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Fotakopoulos G, Gatos C, Georgakopoulou VE, Lempesis IG, Spandidos DA, Trakas N, Sklapani P, Fountas KN. Role of decompressive craniectomy in the management of acute ischemic stroke (Review). Biomed Rep 2024; 20:33. [PMID: 38273901 PMCID: PMC10809310 DOI: 10.3892/br.2024.1721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 12/07/2023] [Indexed: 01/27/2024] Open
Abstract
The application of decompressive craniectomy (DC) is thoroughly documented in the management of brain edema, particularly following traumatic brain injury. However, an increasing amount of concern is developing among the universal medical community as regards the application of DC in the treatment of other causes of brain edema, such as subarachnoid hemorrhage, cerebral hemorrhage, sinus thrombosis and encephalitis. Managing stroke continues to remain challenging, and demands the aggressive and intensive consulting of a number of medical specialties. Middle cerebral artery (MCA) infarcts, which consist of 1-10% of all supratentorial infarcts, are often associated with mass effects, and high mortality and morbidity rates. Over the past three decades, a number of neurosurgical medical centers have reported their experience with the application of DC in the treatment of malignant MCA infarction with varying results. In addition, over the past decade, major efforts have been dedicated to multicenter randomized clinical trials. The present study reviews the pertinent literature to outline the use of DC in the management of malignant MCA infarction. The PubMed database was systematically searched for the following terms: 'Malignant cerebral infarction', 'surgery for stroke', 'DC for cerebral infarction', and all their combinations. Case reports were excluded from the review. The articles were categorized into a number of groups; the majority of these were human clinical studies, with a few animal experimental clinical studies. The surgical technique involved was DC, or hemicraniectomy. Other aspects that were included in the selection of articles were methodological characteristics and the number of patients. The multicenter randomized trials were promising. The mortality rate has unanimously decreased. As for the functional outcome, different scales were employed; the Glasgow Outcome Scale Extended was not sufficient; the Modified Rankin Scale and Bathel index, as well as other scales, were applied. Other aspects considered were demographics, statistics and the very interesting radiological ones. There is no doubt that DC decreases mortality rates, as shown in all clinical trials. Functional outcome appears to be the goal standard in modern-era neurosurgery, and quality of life should be further discussed among the medical community and with patient consent.
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Affiliation(s)
- George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | - Charalambos Gatos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | | | - Ioannis G. Lempesis
- Department of Pathophysiology, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Pagona Sklapani
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Kostas N. Fountas
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
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Buffagni D, Zamarron A, Melgosa I, Gutierrez-Gonzalez R. Long-term quality of life after decompressive craniectomy. Front Neurol 2023; 14:1222080. [PMID: 37564730 PMCID: PMC10410286 DOI: 10.3389/fneur.2023.1222080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/03/2023] [Indexed: 08/12/2023] Open
Abstract
Introduction This study aims to assess the quality of life (QoL) in patients who have undergone decompressive craniectomy (DC) for any pathology that has caused life-threatening intracranial hypertension. Similarly, it aims to evaluate QoL perceived by caregivers or external informants. In addition to that, the last purpose is to determine which clinical or therapeutic factors could correlate with a better QoL. Methods A single-center cross-sectional study was designed. All patients over 18 years old who underwent a supratentorial DC at our department due to intracranial hypertension of any etiology, from January 2015 to December 2021, were retrospectively selected. Patients with incomplete follow-up (under 1 year from the event or those who died) or who declined to participate in the study were excluded. QoL was assessed with SF-36 and CAVIDACE scales. The correlation between clinical and therapeutic variables and SF-36 subscales was studied with Spearman's correlation and the Mann-Whitney U-test. Results A total of 55 consecutive patients were recruited: 22 patients had died, three were missed for follow-up, and 15 declined to participate, thus 15 subjects were finally included. The mean follow-up was 47 months (IQR 21.5-67.5). A significant reduction in the "role physical" and "role emotional" subscales of SF-36 was observed compared with the general population. According to caregivers, a significant reduction was assigned to the "physical wellbeing" and "rights" domains. The "physical functioning" score was poorer in women, older patients, those with dominant hemisphere disease, those who required tracheostomy, and those with poor outcomes in the modified Rankin scale. A strong correlation was found between the QoL index at the CAVIDACE scale and the SF-36 subscales "physical functioning" and "role physical". Conclusion Most patients and caregivers reported acceptable QoL after DC due to a life-threatening disease. A significant reduction in SF- 36 subscales scores "role limitation due to physical problems" and "role limitation due to emotional problems" was referred by patients. According to caregivers' QoL perception, only 25% of the survey's participants showed low scores in the QoL index of the CAVIDACE scale. Only 26.7% of the patients showed mood disorders.
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Affiliation(s)
- Daniel Buffagni
- Department of Surgery, Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Alvaro Zamarron
- Department of Neurosurgery, Puerta de Hierro University Hospital, IDIPHISA, Madrid, Spain
| | - Isabel Melgosa
- Department of Anesthesiology, Marques de Valdecilla University Hospital, Santander, Spain
| | - Raquel Gutierrez-Gonzalez
- Department of Surgery, Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
- Department of Neurosurgery, Puerta de Hierro University Hospital, IDIPHISA, Madrid, Spain
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Krishnan K, Hollingworth M, Nguyen TN, Kumaria A, Kirkman MA, Basu S, Tolias C, Bath PM, Sprigg N. Surgery for Malignant Acute Ischemic Stroke: A Narrative Review of the Knowns and Unknowns. Semin Neurol 2023; 43:370-387. [PMID: 37595604 DOI: 10.1055/s-0043-1771208] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
Malignant acute ischemic stroke (AIS) is characterized by acute neurological deterioration caused by progressive space-occupying brain edema, often occurring in the first hours to days after symptom onset. Without any treatment, the result is often fatal. Despite advances in treatment for AIS, up to 80% of patients with a large hemispheric stroke or cerebellar stroke are at risk of poor outcome. Decompressive surgery can be life-saving in a subgroup of patients with malignant AIS, but uncertainties exist on patient selection, predictors of malignant infarction, perioperative management, and timing of intervention. Although survivors are left disabled, most agree with the original decision to undergo surgery and would make the same decision again. In this narrative review, we focus on the clinical and radiological predictors of malignant infarction in AIS and outline the technical aspects of decompressive surgery as well as duraplasty and cranioplasty. We discuss the current evidence and recommendations for surgery in AIS, highlighting gaps in knowledge, and suggest directions for future studies. KEY POINTS: · Acute ischemic stroke from occlusion of a proximal intracranial artery can progress quickly to malignant edema, which can be fatal in 80% of patients despite medical management.. · Decompression surgery is life-saving within 48 hours of stroke onset, but the benefits beyond this time and in the elderly are unknown.. · Decompressive surgery is associated with high morbidity, particularly in the elderly. The decision to operate must be made after considering the individual's preference and expectations of quality of life in the context of the clinical condition.. · Further studies are needed to refine surgical technique including value of duraplasty and understand the role monitoring intracranial pressure during and after decompressive surgery.. · More studies are needed on the pathophysiology of malignant cerebral edema, prediction models including imaging and biomarkers to identify which subgroup of patients will benefit from decompressive surgery.. · More research is needed on factors associated with morbidity and mortality after cranioplasty, safety and efficacy of implants, and comparisons between them.. · Further studies are needed to assess the long-term effects of physical disability and quality of life of survivors after surgery, particularly those with severe neurological deficits..
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Affiliation(s)
- Kailash Krishnan
- Stroke Unit, Department of Acute Medicine Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Milo Hollingworth
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Thanh N Nguyen
- Department of Neurology, Neurosurgery and Radiology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Ashwin Kumaria
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Matthew A Kirkman
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Surajit Basu
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Christos Tolias
- Department of Neurosurgery, King's College Hospitals NHS Foundation Trust, London, United Kingdom
| | - Philip M Bath
- Stroke Unit, Department of Acute Medicine Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Nikola Sprigg
- Stroke Unit, Department of Acute Medicine Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
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Berger N, Brunner A, Wünsch G, Nistl O, Pinter D, Fandler-Höfler S, Haidegger M, Pichler A, Hatab I, Mokry M, Wolfsberger S, Enzinger C, Gattringer T, Kneihsl M. Long-term outcome after decompressive hemicraniectomy for malignant middle cerebral artery infarction. J Neurol 2023:10.1007/s00415-023-11679-1. [PMID: 37004558 PMCID: PMC10066964 DOI: 10.1007/s00415-023-11679-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/15/2023] [Accepted: 03/18/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Although decompressive hemicraniectomy (DHC) is a lifesaving treatment strategy for patients with malignant middle cerebral artery infarction (mMCAi), only one in four patients achieves low to moderate post-stroke disability according to previous studies. However, the short follow-up periods in prior studies could have overestimated the poor clinical prognosis. This study therefore examined the long-term outcome after DHC for mMCAi. METHODS We retrospectively included all patients who had undergone DHC after mMCAi at the University Hospital Graz between 2006 and 2019. Demographics, clinical data and complications were collected from electronic clinical patient records. To investigate long-term prognosis, all patients were followed up to 14 years after stroke including quality of life (QOL) assessment. Post-stroke disability was rated according to the modified Rankin Scale (mRS). RESULTS Of 47 patients that had undergone DHC for mMCAi, follow-up data were available in 40 patients (mean age: 48 years; 40% female). Six months after the mMCAi, 14 patients had died (35%) and nine (23%) had a low to moderate post-stroke disability (mRS 0-3). Of 26 stroke survivors, half (50%) showed further mRS improvement (≥ 1 point) during the long-term follow-up period (mean follow-up time: 8 years). At last follow-up, 17 patients had achieved an mRS score of ≤ 3 (65% versus 35% after 6 months; p = 0.008) and 55% had no signs of depression and anxiety, and 50% no signs of pain or discomfort in QOL assessment. CONCLUSION This study shows substantial long-term improvement of functional disability and reasonable QOL in mMCAi patients after DHC.
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Affiliation(s)
- Natalie Berger
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Anna Brunner
- Department of Neurosurgery, Medical University of Graz, Graz, Austria
| | - Gerit Wünsch
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Oliver Nistl
- Division of Neuroradiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Daniela Pinter
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | | | | | - Isra Hatab
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Michael Mokry
- Department of Neurosurgery, Medical University of Graz, Graz, Austria
| | | | | | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Markus Kneihsl
- Department of Neurology, Medical University of Graz, Graz, Austria.
- Division of Neuroradiology, Department of Radiology, Medical University of Graz, Graz, Austria.
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Decompressive Craniectomy for Infarction and Intracranial Hemorrhages. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00078-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Räty S, Georgiopoulos G, Aarnio K, Martinez-Majander N, Uhl E, Ntaios G, Strbian D. Hemicraniectomy for Dominant vs Nondominant Middle Cerebral Artery Infarction: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2021; 30:106102. [PMID: 34536811 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106102] [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: 07/15/2021] [Accepted: 08/31/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Decompressive hemicraniectomy decreases mortality and severe disability from space-occupying middle cerebral artery infarction in selected patients. However, attitudes towards hemicraniectomy for dominant-hemispheric stroke have been hesitant. This systematic review and meta-analysis examines the association of stroke laterality with outcome after hemicraniectomy. MATERIALS AND METHODS We performed a systematic literature search up to 6th February 2020 to retrieve original articles about hemicraniectomy for space-occupying middle cerebral artery infarction that reported outcome in relation to laterality. The primary outcome was severe disability (modified Rankin Scale 4‒6 or 5‒6 or Glasgow Outcome Scale 1‒3) or death. A two-stage combined individual patient and aggregate data meta-analysis evaluated the association between dominant-lateralized stroke and (a) short-term (≤ 3 months) and (b) long-term (> 3 months) outcome. We performed sensitivity analyses excluding studies with sheer mortality outcome, second-look strokectomy, low quality, or small sample size, and comparing populations from North America/Europe vs Asia/South America. RESULTS The analysis included 51 studies (46 observational studies, one nonrandomized trial, and four randomized controlled trials) comprising 2361 patients. We found no association between dominant laterality and unfavorable short-term (OR 1.00, 95% CI 0.69‒1.45) or long-term (OR 1.01, 95% CI 0.76‒1.33) outcome. The results were unchanged in all sensitivity analyses. The grade of evidence was very low for short-term and low for long-term outcome. CONCLUSIONS This meta-analysis suggests that patients with dominant-hemispheric stroke have equal outcome after hemicraniectomy compared to patients with nondominant stroke. Despite the shortcomings of the available evidence, our results do not support withholding hemicraniectomy based on stroke laterality.
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Affiliation(s)
- Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Helsinki 00290, Finland.
| | - Georgios Georgiopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Greece; School of Biomedical Engineering and Imaging Sciences, King's College, London, UK
| | - Karoliina Aarnio
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Helsinki 00290, Finland
| | - Nicolas Martinez-Majander
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Helsinki 00290, Finland
| | - Eberhard Uhl
- Department of Neurosurgery, Justus-Liebig-University, Giessen, Germany
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Helsinki 00290, Finland
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Lim JX, Vedicherla SV, Chan SKS, Primalani NK, Tan AJL, Saffari SE, Lee L. Decompressive craniectomy for internal carotid artery and middle carotid artery infarctions: a long-term comparative outcome study. Neurosurg Focus 2021; 51:E10. [PMID: 34198256 DOI: 10.3171/2021.4.focus21123] [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: 02/28/2021] [Accepted: 04/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Malignant internal carotid artery (ICA) infarction is an entirely different disease entity when compared with middle cerebral artery (MCA) infarction. Because of an increased area of infarction, it is assumed to have a poorer prognosis; however, this has never been adequately investigated. Decompressive craniectomy (DC) for malignant MCA infarction has been shown to improve mortality rates in several randomized controlled trials. Conversely, aggressive surgical decompression for ICA infarction has not been recommended. The authors sought to compare the functional outcomes and survival between patients with ICA infarctions and those with MCA infarctions after DC in the largest series to date to investigate this assumption. METHODS A multicenter retrospective review of 154 consecutive DCs for large territory cerebral infarctions performed from 2005 to 2020 were analyzed. Patients were divided into ICA and MCA groups depending on the territory of infarction. Variables, including age, sex, medical comorbidities, laterality of the infarction, preoperative neurological status, primary stroke treatment, and the time from stroke onset to DC, were recorded. Univariable and multivariable analyses were performed for the clinical exposures for functional outcomes (modified Rankin Scale [mRS] score) on discharge and at the 1- and 6-month follow-ups, and for mortality, both inpatient and at the 1-year follow-up. A favorable mRS score was defined as 0-2. RESULTS There were 67 patients (43.5%) and 87 patients (56.5%) in the ICA and MCA groups, respectively. Univariable analysis showed that the ICA group had a comparably favorable mRS (OR 0.15 [95% CI 0.18-1.21], p = 0.077). Inpatient mortality (OR 1.79 [95% CI 0.79-4.03], p = 0.16) and 1-year mortality (OR 2.07 [95% CI 0.98-4.37], p = 0.054) were comparable between the groups. After adjustment, a favorable mRS score at 6 months (OR 0.17 [95% CI 0.018-1.59], p = 0.12), inpatient mortality (OR 1.02 [95% CI 0.29-3.57], p = 0.97), and 1-year mortality (OR 0.94 [95% CI 0.41-2.69], p = 0.88) were similar in both groups. The overall survival, plotted using the Cox proportional hazard regression, did not show a significant difference between the ICA and MCA groups (HR 0.581). CONCLUSIONS Unlike previous smaller studies, this study found that patients with malignant ICA infarction had a functional outcome and survival that was similar to those with MCA infarction after DC. Therefore, DC can be offered for malignant ICA infarction for life-saving purposes with limited functional recovery.
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Affiliation(s)
- Jia Xu Lim
- 1Department of Neurosurgery, National Neuroscience Institute; and
| | | | | | | | - Audrey J L Tan
- 1Department of Neurosurgery, National Neuroscience Institute; and
| | | | - Lester Lee
- 1Department of Neurosurgery, National Neuroscience Institute; and.,3Duke-NUS Medical School, Singapore
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Naidu PB, Vivek V, Shareef MH, tilak S, Ganesh K. Decompressive hemicraniectomy in malignant MCA infarct in a tertiary centre. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.101019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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García-Feijoo P, Isla A, Díez-Tejedor E, Mansilla B, Palpan Flores A, Sáez-Alegre M, Vivancos C. Decompressive craniectomy in malignant middle cerebral artery infarction: family perception, outcome and prognostic factors. Neurocirugia (Astur) 2019; 31:7-13. [PMID: 31445797 DOI: 10.1016/j.neucir.2019.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 05/27/2019] [Accepted: 07/07/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The prognosis of one hemisphere malignant infarction creates doubt among neurosurgeons about decompressive hemicraniectomy indication. What results are achieved in the short to medium term? Are families satisfied with the surgery once the patient is at home? In the present study, we analyze our experience in this matter during the last thirteen years. MATERIAL AND METHODS In our review, twenty-one patients were included from 2004 to 2017, according to the protocol for the management of ischaemic stroke that is implemented in our institution. The relatives were interviewed by telephone. The functional outcome at discharge, 3 months, 1 year, and at present was measured using the modified Rankin scale (mRS). RESULTS Patient age was shown to be directly related to the mRS (r=0.56; p=0.035) and 37.5% achieved a good outcome (mRS≤3); 78.9% of the interviewed relatives would repeat the surgical decision. CONCLUSIONS We present a 21 patients group where the best outcome was achieved in patients ≤60 years old. The severe neurological sequelae in patients with malignant infarction subjected to decompressive hemicraniectomy are tolerated and accepted by most families to the benefit of survival. We must not let this family satisfaction hide the prognosis, having to contextualize it within the real ambulatory situation of the patients.
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Affiliation(s)
| | - Alberto Isla
- Servicio de Neurocirugía, Hospital Universitario La Paz, Madrid, España
| | | | - Beatriz Mansilla
- Servicio de Neurocirugía, Hospital Universitario La Paz, Madrid, España
| | | | | | - Catalina Vivancos
- Servicio de Neurocirugía, Hospital Universitario La Paz, Madrid, España
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Beez T, Munoz-Bendix C, Steiger HJ, Beseoglu K. Decompressive craniectomy for acute ischemic stroke. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:209. [PMID: 31174580 PMCID: PMC6556035 DOI: 10.1186/s13054-019-2490-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/26/2019] [Indexed: 12/21/2022]
Abstract
Malignant stroke occurs in a subgroup of patients suffering from ischemic cerebral infarction and is characterized by neurological deterioration due to progressive edema, raised intracranial pressure, and cerebral herniation. Decompressive craniectomy (DC) is a surgical technique aiming to open the “closed box” represented by the non-expandable skull in cases of refractory intracranial hypertension. It is a valuable modality in the armamentarium to treat patients with malignant stroke: the life-saving effect has been proven for both supratentorial and infratentorial DC in virtually all age groups. This leaves physicians with the difficult task to decide who will require early or preemptive surgery and who might benefit from postponing surgery until clear evidence of deterioration evolves. Together with the patient’s relatives, physicians also have to ascertain whether the patient will have acceptable disability and quality of life in his or her presumed perception, based on preoperative predictions. This complex decision-making process can only be managed with interdisciplinary efforts and should be supported by continued research in the age of personalized medicine.
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Affiliation(s)
- Thomas Beez
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - Christopher Munoz-Bendix
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Hans-Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
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Das S, Mitchell P, Ross N, Whitfield PC. Decompressive Hemicraniectomy in the Treatment of Malignant Middle Cerebral Artery Infarction: A Meta-Analysis. World Neurosurg 2019; 123:8-16. [DOI: 10.1016/j.wneu.2018.11.176] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/18/2018] [Accepted: 11/19/2018] [Indexed: 11/29/2022]
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12
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Waqas M, Malik N, Shamim MS, Nathani KR, Abbasi SA. Quality of Life Among Patients Undergoing Decompressive Craniectomy for Traumatic Brain Injury Using Glasgow Outcome Scale Extended and Quality of Life After Brain Injury Scale. World Neurosurg 2018; 116:e783-e790. [DOI: 10.1016/j.wneu.2018.05.092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 05/13/2018] [Accepted: 05/14/2018] [Indexed: 10/14/2022]
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13
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Kamran S, Salam A, Akhtar N, Alboudi A, Ahmad A, Khan R, Nazir R, Nadeem M, Inshasi J, ElSotouhy A, Al Sulaiti G, Shuaib A. Predictors of In-Hospital Mortality after Decompressive Hemicraniectomy for Malignant Ischemic Stroke. J Stroke Cerebrovasc Dis 2017; 26:1941-1947. [PMID: 28694110 DOI: 10.1016/j.jstrokecerebrovasdis.2017.06.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 10/27/2016] [Accepted: 06/11/2017] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The purpose of this retrospective multicenter, pooled-data analysis was to determine the factors associated with in-hospital mortality in decompressive hemicraniectomy (DHC) for malignant middle cerebral artery (MMCA) stroke. PATIENTS AND METHODS The authors reviewed pooled DHC database from 3 countries for patients with MMCA with hospital mortality in spite of DHC to identify factors that predicted in-hospital mortality after DHC. The identified factors were applied to the group of patients who were selected for DHC but either refused surgery and died or stabilized and did not undergo DHC. FINDINGS There were 137 patients who underwent DHC. Multiple logistic regression analysis showed middle cerebral artery (MCA) with additional infarcts (odds ratio [OR], 7.9: 95% confidence interval [CI], 2.4-26; P = .001), preoperative midline shift of septum pellucidum of 1 cm or more (OR, 3.83: 95% CI, 1.13-12.96; P = .031), and patients who remained unconscious on day 7 postoperatively (8.82: 95% CI; OR, 1.08-71.9; P = .042) were significant independent predictors for in-hospital mortality. The identified factors were applied to the group of MMCA patients not operated (n = 19 refused, n = 47 stabilized) single (P < .001), and two predictive factors (P < .001) were significantly more common in patients who died. Whereas two predicative factors were identified in only 9%-18.2% of survivors, the presence of all three predictive factors was seen only in patients who expired (P < .001). The Hosmer-Lemeshow goodness-of-fit statistics (chi-square = 4.65; P value = .589) indicate that the model adequately describes the data. CONCLUSION Direct physical factors, such as MCA with additional territory infarct, extent of midline shift, and postoperative consciousness level, bore a significant relationship to in-hospital mortality in MMCA patients undergoing DHC.
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Affiliation(s)
- Saadat Kamran
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Weill Cornell School of Medicine, Qatar.
| | - Abdul Salam
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Naveed Akhtar
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Weill Cornell School of Medicine, Qatar
| | - Aymen Alboudi
- Department of Neurology, Rashid Hospital, Dubai, United Arab Emirates
| | - Arsalan Ahmad
- Department of Neurology and Neurosurgery, Shifa International Hospital, Islamabad, Pakistan
| | - Rabia Khan
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Rashed Nazir
- Department of Neurology and Neurosurgery, Shifa International Hospital, Islamabad, Pakistan
| | - Muhammad Nadeem
- Department of Neurology and Neurosurgery, Shifa International Hospital, Islamabad, Pakistan
| | - Jihad Inshasi
- Department of Neurology, Rashid Hospital, Dubai, United Arab Emirates
| | - Ahmed ElSotouhy
- Department of Radiology, Hamad General Hospital, Hamad Medical Corporation, Qatar
| | - Ghanim Al Sulaiti
- Department of Neurosurgery, The Neuroscience Institute Hamad General Hospital, Medical Corporation, Doha, Qatar
| | - Ashfaq Shuaib
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Stroke Program, University of Alberta, Canada
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Revisiting Hemicraniectomy: Late Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke and the Role of Infarct Growth Rate. Stroke Res Treat 2017; 2017:2507834. [PMID: 28409051 PMCID: PMC5376465 DOI: 10.1155/2017/2507834] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 02/22/2017] [Indexed: 11/25/2022] Open
Abstract
Objective and Methods. The outcome in late decompressive hemicraniectomy in malignant middle cerebral artery stroke and the optimal timings of surgery has not been addressed by the randomized trials and pooled analysis. Retrospective, multicenter, cross-sectional study to measure outcome following DHC under 48 or over 48 hours using the modified Rankin scale [mRS] and dichotomized as favorable ≤4 or unfavorable >4 at three months. Results. In total, 137 patients underwent DHC. Functional outcome analyzed as mRS 0–4 versus mRS 5-6 showed no difference in this split between early and late operated on patients [P = 0.140] and mortality [P = 0.975]. Multivariate analysis showed that age ≥ 55 years, MCA with additional infarction, septum pellucidum deviation ≥1 cm, and uncal herniation were independent predictors of poor functional outcome at three months. In the “best” multivariate model, second infarct growth rate [IGR2] >7.5 ml/hr, MCA with additional infarction, and patients with temporal lobe involvement were independently associated with surgery under 48 hours. Both first infarct growth rate [IGR1] and second infarct growth rate [IGR2] were nearly double [P < 0.001] in patients with early surgery [under 48 hours]. Conclusions. The outcome and mortality in malignant middle cerebral artery stroke patients operated on over 48 hours of stroke onset were comparable to those of patients operated on less than 48 hours after stroke onset. Our data identifies IGR, temporal lobe involvement, and middle cerebral artery with additional infarct as independent predictors for early surgery.
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Abstract
Malignant cerebral edema is a potential consequence of large territory cerebral infarction, as the resultant elevation in intracranial pressure may progress to transtentorial herniation, brainstem compression, and death. In appropriate patients, decompressive hemicraniectomy (DHC) reduces mortality without increasing the risk of severe disability. However, as the foundational DHC randomized, controlled trials excluded patients greater than 60 years of age, the appropriateness of DHC in older adults remains controversial. Recent clinical trials among elderly participants, including DESTINY II, reported that DHC reduces mortality, but may leave patients with substantial morbidity. Nationwide analyses have demonstrated generalizability of such data. However, what constitutes an acceptable outcome - the perspective on quality of life after survival with substantial disability - varies between clinicians, patients, and caregivers. Consequently, quality of life measures are being increasingly incorporated into stroke research. This review summarizes the impact of DHC in space-occupying cerebral infarction, and the influence of patient age on postoperative survival, functional capacity, and quality of life-all key factors in the clinical decision process. Ultimately, these data underscore the inherent complexity in balancing scientific evidence, clinical expertise, and patient and family preference when pursuing hemicraniectomy among the elderly.
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Affiliation(s)
- Faith C Robertson
- Harvard Medical School, Boston, Massachusetts, United States of America.,Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Hormuzdiyar H Dasenbrock
- Harvard Medical School, Boston, Massachusetts, United States of America.,Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.,Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - William B Gormley
- Harvard Medical School, Boston, Massachusetts, United States of America.,Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.,Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
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16
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Patient Age and the Outcomes after Decompressive Hemicraniectomy for Stroke: A Nationwide Inpatient Sample Analysis. Neurocrit Care 2016; 25:371-383. [DOI: 10.1007/s12028-016-0287-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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17
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Torbey MT, Bösel J, Rhoney DH, Rincon F, Staykov D, Amar AP, Varelas PN, Jüttler E, Olson D, Huttner HB, Zweckberger K, Sheth KN, Dohmen C, Brambrink AM, Mayer SA, Zaidat OO, Hacke W, Schwab S. Evidence-based guidelines for the management of large hemispheric infarction : a statement for health care professionals from the Neurocritical Care Society and the German Society for Neuro-intensive Care and Emergency Medicine. Neurocrit Care 2016; 22:146-64. [PMID: 25605626 DOI: 10.1007/s12028-014-0085-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Large hemispheric infarction (LHI), also known as malignant middle cerebral infarction, is a devastating disease associated with significant disability and mortality. Clinicians and family members are often faced with a paucity of high quality clinical data as they attempt to determine the most appropriate course of treatment for patients with LHI, and current stroke guidelines do not provide a detailed approach regarding the day-to-day management of these complicated patients. To address this need, the Neurocritical Care Society organized an international multidisciplinary consensus conference on the critical care management of LHI. Experts from neurocritical care, neurosurgery, neurology, interventional neuroradiology, and neuroanesthesiology from Europe and North America were recruited based on their publications and expertise. The panel devised a series of clinical questions related to LHI, and assessed the quality of data related to these questions using the Grading of Recommendation Assessment, Development and Evaluation guideline system. They then developed recommendations (denoted as strong or weak) based on the quality of the evidence, as well as the balance of benefits and harms of the studied interventions, the values and preferences of patients, and resource considerations.
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Affiliation(s)
- Michel T Torbey
- Cerebrovascular and Neurocritical Care Division, Department of Neurology and Neurosurgery, The Ohio State University Wexner Medical Center Comprehensive Stroke Center, 395 W. 12th Avenue, 7th Floor, Columbus, OH, 43210, USA,
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18
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Neugebauer H, Jüttler E, Mitchell P, Hacke W. Decompressive Craniectomy for Infarction and Hemorrhage. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00076-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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19
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Rastogi V, Lamb DG, Williamson JB, Stead TS, Penumudi R, Bidari S, Ganti L, Heilman KM, Hedna VS. Hemispheric differences in malignant middle cerebral artery stroke. J Neurol Sci 2015; 353:20-7. [PMID: 25959980 DOI: 10.1016/j.jns.2015.04.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 04/21/2015] [Accepted: 04/23/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND We recently reported that left versus right hemisphere cerebral infarctions patients more frequently have worse outcomes. However our clinical experience led us to suspect that the incidence of malignant middle cerebral artery infarctions (MMCA) was higher in the right compared to the left hemispheric strokes. OBJECTIVE To determine whether laterality in MMCA stroke is an important determinant of stroke sequelae. METHODS A systematic search was performed for publications in PubMed using "malignant middle cerebral artery and infarction". A total of 73 relevant studies were abstracted. RESULTS MMCA laterality data were available for 2673 patients, with 1687 (63%) right hemispheric involvement, thus right being more commonly associated with MMCA (binomial test, p<0.05). While mortality rates were similar, right hemispheric MMCA (n=271) had mortality of 31% (n=85) whereas left hemispheric MMCA (n=144) had mortality of 36% (n=53), morbidity rates were worse on the right. CONCLUSION MMCA stroke appears to be more common on the right, and this laterality is also associated with significantly higher morbidity. Further prospective studies are needed to more completely understand the nature of this laterality as well as test possible new treatments to reduce mortality and morbidity associated with MMCA.
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Affiliation(s)
- Vaibhav Rastogi
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States
| | - Damon G Lamb
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States; Malcom Randall VAMC, Gainesville, FL 32608, United States
| | - John B Williamson
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States; Malcom Randall VAMC, Gainesville, FL 32608, United States
| | - Thor S Stead
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States
| | - Rachel Penumudi
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States
| | - Sharathchandra Bidari
- Department of Radiology, University of Florida College of Medicine, Gainesville, FL 32611, United States
| | - Latha Ganti
- Lake City VAMC, NF/SGVHS, Lake City, FL 32025-5808, United States
| | - Kenneth M Heilman
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States; Malcom Randall VAMC, Gainesville, FL 32608, United States
| | - Vishnumurthy S Hedna
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States.
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Neugebauer H, Creutzfeldt CJ, Hemphill JC, Heuschmann PU, Jüttler E. DESTINY-S: attitudes of physicians toward disability and treatment in malignant MCA infarction. Neurocrit Care 2015; 21:27-34. [PMID: 24549936 DOI: 10.1007/s12028-014-9956-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Decompressive hemicraniectomy (DHC) reduces mortality and improves outcome after malignant middle cerebral artery (MCA) infarction but leaves a high number of survivors severely disabled. Attitudes among physicians toward the degree of disability that is considered acceptable and the impact of aphasia may play a major role in treatment decisions. METHODS DESTINY-S is a multicenter, international, cross-sectional survey among 1,860 physicians potentially involved in the treatment of malignant MCA infarction. Questions concerned the grade of disability, the hemisphere of the stroke, and the preferred treatment for malignant MCA infarction. RESULTS mRS scores of 3 or better were considered acceptable by the majority of respondents (79.3%). Only few considered a mRS score of 5 still acceptable (5.8%). A mRS score of 4 was considered acceptable by 38.0%. Involved hemisphere (dominant vs. non-dominant) was considered a major clinical symptom influencing treatment decisions in 47.7% of respondents, also reflected by significantly different rates for DHC as preferred treatment in dominant versus non-dominant hemispheric infarction (46.9 vs. 72.9%). Significant differences in acceptable disability and treatment decisions were found among geographic regions, medical specialties, and respondents with different work experiences. CONCLUSION Little consensus exists among physicians regarding acceptable outcome and therapeutic management after malignant MCA infarction, and physician's recommendations do not correlate with available evidence. We advocate for a decision-making process that balances scientific evidence, patient preference, and clinical expertise.
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Affiliation(s)
- Hermann Neugebauer
- Department of Neurology, RKU - University- and Rehabilitation Hospitals Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany,
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21
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Abstract
Objective:Decompressive hemicraniectomy (DH) has been shown to reduce mortality in patients with malignant middle cerebral artery (MCA) territory infarction. However, many patients survive with moderate-to-severe disability and controversy exists as to whether this should be considered good outcome. To answer this question, we assessed the quality of life (QoL) of patients after DH for malignant MCA territory infarction in our milieu.Methods:The outcome of all patients undergoing DH for malignant MCAterritory infarction between 2001 and 2009 was assessed using retrospective chart analysis and telephone follow-up in survivors. Functional outcome was determined using Glasgow outcome scale, modifed Rankin scale (mRS), and Barthel index (BI). The stroke impact scale was used to assess QoL.Results:There were 14 patients, 6 men and 8 women, with a mean age of 44 years (range 27-57). All patients had reduced level of consciousness preoperatively. Five had dominant-hemisphere stroke. Median time to surgery was 45 hours (range 1- 96). Two patients died and one was lost to follow-up. Of 11 survivors, 7 (63.6%) had a favorable functional outcome (mRS<4). No patient was in persistent vegetative state. Despite impaired QoL, particularly in physical domains, the majority of interviewed patients and caregivers (7 of 8), including those with dominant-hemisphere stroke, were satisfied after a median follow-up of 18 months (range 6-43).Conclusion:Most patients report satisfactory QoL despite significant disability even in the face of moderate-to-severe disability and dominant-hemsiphere stroke. Dominant-hemisphere malignant MCA territory infarction should not be considered a contraindication to DH.
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Sundseth J, Sundseth A, Thommessen B, Johnsen LG, Altmann M, Sorteberg W, Lindegaard KF, Berg-Johnsen J. Long-Term Outcome and Quality of Life After Craniectomy in Speech-Dominant Swollen Middle Cerebral Artery Infarction. Neurocrit Care 2014; 22:6-14. [DOI: 10.1007/s12028-014-0056-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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van Middelaar T, Nederkoorn PJ, van der Worp HB, Stam J, Richard E. Quality of Life after Surgical Decompression for Space-Occupying Middle Cerebral Artery Infarction: Systematic Review. Int J Stroke 2014; 10:170-6. [DOI: 10.1111/ijs.12329] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 05/20/2014] [Indexed: 01/05/2023]
Abstract
Background and Purpose In patients with space-occupying middle cerebral artery infarction, surgical decompression strongly reduces risk of death and increases the chance of a favorable outcome. This comes at the expense of an increase in the risk of survival with (moderately) severe disability. We assessed quality of life, depression, and caregiver burden in these patients. Summary of Review We systematically reviewed the literature by searching MEDLINE, EMBASE, and PsycINFO up to March 2014. We included randomized controlled trials, cohort studies, case–control studies, and case series with quality of life, depression, or caregiver burden as primary or secondary outcome. Seventeen articles reporting on 459 patients were included. At final follow-up at 7 to 51 months, 1344 patients (30%) had died, and 34 (11%) were lost to follow up. Data on 291 patients were available, of whom 81 of 213 survivors (39%) achieved good functional outcome at final follow-up (modified Rankin Scale ⩽3). Mean quality of life was 46% to 67% of the best possible score when based on questionnaires or visual analogue scales. At final follow-up, 143 of 189 patients (76%) would in retrospect again choose for surgical decompression. Severe depressive symptoms were present in 14 of 113 patients (16%). Three studies investigated caregiver burden and reported substantial burden. Patients more than 60 years old had a lower quality of life in comparison with younger patients. Conclusions Most patients treated with surgical decompression for space-occupying infarction have a reasonable quality of life at long-term follow-up and are satisfied with the treatment received. Severe depressive symptoms are uncommon.
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Affiliation(s)
- Tessa van Middelaar
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Paul J. Nederkoorn
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - H. Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Stam
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Edo Richard
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
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Mendelsohn D, Haw CS, Illes J. Convergent Expert Views on Decision-Making for Decompressive Craniectomy in Malignant MCA Syndrome. NEUROETHICS-NETH 2014. [DOI: 10.1007/s12152-014-9206-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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25
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Impact of advanced healthcare directives on treatment decisions by physicians in patients with acute stroke. Crit Care Med 2013; 41:1468-75. [PMID: 23552508 DOI: 10.1097/ccm.0b013e31827cab82] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The implementation of advanced healthcare directives, prepared by almost half of the adult population in United States remains relatively under studied. We determined the impact of advanced healthcare directives on treatment decisions by multiple physicians in stroke patients. METHODS A deidentified summary of clinical and radiological records of 28 patients with stroke was given to six stroke physicians who were not involved in the care of the patients. Each physician independently rated 28 treatment decisions per patient in the presence or absence of advanced healthcare directives 1 month apart to allow memory washout. The percentage agreement to treat/intervene per patient and proportion of treatment withheld as a group were estimated for each of the 28 treatment decision items. We also determined the interobserver reliability between the two raters (attorneys) in interpretation of six items characterizing the adequacy of documentation within the 28 advanced healthcare directives. RESULTS The percentage agreement among physician raters for treatment decisions in 28 stroke patients was highest for treatment of hyperpyrexia (100%, 100%) and lowest for ICU monitoring duration based on family-physician considerations outside of accepted criteria within institution (68%, 69%) in presence and absence of advanced healthcare directives. The physician rater agreement in choosing "yes" was highest for "routine-complexity" treatment decisions and lowest for "moderate-complexity" treatment decisions. The choice of withholding treatment in "routine-complexity," "moderate-complexity," or "high-complexity" treatment decisions was remarkably similar among raters in presence or absence of advanced healthcare directives. The only treatment decision that showed an impact of advanced healthcare directives was ICU monitoring withheld in 32% of treatment decisions in presence of directives (compared with 8% in the absence of directives). IV medication and defibrillation for cardiac arrest was withheld in 29% (compared with 19%) of the treatment decisions in the presence of advanced healthcare directives. The two attorney raters found the description of acceptable outcome inadequate in 14 and 21 of 28 advanced healthcare directives reviewed, respectively. The overall mean kappa for agreement regarding adequacy of documentation was modest (43%) for "does the advanced healthcare directive specify which treatments the patient would choose, or refuse to receive if they were diagnosed with an acute, terminal condition?" and lowest (3%) for "description of acceptable outcome." CONCLUSIONS We did not find any prominent differences in most "routine-complexity," "moderate-complexity," or "high-complexity" treatment decisions in patient management in the presence of advanced healthcare directives. Presence of advanced healthcare directives also did not reduce the prominent variance among physicians in treatment decisions.
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Honeybul S, Ho KM. The current role of decompressive craniectomy in the management of neurological emergencies. Brain Inj 2013; 27:979-91. [DOI: 10.3109/02699052.2013.794974] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Hemicraniectomy in the management of space-occupying ischemic stroke. J Clin Neurosci 2013; 20:6-12. [DOI: 10.1016/j.jocn.2012.02.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Revised: 02/10/2012] [Accepted: 02/13/2012] [Indexed: 01/04/2023]
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Rahme R, Zuccarello M, Kleindorfer D, Adeoye OM, Ringer AJ. Decompressive hemicraniectomy for malignant middle cerebral artery territory infarction: is life worth living? J Neurosurg 2012; 117:749-54. [PMID: 22920962 DOI: 10.3171/2012.6.jns111140] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Although decompressive hemicraniectomy has been shown to reduce death and improve functional outcome following malignant middle cerebral artery territory infarction, there is ongoing debate as to whether surgery should be routinely performed, considering the very high rates of disability and functional dependence in survivors. Through a systematic review of the literature, the authors sought to determine the outcome from a patient's perspective. METHODS In September 2010, a MEDLINE search of the English-language literature was performed using various combinations of 12 key words. A total of 16 papers were reviewed and individual study data were extracted. RESULTS There was significant variability in study design, patient eligibility criteria, timing of surgery, and methods of outcome assessment. There were 382 patients (59% male, 41% female) with a mean age of 50 years, 25% with dominant-hemisphere infarction. The mortality rate was 24% and the mean follow-up in survivors was 19 months (range 3-114 months). Of 156 survivors with available modified Rankin Scale (mRS) scores, 41% had favorable functional outcome (mRS Score ≤ 3), whereas 47% had moderately severe disability (mRS Score 4). Among 157 survivors with quality of life assessment, the mean overall reduction was 45%: 67% for physical aspect and 37% for psychosocial aspect. Of 114 screened survivors, depression affected 56% and was moderate or severe in 25%. Most patients and/or caregivers (77% of the 209 interviewed) were satisfied and would give consent again for the procedure. CONCLUSIONS Despite high rates of physical disability and depression, the vast majority of patients are satisfied with life and do not regret having undergone surgery.
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Affiliation(s)
- Ralph Rahme
- Departments of Neurosurgery, University of Cincinnati and Mayfield Clinic, Cincinnati, OH, USA.
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von Sarnowski B, Kleist-Welch Guerra W, Kohlmann T, Moock J, Khaw A, Kessler C, Schminke U, Schroeder H. Long-term health-related quality of life after decompressive hemicraniectomy in stroke patients with life-threatening space-occupying brain edema. Clin Neurol Neurosurg 2012; 114:627-33. [DOI: 10.1016/j.clineuro.2011.12.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 12/06/2011] [Accepted: 12/17/2011] [Indexed: 11/16/2022]
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Abstract
Decompressive craniectomy (DC) is the surgical management removing part of the skull vault over a swollen brain used to treat elevated intracranial pressure that is unresponsive to maximal medical therapy. The commonest indication for DC is traumatic brain injury (TBI) or middle cerebral artery (MCA) infarction, though DC has been reported to have been used for treatment of aneurysmal subarachnoid haemorrhage and venous infarction. Despite an increasing number of reports supportive of DC, the controversy over the suitability of the procedure and criteria for patient selection remains unresolved. Although the majority of published studies are retrospective, the recent publication of several randomised prospective studies prompts a re-evaluation of the use of DC. We review the literature concerning the pathophysiology, indication, surgical techniques and timing, complications and long-term effects of DC (including reversal with cranioplasty), in order to rationalise its use. We conclude that at the time of this review, though we cannot support the routine use of DC in TBI or MCA stroke, there is evidence that early and aggressive use of DC in TBI patients with intracranial haematomas or younger malignant MCA stroke patients may improve outcome. Though the results of the DECRA trial suggest that primary DC may worsen outcome, the decision to perform DC after diffuse TBI is still individualised. We await the results of the RESCUEicp trial to ascertain whether an evidence-based protocol for its use can be agreed in the future.
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Affiliation(s)
| | - A Tarnaris
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, UK
| | - J Wasserberg
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, UK
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Woertgen C, Rothoerl RD, Hosemann W, Strutz J. Quality of Life following Surgery for Malignancies of the Anterior Skull Base. Skull Base 2011; 17:119-23. [PMID: 17768441 PMCID: PMC1876151 DOI: 10.1055/s-2006-953513] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Radical surgery combined with postoperative radiation is recommended to achieve the best outcomes in patients suffering from malignant anterior skull base tumors. However, information on the impact of such treatment on the quality of life of these patients is sparse. This retrospective study evaluated quality of life in patients with anterior skull base malignancies after transdural resection and radiotherapy. At follow-up, 36% of the patients were alive (mean survival time, 39 months). Only 45% of the patients were able to work in their previous occupation a mean of 15 months after surgery. At follow-up, 58% of the patients had a recurrent tumor. The mean quality of life index was 42 points (range, 0 to 100). The lowest values were on the job item, and the highest mean value was on the family item. All patients, dependents, or both would agree to surgery in the future. Based on these findings, quality of life after transdural surgery for the treatment of anterior skull base malignancies seems to be low.
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Affiliation(s)
- Chris Woertgen
- Department of Neurosurgery, University of Regensburg, Regensburg, Germany
| | - Ralf Dirk Rothoerl
- Department of Neurosurgery, University of Regensburg, Regensburg, Germany
| | - Werner Hosemann
- Department of Ear, Nose, and Throat Surgery, University of Greifswald, Greifswald, Germany
| | - Jürgen Strutz
- Department of Ear, Nose, and Throat Surgery, University of Regensburg, Regensburg, Germany
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Affiliation(s)
- Dimitre Staykov
- Department of Neurology, Emory University School of Medicine, Marcus Stroke and Neuroscience Center, Atlanta, GA 30303, USA
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Mattos JP, Joaquim AF, Almeida JPCD, Albuquerque LAFD, Silva EGD, Marenco HA, Oliveira ED. Decompressive craniectomy in massive cerebral infarction. ARQUIVOS DE NEURO-PSIQUIATRIA 2011; 68:339-45. [PMID: 20602032 DOI: 10.1590/s0004-282x2010000300002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Accepted: 09/14/2009] [Indexed: 11/22/2022]
Abstract
Twenty one patients were submitted to decompressive craniectomy for massive cerebral infarct. Ten patients (47.6%) presented a good outcome at the 6 months evaluation, eight had a poor outcome (38%) and three died (14.2%). There was no outcome statistical difference between surgery before and after 24 hours of ictus, dominant and non-dominant stroke groups. Patients older than 60 years and those who had a Glasgow Coma Scale (GCS)<8 in the pre-surgical exam presented worst outcome at six months (p<0.05). Decompressive craniectomy for space-occupying large hemispheric infarction increases the probability of survival. Age lower than 60 years, GCS >8 at pre-surgical exam and decompressive craniectomy before signs of brain herniation represent the main factors related to a better outcome. Dominant hemispheric infarction does not represent exclusion criteria.
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Diedler J, Sykora M, Hacke W. Critical Care of the Patient with Acute Stroke. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10052-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Jüttler E, Hacke W. Cerebral Infarction. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10078-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Sykora M, Diedler J, Jüttler E, Steiner T, Zweckberger K, Hacke W, Unterberg A. Intensive care management of acute stroke: surgical treatment. Int J Stroke 2010; 5:170-7. [PMID: 20536614 DOI: 10.1111/j.1747-4949.2010.00426.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Controversy still exists on surgical management of acute stroke. Even if surgical therapy represents often a life-saving measure, the issue of acceptable outcome remains open. Persuasive evidence for outcome benefit is limited. For large ischaemic strokes, recent convincing data suggest that decompressive surgery significantly reduces mortality and improves outcome quality. On the other hand, despite the long tradition in surgical removal of intracranial haematomas, the recent evidence has not been sufficient to resolve the basic argument whether to operate or not. Most recently, hopeful preliminary data have emerged on new approaches in the treatment of intraventricular haemorrhage. In this article, we review the current neurosurgical options in acute ischaemic and haemorrhagic stroke.
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Affiliation(s)
- Marek Sykora
- Department of Neurology, University of Heidelberg, Heidelberg, Germany.
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Abstract
PURPOSE OF REVIEW Malignant hemispheric infarction is associated with a high mortality rate, approximately 80%, as a result of the development of intracranial pressure gradients, brain tissue shift, and herniation. By allowing the brain to swell outwards and equalizing pressure gradients, decompressive craniectomy appears to significantly reduce the mortality to approximately 20%. This review takes a comprehensive look at the evidence highlighting the benefits and limits of decompressive craniectomy in malignant cerebral infarction. RECENT FINDINGS Three recent European randomized trials have provided compelling evidence that decompressive hemicraniectomy for large hemispheric infarction is not only lifesaving, but also leads to improved functional outcome in patients 60 years of age or less when treated within 48 h of stroke onset. SUMMARY Early decompressive hemicraniectomy (<or=48 h) should be strongly considered in any patient 60 years old or less presenting with malignant hemispheric infarction. Further studies are needed to establish objective neuroimaging criteria for aggressive intervention, and to clarify the role of decompressive surgery in older patients (>60 years old) and perhaps, when delayed beyond 48 h.
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Do patients have any special medical or rehabilitation difficulties after a craniectomy for malignant cerebral infarction during their hospitalization in a physical medicine and rehabilitation department? Ann Phys Rehabil Med 2010; 53:86-95. [DOI: 10.1016/j.rehab.2009.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Accepted: 12/03/2009] [Indexed: 11/16/2022]
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Abstract
PURPOSE OF REVIEW Space-occupying, malignant hemispheric infarction is one of the most devastating forms of ischemic stroke. Several case series had suggested decompressive hemicraniectomy as a life-saving therapy, but, until recently, there was no proof for this procedure from randomized controlled trials. RECENT FINDINGS In 2007, results from a pooled analysis of three European trials as well as data from two of these trials were published and yield compelling evidence for the benefit of hemicraniectomy. SUMMARY Data from the published trials leave no doubt about the benefit especially the life-saving character of hemicraniectomy for malignant hemispheric infarction. However, some open questions (i.e. timing of surgery, age limit for hemicraniectomy) remain to be answered in the future.
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Huttner HB, Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol 2009; 8:949-58. [DOI: 10.1016/s1474-4422(09)70224-8] [Citation(s) in RCA: 164] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Diedler J, Sykora M, Blatow M, Jüttler E, Unterberg A, Hacke W. Decompressive surgery for severe brain edema. J Intensive Care Med 2009; 24:168-78. [PMID: 19321537 DOI: 10.1177/0885066609332808] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Decompressive surgery has since long been a promising therapeutic approach for patients with acute severe brain injury at risk to develop severe brain edema. The underlying rationale of removing part of the cranium is to create space for the expanding brain to prevent secondary damage to vital brain tissue. However, until recently, randomized controlled trials that demonstrate the efficacy of decompressive surgery or benefit for outcome were missing. This has changed since the results of 3 randomized trials on hemicraniectomy in malignant infarction of the middle cerebral artery have been published in 2007. In this article, the current evidence for decompressive surgery in the treatment of cerebral ischemia, intracranial hemorrhage, traumatic brain injury, inflammatory diseases, or severe metabolic derangements is reviewed. Although there is increasing evidence for the efficacy of decompressive surgery in reducing intracranial pressure and even mortality, a critical point remains the definition of good or acceptable outcome.
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Affiliation(s)
- Jennifer Diedler
- Department of Neurology, University of Heidelberg, Heidelberg, Germany.
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Quality of life and neurobehavioral changes in survivors of malignant middle cerebral artery infarction. J Neurol 2009; 256:1126-33. [DOI: 10.1007/s00415-009-5083-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2008] [Revised: 02/15/2009] [Accepted: 02/18/2009] [Indexed: 10/21/2022]
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Kim KT, Park JK, Kang SG, Cho KS, Yoo DS, Jang DK, Huh PW, Kim DS. Comparison of the effect of decompressive craniectomy on different neurosurgical diseases. Acta Neurochir (Wien) 2009; 151:21-30. [PMID: 19096757 DOI: 10.1007/s00701-008-0164-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2008] [Accepted: 07/09/2008] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many previous studies have reported that decompressive craniectomy has improved clinical outcomes in patients with intractable increased intracranial pressure (ICP) caused by various neurosurgical diseases. However there is no report that compares the effectiveness of the procedure in the different conditions. The authors performed decompressive craniectomy following a constant surgical indication and compared the clinical outcomes in different neurosurgical diseases. MATERIALS AND METHODS Seventy five patients who underwent decompressive craniectomy were analysed retrospectively. There were 28 with severe traumatic brain injury (TBI), 24 cases with massive intracerebral haemorrhage (ICH), and 23 cases with major infarction (MI). The surgical indications were GCS score less than 8 and/or a midline shift more than 6 mm on CT. The clinical outcomes were assessed on the basis of mortality and Glasgow Outcome Scale (GOS) scores. The changes of ventricular pressure related to the surgical intervention were also compared between the different disease groups. FINDINGS Clinical outcomes were evaluated 6 months after decompressive craniectomy. The mortality was 21.4% in patients with TBI, 25% in those with ICH and 60.9% in MI. A favourable outcome, i.e. GOS 4-5 (moderate disability or better) was observed in 16 (57.1%) patients with TBI, 12 (50%) with ICH and 7 (30.4%) with MI. The change of ventricular pressure after craniectomy and was 53.2 (reductions of 17.4%) and further reduced by 14.9% (with dural opening) and (24.8%) after returning to its recovery room, regardless of the diseases group. CONCLUSIONS According to the mortality and GOS scores, decompressive craniectomy with dural expansion was found to be more effective in patients with ICH or TBI than in the MI group. However, the ventricular pressure change during the decompressive craniectomy was similar in the different disease groups. The authors thought that decompressive craniectomy should be performed earlier for the major infarction patients.
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Affiliation(s)
- Ki-Tae Kim
- Department of Radiology, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, South Korea
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Schneck MJ, Origitano TC. Hemicraniectomy and durotomy for malignant middle cerebral artery infarction. Neurosurg Clin N Am 2008; 19:459-68, vi. [PMID: 18790381 DOI: 10.1016/j.nec.2008.07.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Decompressive hemicraniectomy with durotomy is a life-saving procedure for patients who have large middle cerebral artery or carotid terminus strokes at high risk for malignant cerebral edema. Although randomized clinical trial data are not yet available, there are several case series that attempt to address issues of patient selection and timing of the procedure in the context of survival and functional outcomes. Patients who have an increased number of medical comorbidities, especially older age, are less likely to benefit from the procedure, but patients who have even large dominant hemispheric infarctions may do relatively well in certain circumstances.
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Affiliation(s)
- Michael J Schneck
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL 60153, USA.
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Huttner HB, Jüttler E, Schwab S. Hemicraniectomy for middle cerebral artery infarction. Curr Neurol Neurosci Rep 2008; 8:526-33. [PMID: 18957191 DOI: 10.1007/s11910-008-0083-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The space-occupying so-called "malignant" middle cerebral artery infarction is-besides acute basilar artery occlusion-the most devastating form of ischemic stroke. Until recently, there was no proven treatment. In 2007, results from randomized controlled trials provided evidence for the benefit of early hemicraniectomy with respect to mortality after 3 months. This review focuses on current treatment options for malignant ischemic brain infarction, especially hemicraniectomy. Moreover, major unsolved problems and open questions regarding the disease are discussed, and perspective is given on future clinical studies.
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Affiliation(s)
- Hagen B Huttner
- Department of Neurology, University of Erlangen, Erlangen, Germany
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Abstract
Decompressive Craniectomy (DC) is used to treat elevated intracranial pressure that is unresponsive to conventional treatment modalities. The underlying cause of intracranial hypertension may vary and consequently there is a broad range of literature on the uses of this procedure. Traumatic brain injury (TBI), middle cerebral artery (MCA) infarction, and aneurysmal subarachnoid hemorrhage (SAH) are three conditions for which DC has been predominantly used in the past. Despite an increasing number of reports supportive of DC, the controversy over the suitability of the procedure and criteria for patient selection remains unresolved. Although the majority of published studies is retrospective, the recent publication of several randomized prospective studies prompts a reevaluation of the utility of DC. We review the literature concerning the use of DC in TBI, MCA infarction, and SAH and address the evidence regarding common questions pertaining to the timing of and laterality of the procedure. We conclude that at the time of this review, there still remains insufficient data to support the routine use of DC in TBI, stroke or SAH. There is evidence that early and aggressive use of DC in good-grade patients may improve outcome, but the notion that DC is indicated in these patients is contentious. At this point, the indication for DC should be individualized and its potential implications on long-term outcomes should be comprehensively discussed with the caregivers.
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Skoglund TS, Eriksson-Ritzén C, Sörbo A, Jensen C, Rydenhag B. Health status and life satisfaction after decompressive craniectomy for malignant middle cerebral artery infarction. Acta Neurol Scand 2008; 117:305-10. [PMID: 18076727 DOI: 10.1111/j.1600-0404.2007.00967.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To study the long-term outcome in patients with malignant middle cerebral artery (MCA) infarction treated with decompressive craniectomy. The outcome is described in terms of survival, impairment, disabilities and life satisfaction. MATERIALS AND METHODS Patients were examined at a minimum of 1 year (mean 2.9, range 1-6) after the surgery and classified according to the Glasgow Outcome Scale (GOS), the National Institutes of Health Stroke scale (NIHSS), the Barthel Index (BI), the short-form health survey (SF-36) and the life satisfaction checklist (LiSat-11). RESULTS Eighteen patients were included. The long-term survival was 78%. The mean NIHSS score was 13.8 (range 6-20). No patient was left in a vegetative state. The mean BI was 63.9 (5-100). The SF-36 scores showed that the patients' view of their health was significantly lower in most items compared with that of a reference group. According to the LiSat checklist, 83% found their life satisfying/rather satisfying and 17% found their life rather dissatisfying/dissatisfying. CONCLUSION We conclude that the patients remained in an impaired neurological condition, but had fairly good insight into their limitations. Although their life satisfaction was lower compared with that of the controls, the majority felt that life in general could still be satisfying.
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Affiliation(s)
- T S Skoglund
- Department of Neurosurgery, Sahlgrenska University Hospital, Göteborg, Sweden.
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Jüttler E, Köhrmann M, Aschoff A, Huttner HB, Hacke W, Schwab S. Hemicraniectomy for space-occupying supratentorial ischemic stroke. FUTURE NEUROLOGY 2008. [DOI: 10.2217/14796708.3.3.251] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Space-occupying, malignant hemispheric infarction is one of the most devastating forms of ischemic stroke. Until recently, there was no proven treatment. In 2007, results from randomized, controlled trials provided evidence for the benefit of early hemicraniectomy. This paper provides an overview on the current treatment options for malignant ischemic brain infarction, with a focus on hemicraniectomy. We also discuss major unsolved problems and open questions regarding the disease. Finally, we give a perspective on future clinical studies in this field of stroke.
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Affiliation(s)
- Eric Jüttler
- University of Heidelberg, Department of Neurology, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany
| | - Martin Köhrmann
- University of Erlangen, Department of Neurology, Schwabachanlage 6, D-91054 Erlangen, Germany
| | - Alfred Aschoff
- University of Heidelberg, Department of Neurosurgery, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany
| | - Hagen B Huttner
- University of Erlangen, Department of Neurology, Schwabachanlage 6, D-91054 Erlangen, Germany
| | - Werner Hacke
- University of Heidelberg, Department of Neurology, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany
| | - Stefan Schwab
- University of Erlangen, Department of Neurology, Schwabachanlage 6, D-91054 Erlangen, Germany
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50
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Abstract
Brain edema is a common pathophysiological process seen in many neurosurgical conditions. It can be localized in relation to focal lesions or generalized in diffuse types of brain injury. In addition to local adverse effects occurring at a cellular level, brain edema is associated with raised intracranial pressure (ICP), and both phenomena contribute to poor outcome in patients. One of the goals in treating patients with acute neurosurgical conditions in intensive care is to control brain edema and maintain ICP below target levels. The mainstay of treatment is medical therapy to reduce edema, but in certain patients--for example, those with diffuse severe traumatic brain injury (TBI) and malignant middle cerebral artery infarction--such treatment is not effective. In these patients, opening the skull (decompressive craniectomy) to reduce ICP is a potential option. In this review the authors discuss the role of decompressive craniectomy as a surgical option in patients with brain edema in the context of a variety of pathological entities. They also address the current evidence for the technique (predominantly observational series) and the ongoing randomized studies of decompressive craniectomy in TBI and ischemic stroke.
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Affiliation(s)
- Peter Hutchinson
- University of Cambridge Academic Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, United Kingdom.
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