Prognose und Lebensqualität nach Entlastungstrepanation

Attitudes of Nurses Toward Disability and Treatment in Space-Occupying Middle Cerebral Artery Stroke

BACKGROUND

Attitudes toward the degree of acceptable disability and the importance of aphasia are critical in deciding on decompressive hemicraniectomy (DHC) in space-occupying middle cerebral artery stroke (SOS). The attitudes of nurses deserve strong attention, because of their close interaction with patients during acute stroke treatment.

METHODS

This is a multicenter survey among 627 nurses from 132 hospitals in Germany. Questions address the acceptance of disability, importance of aphasia, and the preferred treatment in the hypothetical case of SOS.

RESULTS

Modified Rankin Scale (mRS) scores of 1 and 2 were considered acceptable by the majority of all respondents (89.7%). A mRS of 3, 4, and 5 was considered acceptable by 60.0, 15.5, and 1.6%, respectively. DHC was indicated as the treatment of choice in 31.4%. Every third participant considered the presence of aphasia important for treatment decision (33.3%). Older respondents more often refrained from DHC, irrespective of the presence of aphasia (dominant hemisphere p = 0.001, non-dominant hemisphere p = 0.004). Differences regarding acceptable disability and treatment decision were dependent on age, sex, and having relatives with stroke.

CONCLUSION

Most German nurses indicate moderately severe disability after SOS not to be acceptable, without emphasizing the presence of aphasia. The results call for greater scientific efforts in order to find reliable predictors for outcome after SOS.

Long-Term Outcomes in Patients Aged ≤70 Years With Intravenous Glyburide From the Phase II GAMES-RP Study of Large Hemispheric Infarction: An Exploratory Analysis

BACKGROUND AND PURPOSE

We aimed to determine whether subjects aged ≤70 years who were treated with intravenous glyburide (RP-1127; BIIB093; glibenclamide) would have better long-term outcomes than those who received placebo.

METHODS

GAMES-RP (Glyburide Advantage in Malignant Edema and Stroke-Remedy Pharmaceuticals) was a prospective, double-blind, randomized, placebo-controlled phase 2 clinical trial. Eighty-six participants, aged 18 to 80 years, who presented to 18 centers with large hemispheric infarction (baseline diffusion-weighted imaging volumes, 82-300 cm³) randomized within 10 hours of symptom onset were enrolled. In the current exploratory analysis, we included participants aged ≤70 years treated with intravenous glyburide (n=35) or placebo (n=30) who met per-protocol criteria. Intravenous glyburide or placebo was administered in a 1:1 ratio. We analyzed 90-day and 12-month mortality, functional outcome (modified Rankin Scale, Barthel Index), and quality of life (EuroQol group 5-dimension). Additional outcomes assessed included blood-brain barrier injury (MMP-9 [matrix metalloproteinase 9]) and cerebral edema (brain midline shift).

RESULTS

Participants ≤70 years of age treated with intravenous glyburide had lower mortality at all time points (log-rank for survival hazards ratio, 0.34; P=0.04). After adjustment for age, the difference in functional outcome (modified Rankin Scale) demonstrated a trend toward benefit for intravenous glyburide-treated subjects at 90 days (odds ratio, 2.31; P=0.07). Repeated measures analysis at 90 days, 6 months, and 12 months using generalized estimating equations showed a significant treatment effect of intravenous glyburide on the Barthel Index (P=0.03) and EuroQol group 5-dimension (P=0.05). Participants treated with intravenous glyburide had lower plasma levels of MMP-9 (189 versus 376 ng/mL; P<0.001) and decreased midline shift (4.7 versus 9 mm; P<0.001) compared with participants who received placebo.

CONCLUSIONS

In this exploratory analysis, participants ≤70 years of age with large hemispheric infarction have improved survival after acute therapy with intravenous glyburide.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01794182.

Attitudes of Patients and Relatives Toward Disability and Treatment in Malignant MCA Infarction

BACKGROUND

Attitudes among patients and relatives toward the degree of acceptable disability and the importance of aphasia are critical in deciding on decompressive hemicraniectomy (DHC) in malignant middle cerebral artery infarction (MMI). However, most MMI patients are not able to communicate their will. Furthermore, attitudes of healthy individuals and relatives may not correspond to those of stroke patients.

METHODS

This is a multicenter survey among 355 patients and 199 relatives during treatment for acute minor or moderate severe ischemic stroke in Germany. Questions address the acceptance of disability, importance of aphasia, and the preferred treatment in the hypothetical case of future MMI.

RESULTS

mRS scores of 2 or better were considered acceptable by the majority of all respondents (72.9-88.1%). A mRS of 3, 4, and 5 was considered acceptable by 56.0, 24.5, and 6.8%, respectively. Except for a mRS of 1, relatives indicated each grade of disability significantly more often acceptable than patients. Differences regarding acceptable disability and treatment decision were depending on family status, housing situation, need of care, and disability. The presence of aphasia was considered important for treatment decision by both patients (46.5%) and relatives (39.2%). Older respondents more often refrained from DHC (p < 0.001).

CONCLUSION

In Germany, there is substantial heterogeneity in patients and relatives regarding acceptable disability, aphasia, and treatment decision in the hypothetical case of MMI. Relatives significantly overestimate the degree of disability that is acceptable to stroke patients. Further studies are warranted to determine whether differences in attitudes impact on the decision to undergo DHC.

Early decompressive craniectomy for malignant cerebral infarction: Meta-analysis and clinical decision algorithm

BACKGROUND

Decompressive craniectomy (DC) is an aggressive life-saving surgical intervention for patients with malignant cerebral infarction (MCI). However, DC remains inconsistently and infrequently utilized, primarily due to enduring concern that increased survival occurs only at the cost of poor functional outcome. Our aim was to clarify the role of DC performed within 48 hours (early DC) for patients with MCI, including patients aged >60 years.

METHODS

We performed a meta-analysis of all available randomized controlled trials comparing early DC to best medical care for MCI. Studies were identified through literature searches of electronic databases including PubMed, EMBASE, and Scopus. We employed a Mantel-Haenszel fixed effects model to assess treatment effect on dichotomized modified Rankin Scale (mRS) outcomes at 12 months.

RESULTS

A total of 289 patients from 6 randomized controlled trials comparing early DC to best medical care were included. Early DC resulted in an increased rate of excellent outcomes, defined as mRS ≤2 (relative risk [RR] 2.81, 95% confidence interval [CI] 1.01-7.82, p = 0.047), and favorable outcomes, defined as mRS ≤3 (RR 2.06, 95% CI 1.25-3.40, p = 0.005). Early DC also increased the rate of survival with unfavorable outcomes, defined as mRS 4-5 (RR 3.03, 95% CI 1.98-4.65, p < 0.001).

CONCLUSIONS

Early DC increases the rate of excellent outcomes, i.e., functional independence, in addition to favorable and unfavorable outcomes; however, these findings must be interpreted within the context of patients' goals of care. We have developed a clinical decision algorithm that incorporates goals of care, which may guide consideration of early DC for MCI in clinical practice.

Quality of life after surgical decompression for a space-occupying middle cerebral artery infarct: A cohort study

BACKGROUND

In patients with a space-occupying middle cerebral artery (MCA) infarct surgical decompression reduces the risk of death, but increases the chance of survival with severe disability. We assessed quality of life (QoL), symptoms of depression, and caregiver burden at long-term follow-up.

METHODS

Patients treated in two academic centres between 2007 and 2012 were included. Follow-up was at least six months. Patients and caregivers were interviewed separately. QoL was assessed with a visual analogue scale and the 36-item Short-Form health survey (SF-36); depression with the Hospital Anxiety and Depression Scale; and caregiver burden with the Caregiver Strain Index.

RESULTS

Twenty five patients were enrolled, of whom seven had an infarct in the dominant hemisphere. After a median follow-up of 26 months (IQR 11-46) the median SF-36 mental component score was 54.4 (IQR 45-60), indicating a mental QoL comparable to that in the general population. The median SF-36 physical component score was 32.7 (IQR 22-38), indicating a worse physical QoL. Dominance of the hemisphere did not influence QoL. 79 % of patients and 65 % of caregivers would, in retrospect, again choose for surgery. 26 % of patients had signs of depression and 64 % of caregivers were substantially burdened in their daily life.

CONCLUSIONS

Mental QoL after surgical decompression for space-occupying MCA infarct is comparable to that in the general population, whereas physical QoL is worse. Dominance of the hemisphere did not influence QoL. The majority of caregivers experience substantial burden. Most patients and caregivers stand by their decision for hemicraniectomy.

Quality of Life after Surgical Decompression for Space-Occupying Middle Cerebral Artery Infarction: Systematic Review

Background and Purpose

In patients with space-occupying middle cerebral artery infarction, surgical decompression strongly reduces risk of death and increases the chance of a favorable outcome. This comes at the expense of an increase in the risk of survival with (moderately) severe disability. We assessed quality of life, depression, and caregiver burden in these patients.

Summary of Review

We systematically reviewed the literature by searching MEDLINE, EMBASE, and PsycINFO up to March 2014. We included randomized controlled trials, cohort studies, case–control studies, and case series with quality of life, depression, or caregiver burden as primary or secondary outcome. Seventeen articles reporting on 459 patients were included. At final follow-up at 7 to 51 months, 1344 patients (30%) had died, and 34 (11%) were lost to follow up. Data on 291 patients were available, of whom 81 of 213 survivors (39%) achieved good functional outcome at final follow-up (modified Rankin Scale ⩽3). Mean quality of life was 46% to 67% of the best possible score when based on questionnaires or visual analogue scales. At final follow-up, 143 of 189 patients (76%) would in retrospect again choose for surgical decompression. Severe depressive symptoms were present in 14 of 113 patients (16%). Three studies investigated caregiver burden and reported substantial burden. Patients more than 60 years old had a lower quality of life in comparison with younger patients.

Conclusions

Most patients treated with surgical decompression for space-occupying infarction have a reasonable quality of life at long-term follow-up and are satisfied with the treatment received. Severe depressive symptoms are uncommon.