic anterior circulation occlusion with a deficit on the NIHSS of 4 to 25 points and treated with intravenous rtPA within the first 4.5 h of their clinical onsets, are eligible for participation in this study. The target time from the onset of symptoms to receive the study drug is of 10 h. Subjects are randomized 1: 1 to receive glibenclamide or placebo with a loading dose of 1.25 mg, followed by 0.625 mg every 8 h for total 5 days. The primary efficacy endpoint is 90-day good outcome, measured as modified Rankin Scale of 0 to 2. Safety outcomes are all-cause 30-day mortality and early neurological deterioration, with a focus on cardiac- and glucose-related serious adverse events. Discussion This study will provide valuable information about the safety and efficacy of oral glibenclamide for AIS patients treated with rtPA. This would bring benefits to a large number of patients if the agent is proved to be effective. Trial registration The trial was registered on September 14th 2017 at www.clinicaltrials.gov having identifier NCT03284463. Registration was performed before recruitment was initiated.
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Affiliation(s)
- Kaibin Huang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou North Avenue 1838#, Guangzhou, 510515, China
| | - Zhong Ji
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou North Avenue 1838#, Guangzhou, 510515, China
| | - Yongming Wu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou North Avenue 1838#, Guangzhou, 510515, China
| | - Yunqiang Huang
- Department of Neurology, Heyuan People's Hospital, Heyuan, China
| | - Guangning Li
- Department of Neurology, Huadu district People's Hospital, Guangzhou, China
| | - Saijun Zhou
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhi Yang
- Department of Neurology, Maoming People's Hospital, Maoming, China
| | - Wenguo Huang
- Department of Neurology, Maoming Hospital of Traditional Chinese Medicine, Maoming, China
| | - Guoshuai Yang
- Department of Neurology, Haikou People's Hospital, Haikou, China
| | - Guohu Weng
- Department of Neurology, Hainan Hospital of Traditional Chinese Medicine, Haikou, China
| | - Pingyan Chen
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Suyue Pan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou North Avenue 1838#, Guangzhou, 510515, China.
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Kaiser EE, Waters ES, Fagan MM, Scheulin KM, Platt SR, Jeon JH, Fang X, Kinder HA, Shin SK, Duberstein KJ, Park HJ, West FD. Characterization of tissue and functional deficits in a clinically translational pig model of acute ischemic stroke. Brain Res 2020; 1736:146778. [PMID: 32194080 PMCID: PMC10671789 DOI: 10.1016/j.brainres.2020.146778] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/04/2020] [Accepted: 03/10/2020] [Indexed: 12/16/2022]
Abstract
The acute stroke phase is a critical time frame used to evaluate stroke severity, therapeutic options, and prognosis while also serving as a major tool for the development of diagnostics. To further understand stroke pathophysiology and to enhance the development of treatments, our group developed a translational pig ischemic stroke model. In this study, the evolution of acute ischemic tissue damage, immune responses, and functional deficits were further characterized. Stroke was induced by middle cerebral artery occlusion in Landrace pigs. At 24 h post-stroke, magnetic resonance imaging revealed a decrease in ipsilateral diffusivity, an increase in hemispheric swelling resulting in notable midline shift, and intracerebral hemorrhage. Stroke negatively impacted white matter integrity with decreased fractional anisotropy values in the internal capsule. Like patients, pigs showed a reduction in circulating lymphocytes and a surge in neutrophils and band cells. Functional responses corresponded with structural changes through reductions in open field exploration and impairments in spatiotemporal gait parameters. Characterization of acute ischemic stroke in pigs provided important insights into tissue and functional-level assessments that could be used to identify potential biomarkers and improve preclinical testing of novel therapeutics.
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Affiliation(s)
- Erin E Kaiser
- Regenerative Bioscience Center, University of Georgia, Athens, GA, United States; Neuroscience Program, Biomedical and Health Sciences Institute, University of Georgia, Athens, GA, United States; Department of Animal and Dairy Science, College of Agricultural and Environmental Sciences, University of Georgia, Athens, GA, United States
| | - Elizabeth S Waters
- Regenerative Bioscience Center, University of Georgia, Athens, GA, United States; Neuroscience Program, Biomedical and Health Sciences Institute, University of Georgia, Athens, GA, United States; Department of Animal and Dairy Science, College of Agricultural and Environmental Sciences, University of Georgia, Athens, GA, United States
| | - Madison M Fagan
- Regenerative Bioscience Center, University of Georgia, Athens, GA, United States; Department of Animal and Dairy Science, College of Agricultural and Environmental Sciences, University of Georgia, Athens, GA, United States
| | - Kelly M Scheulin
- Regenerative Bioscience Center, University of Georgia, Athens, GA, United States; Neuroscience Program, Biomedical and Health Sciences Institute, University of Georgia, Athens, GA, United States; Department of Animal and Dairy Science, College of Agricultural and Environmental Sciences, University of Georgia, Athens, GA, United States
| | - Simon R Platt
- Regenerative Bioscience Center, University of Georgia, Athens, GA, United States; Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, United States
| | - Julie H Jeon
- Department of Foods and Nutrition, College of Family and Consumer Sciences, University of Georgia, Athens, GA, United States
| | - Xi Fang
- Department of Foods and Nutrition, College of Family and Consumer Sciences, University of Georgia, Athens, GA, United States
| | - Holly A Kinder
- Regenerative Bioscience Center, University of Georgia, Athens, GA, United States; Neuroscience Program, Biomedical and Health Sciences Institute, University of Georgia, Athens, GA, United States; Department of Animal and Dairy Science, College of Agricultural and Environmental Sciences, University of Georgia, Athens, GA, United States
| | - Soo K Shin
- Regenerative Bioscience Center, University of Georgia, Athens, GA, United States; Department of Animal and Dairy Science, College of Agricultural and Environmental Sciences, University of Georgia, Athens, GA, United States; Department of Pharmaceutical and Biomedical Sciences, Interdisciplinary Toxicology Institute, University of Georgia, Athens, GA, United States
| | - Kylee J Duberstein
- Regenerative Bioscience Center, University of Georgia, Athens, GA, United States; Department of Animal and Dairy Science, College of Agricultural and Environmental Sciences, University of Georgia, Athens, GA, United States
| | - Hea J Park
- Department of Foods and Nutrition, College of Family and Consumer Sciences, University of Georgia, Athens, GA, United States
| | - Franklin D West
- Regenerative Bioscience Center, University of Georgia, Athens, GA, United States; Neuroscience Program, Biomedical and Health Sciences Institute, University of Georgia, Athens, GA, United States; Department of Animal and Dairy Science, College of Agricultural and Environmental Sciences, University of Georgia, Athens, GA, United States.
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Kim TJ, Lee JS, Yoon JS, Oh MS, Kim JW, Jung KH, Yu KH, Lee BC, Ko SB, Yoon BW. Impact of the Dedicated Neurointensivists on the Outcome in Patients with Ischemic Stroke Based on the Linked Big Data for Stroke in Korea. J Korean Med Sci 2020; 35:e135. [PMID: 32476299 PMCID: PMC7261699 DOI: 10.3346/jkms.2020.35.e135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/22/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Neurocritical care by dedicated neurointensivists may improve outcomes of critically ill patients with severe brain injury. In this study, we aimed to validate whether neurointensive care could improve the outcome in patients with critically ill acute ischemic stroke using the linked big dataset on stroke in Korea. METHODS We included 1,405 acute ischemic stroke patients with mechanical ventilator support in the intensive care unit after an index stroke. Patients were retrieved from linking the Clinical Research Center for Stroke Registry and the Health Insurance Review and Assessment Service data from the period between January 2007 and December 2014. The outcomes were mortality at discharge and at 3 months after an index stroke. The main outcomes were compared between the centers with and without dedicated neurointensivists. RESULTS Among the included patients, 303 (21.6%) were admitted to the centers with dedicated neurointensivists. The patients treated by dedicated neurointensivists had significantly lower in-hospital mortality (18.3% vs. 26.8%, P = 0.002) as well as lower mortality at 3-month (38.0% vs. 49.1%, P < 0.001) than those who were treated without neurointensivists. After adjusting for confounders, a treatment without neurointensivists was independently associated with higher in-hospital mortality (odds ratio [OR], 1.59; 95% confidence intervals [CIs], 1.13-2.25; P = 0.008) and 3-month mortality (OR, 1.48; 95% CIs, 1.12-1.95; P = 0.005). CONCLUSION Treatment by dedicated neurointensivists is associated with lower in-hospital and 3-month mortality using the linked big datasets for stroke in Korea. This finding stresses the importance of neurointensivists in treating patients with severe ischemic stroke.
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Affiliation(s)
- Tae Jung Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ji Sung Lee
- Department of Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Sun Yoon
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Ji Woo Kim
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Keun Hwa Jung
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Kyung Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Byung Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sang Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea.
| | - Byung Woo Yoon
- Department of Neurology, Seoul National University Hospital, Seoul, Korea.
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