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Gheewala H, Aldergham M, Rosahl S, Stoffel M, Ryang YM, Heese O, Gerlach R, Burger R, Carl B, Kristof RA, Westermaier T, Terzis J, Youssef F, Gonzalez GR, Bold F, Allam A, Kuhlen R, Hohenstein S, Bollmann A, Dengler J. Decompressive Surgery in the Treatment of Acute Ischemic Stroke during the First Four Waves of the COVID-19 Pandemic in Germany: A Nationwide Observational Cohort Study. J Neurol Surg A Cent Eur Neurosurg 2024; 85:478-484. [PMID: 37595628 DOI: 10.1055/a-2156-5363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
BACKGROUND The COVID-19 pandemic has significantly affected acute ischemic stroke (AIS) care. In this study, we examined the effects of the pandemic on neurosurgical AIS care by means of decompressive surgery (DS). METHODS In this retrospective observational study, we compared the characteristics, in-hospital processes, and in-hospital mortality rates among patients hospitalized for AIS during the first four waves of the pandemic (between January 1, 2020 and October 26, 2021) versus the corresponding periods in 2019 (prepandemic). We used administrative data from a nationwide hospital network in Germany. RESULTS Of the 177 included AIS cases with DS, 60 were from 2019 and 117 from the first four pandemic waves. Compared with the prepandemic levels, there were no changes in weekly admissions for DS during the pandemic. The same was true for patient age (range: 51.7-60.4 years), the number of female patients (range: 33.3-57.1%), and the prevalence of comorbidity, as measured by the Elixhauser Comorbidity Index (range: 13.2-20.0 points). Also, no alterations were observed in transfer to the intensive care unit (range: 87.0-100%), duration of in-hospital stay (range: 14.6-22.7 days), and in-hospital mortality rates (range: 11.8-55.6%). CONCLUSION In Germany, compared with the prepandemic levels, AIS patients undergoing DS during the first four waves of the pandemic showed no changes in demographics, rates of comorbidity, and in-hospital mortality rates. This is in contrast to previous evidence on patients with less critical types of AIS not requiring DS and underlines the uniqueness of the subgroup of AIS patients requiring DS. Our findings suggests that these patients, in contrast to AIS patients in general, were unable to forgo hospitalization during the COVID-19 pandemic. Maintaining the delivery of DS is an essential aspect of AIS care during a pandemic.
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Affiliation(s)
- Hussain Gheewala
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Campus Bad Saarow, Bad Saarow, Germany
- Department of Neurosurgery, HELIOS Hospital Bad Saarow, Bad Saarow, Germany
| | - Muath Aldergham
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Campus Bad Saarow, Bad Saarow, Germany
- Department of Vascular Surgery, HELIOS Hospital Bad Saarow, Bad Saarow, Germany
| | - Steffen Rosahl
- Department of Neurosurgery, HELIOS Hospital Erfurt, Erfurt, Germany
| | - Michael Stoffel
- Department of Neurosurgery, HELIOS Hospital Krefeld, Krefeld, Germany
| | - Yu-Mi Ryang
- Department of Neurosurgery and Center for Spine Therapy, HELIOS Hospital Berlin Buch, Berlin, Germany
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Oliver Heese
- Department of Neurosurgery and Spinal Surgery, HELIOS Hospital Schwerin - University Campus of MSH Medical School Hamburg, Schwerin, Germany
| | - Rüdiger Gerlach
- Department of Neurosurgery, HELIOS Hospital Erfurt, Erfurt, Germany
| | - Ralf Burger
- Department of Neurosurgery, HELIOS Hospital Uelzen, Uelzen, Germany
| | - Barbara Carl
- Department of Neurosurgery, University of Marburg, Marburg, Germany
- Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
- Department of Neurosurgery, HELIOS Dr. Horst Schmidt Kliniken, Wiesbaden, Germany
| | - Rudolf A Kristof
- Department of Neurosurgery, HELIOS Hospital Meiningen, Meiningen, Germany
| | | | - Jorge Terzis
- Department of Neurosurgery, HELIOS Hospital Wuppertal, Wuppertal, Germany
| | - Farid Youssef
- Department of Neurosurgery, HELIOS Hospital Plauen, Plauen, Germany
| | - Gerardo Rico Gonzalez
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Campus Bad Saarow, Bad Saarow, Germany
- Department of Neurosurgery, HELIOS Hospital Bad Saarow, Bad Saarow, Germany
| | - Frederic Bold
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Campus Bad Saarow, Bad Saarow, Germany
- Department of Anesthesiology and Intensive Care Medicine, HELIOS Hospital Bad Saarow, Bad Saarow, Germany
| | - Ali Allam
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Campus Bad Saarow, Bad Saarow, Germany
- Department of Anesthesiology and Intensive Care Medicine, HELIOS Hospital Bad Saarow, Bad Saarow, Germany
| | | | - Sven Hohenstein
- Real World Evidence and Health Technology Assessment, Helios Health Institute, Berlin, Germany
| | - Andreas Bollmann
- Real World Evidence and Health Technology Assessment, Helios Health Institute, Berlin, Germany
- Department of Electrophysiology, Heart Center Leipzig, Leipzig, Germany
| | - Julius Dengler
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Campus Bad Saarow, Bad Saarow, Germany
- Department of Neurosurgery, HELIOS Hospital Bad Saarow, Bad Saarow, Germany
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Brindley PG, Sanderson M, Anderson D, O’Kelly C. Decompressive craniectomy: A primer for acute care practitioners. J Intensive Care Soc 2024; 25:339-345. [PMID: 39224422 PMCID: PMC11366190 DOI: 10.1177/17511437241237760] [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] [Indexed: 09/04/2024] Open
Abstract
Decompressive craniectomy (DC) involves surgical removal of the skull that overlies swollen, imperiled, brain. This is done to combat intracranial hypertension and mitigate a vicious cycle of secondary brain injury. If, instead, this pathophysiology goes uninterrupted, it can mean brain herniation and brain stem death. As such, DC can save lives when all else fails. Regardless, it is no panacea and can also "ruin deaths," and leave patients profoundly disabled. DC is not a new procedure; however, this therapy is increasingly noteworthy due to advances in neurocritical care, alongside ethical concerns. We cover the physiological rationale, the surgical basics, the trial data, and focus on secondary decompression (for refractory intracranial pressure (ICP)) rather than primary decompression (i.e. during evacuation of an intracranial mass). Given that DC should not be undertaken indiscriminately, we conclude by introducing ways in which to discuss DC with families and colleagues. Our goal is to provide a primer and common resource for the multidisciplinary team. We aim to increase not only knowledge but wisdom, prudence, collegiality, and family-focused care.
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Affiliation(s)
| | - Mark Sanderson
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Dustin Anderson
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Cian O’Kelly
- Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
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3
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Ong CJ, Chatzidakis S, Ong JJ, Feske S. Updates in Management of Large Hemispheric Infarct. Semin Neurol 2024; 44:281-297. [PMID: 38759959 PMCID: PMC11210577 DOI: 10.1055/s-0044-1787046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
This review delves into updates in management of large hemispheric infarction (LHI), a condition affecting up to 10% of patients with supratentorial strokes. While traditional management paradigms have endured, recent strides in research have revolutionized the approach to acute therapies, monitoring, and treatment. Notably, advancements in triage methodologies and the application of both pharmacological and mechanical abortive procedures have reshaped the acute care trajectory for patients with LHI. Moreover, ongoing endeavors have sought to refine strategies for the optimal surveillance and mitigation of complications, notably space-occupying mass effect, which can ensue in the aftermath of LHI. By amalgamating contemporary guidelines with cutting-edge clinical trial findings, this review offers a comprehensive exploration of the current landscape of acute and ongoing patient care for LHI, illuminating the evolving strategies that underpin effective management in this critical clinical domain.
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Affiliation(s)
- Charlene J. Ong
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, Massachusetts
| | - Stefanos Chatzidakis
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jimmy J. Ong
- Department of Neurology, Sidney Kimmel Medical College, Philadelphia, Pennsylvania
- Department of Neurology, Jefferson Einstein Hospital, Philadelphia, Pennsylvania
| | - Steven Feske
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, Massachusetts
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4
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Im SH, Yoo DS, Park HK. Proper Indication of Decompressive Craniectomy for the Patients with Massive Brain Edema after Intra-arterial Thrombectomy. J Korean Neurosurg Soc 2024; 67:227-236. [PMID: 38173228 PMCID: PMC10924906 DOI: 10.3340/jkns.2023.0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 08/21/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE Numerous studies have indicated that early decompressive craniectomy (DC) for patients with major infarction can be life-saving and enhance neurological outcomes. However, most of these studies were conducted by neurologists before the advent of intra-arterial thrombectomy (IA-Tx). This study aims to determine whether neurological status significantly impacts the final clinical outcome of patients who underwent DC following IA-Tx in major infarction. METHODS This analysis included 67 patients with major anterior circulation major infarction who underwent DC after IA-Tx, with or without intravenous tissue plasminogen activator. We retrospectively reviewed the medical records, radiological findings, and compared the neurological outcomes based on the "surgical time window" and neurological status at the time of surgery. RESULTS For patients treated with DC following IA-Tx, a Glasgow coma scale (GCS) score of 7 was the lowest score correlated with a favorable outcome (p=0.013). Favorable outcomes were significantly associated with successful recanalization after IA-Tx (p=0.001) and perfusion/diffusion (P/D)-mismatch evident on magnetic resonance imaging performed immediately prior to IA-Tx (p=0.007). However, the surgical time window (within 36 hours, p=0.389; within 48 hours, p=0.283) did not correlate with neurological outcomes. CONCLUSION To date, early DC surgery after major infarction is crucial for patient outcomes. However, this study suggests that the indication for DC following IA-Tx should include neurological status (GCS ≤7), as some patients treated with early DC without considering the neurological status may undergo unnecessary surgery. Recanalization of the occluded vessel and P/D-mismatch are important for long-term neurological outcomes.
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Affiliation(s)
- Sang-Hyuk Im
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do-Sung Yoo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hae-Kwan Park
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Rostami A, Elyassirad D, Vatanparast M, Abouei Mehrizi MA, Hasanpour M, Rezaee H, Haghir A, Keykhosravi E. Functional Outcome and Mortality Predictors in Patients with Cerebral Ischemic Infarction After Decompressive Craniectomy: Cross-Sectional Study. World Neurosurg 2024; 182:e847-e853. [PMID: 38101538 DOI: 10.1016/j.wneu.2023.12.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 12/09/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE Surgeons commonly perform Decompressive craniectomy (DC) to manage patients with cerebral ischemic infarction. However, there are conflicting data on the long-term functional outcomes following DC. Therefore, this study aims to determine the functional outcome of patients with cerebral ischemic infarction after DC. METHODS This prospective and retrospective cross-sectional study included 148 patients with cerebral ischemic infarction who underwent DC at Ghaem Hospital, Mashhad, Iran, from March 2011 to March 2021. The Modified Rankin Scale (mRS) assesses disability in these patients and determines the recovery and degree of long-term functional outcomes. Demographic and clinical data were extracted and recorded in a researcher-made questionnaire. RESULTS In summary, the follow-up revealed a survival rate of 39.2% among patients with ischemic stroke. The comparison of the mean infarct volume in patients with various mRS scores showed that the mean infarct volume was significantly higher in patients with unfavorable functional outcomes, based on mRS scores at discharge (P = 0.05), 3 months mRS (P < 0.01), and mRS score at final follow-up (P = 0.01). Final mortality was higher in patients with higher mRS scores at discharge, after 3 months, and final follow-up (P < 0.01). Older age and infarction volume can predict mRS and mortality in patients with ischemic stroke (P < 0.01). CONCLUSIONS The present study showed that mortality and mRS scores at various times are associated with infarction volume and older age in patients with ischemic stroke.
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Affiliation(s)
- Amin Rostami
- Department of Neurosurgery, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Daniel Elyassirad
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahsa Vatanparast
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Mohammad Hasanpour
- Department of Neurosurgery, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Rezaee
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amirhosein Haghir
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ehsan Keykhosravi
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran.
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Hua X, Liu M, Wu S. Definition, prediction, prevention and management of patients with severe ischemic stroke and large infarction. Chin Med J (Engl) 2023; 136:2912-2922. [PMID: 38030579 PMCID: PMC10752492 DOI: 10.1097/cm9.0000000000002885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Indexed: 12/01/2023] Open
Abstract
ABSTRACT Severe ischemic stroke carries a high rate of disability and death. The severity of stroke is often assessed by the degree of neurological deficits or the extent of brain infarct, defined as severe stroke and large infarction, respectively. Critically severe stroke is a life-threatening condition that requires neurocritical care or neurosurgical intervention, which includes stroke with malignant brain edema, a leading cause of death during the acute phase, and stroke with severe complications of other vital systems. Early prediction of high-risk patients with critically severe stroke would inform early prevention and treatment to interrupt the malignant course to fatal status. Selected patients with severe stroke could benefit from intravenous thrombolysis and endovascular treatment in improving functional outcome. There is insufficient evidence to inform dual antiplatelet therapy and the timing of anticoagulation initiation after severe stroke. Decompressive hemicraniectomy (DHC) <48 h improves survival in patients aged <60 years with large hemispheric infarction. Studies are ongoing to provide evidence to inform more precise prediction of malignant brain edema, optimal indications for acute reperfusion therapies and neurosurgery, and the individualized management of complications and secondary prevention. We present an evidence-based review for severe ischemic stroke, with the aims of proposing operational definitions, emphasizing the importance of early prediction and prevention of the evolution to critically severe status, summarizing specialized treatment for severe stroke, and proposing directions for future research.
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Affiliation(s)
- Xing Hua
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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7
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Liu G, Tian F, Zhu Y, Jiang M, Cui L, Zhang Y, Wang Y, Su Y. The predictive value of EEG reactivity by electrical stimulation and quantitative analysis in critically ill patients with large hemispheric infarction. J Crit Care 2023; 78:154358. [PMID: 37329762 DOI: 10.1016/j.jcrc.2023.154358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 05/05/2023] [Accepted: 06/02/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE The intensive care of critically ill patients with large hemispheric infarction improves the survival rate. However, established prognostic markers for neurological outcome show variable accuracy. We aimed to assess the value of electrical stimulation and quantitative analysis of EEG reactivity for early prognostication in this critically ill population. MATERIALS AND METHODS We prospectively enrolled consecutive patients between January 2018 and December 2021. EEG reactivity was randomly performed by pain or electrical stimulation via visual and quantitative analysis. Neurological outcome within 6-month was dichotomized as good (modified Rankin Scale, mRS 0-3) or poor (mRS 4-6). RESULTS Ninety-four patients were admitted, and 56 were included in the final analysis. EEG reactivity using electrical stimulation was superior to pain stimulation for good outcome prediction (visual analysis: AUC 0.825 vs. 0.763, P = 0.143; quantitative analysis: AUC 0.931 vs. 0.844, P = 0.058). The AUC of EEG reactivity by pain stimulation with visual analysis was 0.763, which increased to 0.931 by electrical stimulation with quantitative analysis (P = 0.006). When using quantitative analysis, the AUC of EEG reactivity increased (pain stimulation 0.763 vs. 0.844, P = 0.118; electrical stimulation 0.825 vs. 0.931, P = 0.041). CONCLUSION EEG reactivity by electrical stimulation and quantitative analysis seems a promising prognostic factor in these critical patients.
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Affiliation(s)
- Gang Liu
- Neurocritical Care Unit, Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Fei Tian
- Neurocritical Care Unit, Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Yu Zhu
- Neurocritical Care Unit, Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Mengdi Jiang
- Neurocritical Care Unit, Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Lili Cui
- Neurocritical Care Unit, Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Yan Zhang
- Neurocritical Care Unit, Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Yuan Wang
- Neurocritical Care Unit, Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing 10053, China.
| | - Yingying Su
- Neurocritical Care Unit, Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing 10053, China.
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Migdady I, Johnson-Black PH, Leslie-Mazwi T, Malhotra R. Current and Emerging Endovascular and Neurocritical Care Management Strategies in Large-Core Ischemic Stroke. J Clin Med 2023; 12:6641. [PMID: 37892779 PMCID: PMC10607145 DOI: 10.3390/jcm12206641] [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: 09/16/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
The volume of infarcted tissue in patients with ischemic stroke is consistently associated with increased morbidity and mortality. Initial studies of endovascular thrombectomy for large-vessel occlusion excluded patients with established large-core infarcts, even when large volumes of salvageable brain tissue were present, due to the high risk of hemorrhagic transformation and reperfusion injury. However, recent retrospective and prospective studies have shown improved outcomes with endovascular thrombectomy, and several clinical trials were recently published to evaluate the efficacy of endovascular management of patients presenting with large-core infarcts. With or without thrombectomy, patients with large-core infarcts remain at high risk of in-hospital complications such as hemorrhagic transformation, malignant cerebral edema, seizures, and others. Expert neurocritical care management is necessary to optimize blood pressure control, mitigate secondary brain injury, manage cerebral edema and elevated intracranial pressure, and implement various neuroprotective measures. Herein, we present an overview of the current and emerging evidence pertaining to endovascular treatment for large-core infarcts, recent advances in neurocritical care strategies, and their impact on optimizing patient outcomes.
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Affiliation(s)
- Ibrahim Migdady
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Phoebe H. Johnson-Black
- Department of Neurosurgery, Division of Neurocritical Care, UCLA David Geffen School of Medicine, Ronald Reagan Medical Center, Los Angeles, CA 90095, USA;
| | | | - Rishi Malhotra
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
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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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10
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Kim JH, Choo YH, Jeong H, Kim M, Ha EJ, Oh J, Lee S. Recent Updates on Controversies in Decompressive Craniectomy and Cranioplasty: Physiological Effect, Indication, Complication, and Management. Korean J Neurotrauma 2023; 19:128-148. [PMID: 37431371 PMCID: PMC10329888 DOI: 10.13004/kjnt.2023.19.e24] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 06/12/2023] [Indexed: 07/12/2023] Open
Abstract
Decompressive craniectomy (DCE) and cranioplasty (CP) are surgical procedures used to manage elevated intracranial pressure (ICP) in various clinical scenarios, including ischemic stroke, hemorrhagic stroke, and traumatic brain injury. The physiological changes following DCE, such as cerebral blood flow, perfusion, brain tissue oxygenation, and autoregulation, are essential for understanding the benefits and limitations of these procedures. A comprehensive literature search was conducted to systematically review the recent updates in DCE and CP, focusing on the fundamentals of DCE for ICP reduction, indications for DCE, optimal sizes and timing for DCE and CP, the syndrome of trephined, and the debate on suboccipital CP. The review highlights the need for further research on hemodynamic and metabolic indicators following DCE, particularly in relation to the pressure reactivity index. It provides recommendations for early CP within three months of controlling increased ICP to facilitate neurological recovery. Additionally, the review emphasizes the importance of considering suboccipital CP in patients with persistent headaches, cerebrospinal fluid leakage, or cerebellar sag after suboccipital craniectomy. A better understanding of the physiological effects, indications, complications, and management strategies for DCE and CP to control elevated ICP will help optimize patient outcomes and improve the overall effectiveness of these procedures.
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Affiliation(s)
- Jae Hyun Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Heewon Jeong
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea
| | - Moinay Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jiwoong Oh
- Division of Neurotrauma & Neurocritical Care Medicine, Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seungjoo Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Arai N, Abe Y, Metani H, Hiraoka T, Hanayama K. Effect of cranioplasty on FIM in patients with severe cerebral infarction after cerebral decompression. JAPANESE JOURNAL OF COMPREHENSIVE REHABILITATION SCIENCE 2023; 14:33-38. [PMID: 37859786 PMCID: PMC10585017 DOI: 10.11336/jjcrs.14.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 10/21/2023]
Abstract
Arai N, Abe Y, Metani H, Hiraoka T, Hanayama K. Effect of cranioplasty on FIM in patients with severe cerebral infarction after cerebral decompression. Jpn J Compr Rehabil Sci 2023; 14: 33-38. Objective The functional effects of cranioplasty were measured in patients with severe cerebral infarction who had undergone cerebral decompression by comparing the functional independence measure (FIM) during convalescent rehabilitation before and after cranioplasty. Methods The study design was a single-center retrospective cohort study. Results Fifty-five patients underwent cerebral decompression after cerebral infarction at our hospital, six of whom were included in this study. Two patients who exhibited cranial depression had no changes in FIM one month prior to cranioplasty. However, the FIM increased one month postoperatively. These patients showed a large increase in the scores for movement and transfer. Discussion Cranioplasty may play a role in improving ability during convalescent rehabilitation in patients with severe cerebral infarction who undergo cerebral decompression, especially in movement and transfer items.
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Affiliation(s)
- Nobuyuki Arai
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Yasumasa Abe
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Hiromichi Metani
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Takashi Hiraoka
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Kozo Hanayama
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
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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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Outcomes of decompressive craniectomy for large territory cerebral infarction with and without prior reperfusion: a multicentre retrospective review. Acta Neurochir (Wien) 2023; 165:599-604. [PMID: 36808008 DOI: 10.1007/s00701-023-05516-7] [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: 12/05/2022] [Accepted: 01/26/2023] [Indexed: 02/21/2023]
Abstract
PURPOSE Reperfusion therapy has greatly improved outcomes of ischaemic stroke but remains associated with haemorrhagic conversion and early deterioration in a significant proportion of patients. Outcomes in terms of function and mortality are mixed and the evidence for decompressive craniectomies (DC) in this context remains sparse. We aim to investigate the clinical efficacy of DC in this group of patients compared to those without prior reperfusion therapy. METHODS A multicentre retrospective study was conducted between 2005 and 2020, and all patients with DC for large territory infarctions were included. Outcomes in terms of inpatient and long-term modified Rankin scale (mRS) and mortality were assessed at various time points and compared using both univariable and multivariable analyses. Favourable mRS was defined as 0-3. RESULTS There were 152 patients included in the final analysis. The cohort had a mean age of 57.5 years and median Charlson comorbidity index of 2. The proportion of preoperative anisocoria was 15.1%, median preoperative Glasgow coma scale was 9, the ratio of left-sided stroke was 40.1%, and ICA infarction was 42.8%. There were 79 patients with prior reperfusion and 73 patients without. After multivariable analysis, the proportion of favourable 6-month mRS (reperfusion, 8.2%; no reperfusion, 5.4%) and 1-year mortality (reperfusion, 26.7%; no reperfusion, 27.3%) were similar in both groups. Subgroup analysis of thrombolysis and/or thrombectomy against no reperfusion was also unremarkable. CONCLUSION Reperfusion therapy prior to DC performed for large territory cerebral infarctions does not affect the functional outcome and mortality in a well-selected patient population.
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Nontraumatic Neurosurgical Emergencies. Crit Care Nurs Q 2023; 46:2-16. [DOI: 10.1097/cnq.0000000000000434] [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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15
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Anke P, Kjelsberg Pedersen L, Mathiesen EB, Ingebrigtsen T. Decompressive hemicraniectomy for space-occupying brain infarction: Nationwide population-based registry study. J Stroke Cerebrovasc Dis 2022; 31:106831. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 10/09/2022] [Indexed: 11/05/2022] Open
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Dower A, Mulcahy M, Maharaj M, Chen H, Lim CED, Li Y, Sheridan M. Surgical decompression for malignant cerebral oedema after ischaemic stroke. Cochrane Database Syst Rev 2022; 11:CD014989. [PMID: 36385224 PMCID: PMC9667531 DOI: 10.1002/14651858.cd014989.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Large territory middle cerebral artery (MCA) ischaemic strokes account for around 10% of all ischaemic strokes and have a particularly devastating prognosis when associated with malignant oedema. Progressive cerebral oedema starts developing in the first 24 to 48 hours of stroke ictus with an associated rise in intracranial pressure. The rise in intracranial pressure may eventually overwhelm compensatory mechanisms leading to a cascading secondary damage to surrounding unaffected parenchyma. This downward spiral can rapidly progress to death or severe neurological disability. Early decompressive craniectomy to relieve intracranial pressure and associated tissue shift can help ameliorate this secondary damage and improve outcomes. Evidence has been accumulating of the benefit of early surgical decompression in stroke patients. Earlier studies have excluded people above the age of 60 due to associated poor outcomes; however, newer trials have included this patient subgroup. This review follows a Cochrane Review published in 2012. OBJECTIVES To assess the effectiveness of surgical decompression in people with malignant oedema after ischaemic stroke with regard to reduction in mortality and improved functional outcome. We also aimed to examine the adverse effects of surgical decompression in this patient cohort. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2022, Issue 7 of 12), MEDLINE Ovid, Embase Ovid, Web of Science Core Collection, Scopus databases, ClinicalTrials.gov, and the WHO ICTRP to July 2022. We also reviewed the reference lists of relevant articles. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing decompressive craniectomy with medical management to best medical management alone for people with malignant cerebral oedema after MCA ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results, assessed study eligibility, performed risk of bias assessment, and extracted the data. The primary outcomes were death and death or severe disability (modified Rankin Scale (mRS) > 4) at 6 to 12 months follow-up. Other outcomes included death or moderate disability (mRS > 3), severe disability (mRS = 5), and adverse events. We assessed the certainty of the evidence using the GRADE approach, categorising it as high, moderate, low, or very low. MAIN RESULTS We included nine RCTs with a total of 513 participants included in the final analysis. Three studies included patients younger than 60 years of age; two trials accepted patients up to 80 years of age; and one trial only included patients 60 years or older. The majority of included trials (six) mandated a time from stroke ictus to treatment of < 48 hours, whilst in two of them this was < 96 hours. Surgical decompression was associated with a reduction in death (odds ratio (OR) 0.18, 95% confidence interval (CI) 0.12 to 0.27, 9 trials, 513 participants, P < 0.001; high-certainty evidence); death or severe disability (mRS > 4, OR 0.22, 95% CI 0.15 to 0.32, 9 trials, 513 participants, P < 0.001; high-certainty evidence); and death or moderate disability (mRS > 3, OR 0.34, 95% CI 0.22 to 0.52, 9 trials, 513 participants, P < 0.001; moderate-certainty evidence). Subgroup analysis did not reveal any significant effect on treatment outcomes when analysing age (< 60 years versus ≥ 60 years); time from stroke ictus to intervention (< 48 hours versus ≥ 48 hours); or dysphasia. There was a significant subgroup effect of time at follow-up (6 versus 12 months, P = 0.02) on death as well as death or severe disability (mRS > 4); however, the validity of this finding was affected by fewer participant numbers in the six-month follow-up subgroup. There was no consistent reporting of per-participant adverse event rates in any of the included studies, which prevented further analysis. AUTHORS' CONCLUSIONS Surgical decompression improves outcomes in the management of malignant oedema after acute ischaemic stroke, including a considerable reduction in death or severe disability (mRS > 4) and a reduction in death or moderate disability (mRS > 3). Whilst there is evidence that this positive treatment effect is present in patients > 60 years old, it is important to take into account that these patients have a poorer prospect of functional survival independent of this treatment effect. In interpreting these results it must also be considered that the data demonstrating benefit are drawn from a unique patient subset with profound neurological deficit, reduced level of consciousness, and no pre-morbid disability or severe comorbidity.
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Affiliation(s)
- Ashraf Dower
- Liverpool Hospital, Liverpool, Australia
- Department of Neurosurgery, Westmead Hospital, Sydney, Australia
| | - Michael Mulcahy
- Department of Neurosurgery, John Hunter Hospital, Newcastle, Australia
| | - Monish Maharaj
- Department of Neurosurgery, Waikato Hospital, Hamilton, New Zealand
| | - Hui Chen
- School of Life Sciences, University of Technology Sydney, Sydney, Australia
| | | | - Yingda Li
- Department of Neurosurgery, Westmead Hospital, Sydney, Australia
| | - Mark Sheridan
- Department of Neurosurgery, Liverpool Hospital, University of New South Wales, Sydney, Australia
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Pape P, Jensen AH, Bergdal O, Munch TN, Rudolph SS, Rasmussen LS. Time to CT scan for patients with acute severe neurological symptoms: a quality assurance study. Sci Rep 2022; 12:15269. [PMID: 36088471 PMCID: PMC9464221 DOI: 10.1038/s41598-022-19512-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 08/30/2022] [Indexed: 11/25/2022] Open
Abstract
Emergent brain computed tomography (CT) scan allows for identification of patients presenting with acute severe neurological symptoms in whom medical and surgical interventions may be lifesaving. The aim of this study was to evaluate if time to CT from arrival at the emergency department exceeded 30 min in patients admitted with acute severe neurological symptoms. This was a retrospective register-based quality assurance study. We identified patients admitted to the emergency department with acute severe neurological symptoms between April 1st, 2016 and September 30th, 2020. Data were retrieved from the registry of acute medical team activations. We considered that time to CT from arrival at the emergency department should not exceed 30 min in more than 10% of patients. A total of 559 patients were included. Median time from arrival at the emergency department until CT scan was 24 min (IQR 16–35) in children (< 18 years), 10 min (IQR 7–17) for adults (18–59 years), and 11 min (IQR 7–16) for elders (> 60 years). This time interval exceeded 30 min for 8.2% (95% CI 6.1–10.9) of all included patients, 35.3% of children, 5.9% of adults, and 8.6% of elders. No children died within 30 days. The 30-day mortality was 21.3% (95% CI 16.4–27) in adults, and 43.9% (95% CI 38.2–49.8) in elders. Time from arrival at our emergency department until brain CT scan exceeded 30 min in 8.2% of all included patients but exceeded the defined quality aim in children and could be improved.
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Hu Y, Xiao Q, Shi Z, Hou Y, Chen Z, Cheng J, Li G. Safety and efficacy of low-dose and long-course tirofiban in large hemispheric infarction. Front Neurol 2022; 13:987859. [PMID: 36158948 PMCID: PMC9500446 DOI: 10.3389/fneur.2022.987859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/04/2022] [Indexed: 12/04/2022] Open
Abstract
Background The clinical efficacy and safety of tirofiban in the treatment of large hemispheric infarction (LHI) remain controversial. Methods This study prospectively enrolled patients with acute LHI who were admitted to Putuo Hospital affiliated with Shanghai University of Traditional Chinese Medicine from June 2021 to December 2021. The patients were randomly assigned to the tirofiban group [3–4 μg/(kg·h)] or control group (clopidogrel 75 mg/d). Results A total of 71 patients with acute LHI were selected: 36 in the tirofiban group and 35 in the control group. The reduction of the NIHSS score in the tirofiban group was 2.92 ± 9.31 at discharge, and that of the control group was −3.23 ± 12.06 (p = 0.021, OR, 0.006; 95% CI, 0.004–0.008). Six patients (16.7%) in tirofiban group and 14 patients (40%) in control group died during hospitalization (p = 0.029, OR, 0.300; 95% CI, 0.099–0.908). There was significant difference in Modified Rankin Scale (mRS) 5–6 scores at 90 days between the two groups (p = 0.023, OR, 0.327; 95% CI, 0.124–0.867). However, there was no significant difference in mRS 0–1 (p = 0.321, OR, 0.972; 95% CI, 0.920–1.027), mRS 2 (p = 0.572, OR, 2.00; 95% CI, 0.173–23.109), mRS 3 (p = 0.225, OR, 2.214; 95% CI, 0.601–8.161), or mRS 4(p = 0.284, OR, 1.859; 95% CI, 0.593–5.825) scores between the two groups. There was no difference in symptomatic intracranial hemorrhage (p = 0.29, OR, 0.305; 95% CI, 0.030–3.081), asymptomatic intracranial hemorrhage (p = 0.123, OR, 0.284; 95% CI, 0.053–1.518). There was a significant difference in systemic bleeding events during hospitalization (p = 0.044, OR, 0.309; 95% CI, 0.096–1.000). Conclusions Low-dose and long-course tirofiban treatment may significantly improve the early neurological function and reduce the in-hospital mortality in LHI patients. Meanwhile, tirofiban does not increase the risk of any type of bleeding events.
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National trends in endovascular thrombectomy and decompressive craniectomy for acute ischemic stroke: A study using National Inpatient Sample data from 2006 to 2016. J Clin Neurosci 2022; 101:234-238. [DOI: 10.1016/j.jocn.2022.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 04/18/2022] [Accepted: 04/22/2022] [Indexed: 11/21/2022]
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Cardali SM, Caffo M, Caruso G, Scalia G, Gorgoglione N, Conti A, Vinci SL, Barresi V, Granata F, Ricciardo G, Garufi G, Raffa G, Germanò A. Cisternostomy for malignant middle cerebral artery infarction: proposed pathophysiological mechanisms and preliminary results. Stroke Vasc Neurol 2022; 7:476-481. [PMID: 35672081 PMCID: PMC9811554 DOI: 10.1136/svn-2021-000918] [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: 02/06/2021] [Accepted: 04/16/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The ischaemic stroke of the territory of the middle cerebral artery represents an event burdened by high mortality and severe morbidity. The proposed medical treatments do not always prove effective. Decompressive craniectomy allows the ischaemic tissue to shift through the surgical defect rather than to the unaffected regions of the brain, thus avoiding secondary damage due to increased intracranial pressure. In this study, we propose a novel treatment for these patients characterised by surgical fenestration of the cisterns of the skull base. METHODS We have treated 16 patients affected by malignant middle cerebral artery ischaemia and treated with cisternostomy between August 2018 and December 2019. The clinical history, neurological examination findings and neuroradiological studies (brain CT, CT angiography, MRI) were performed to diagnose stroke. Clinical examination was recorded on admission and preoperatively using the Glasgow Coma Scale and the National Institutes of Health Stroke Scale. RESULTS The study included 16 patients, 10 males and 6 females. The mean age at surgery was 60.1 years (range 19-73). Surgical procedure was performed in all patients. The patients underwent immediate postoperative CT scan and were in the early hours evaluated in sedation window. In total, we recorded two deaths (12.5%). A functional outcome between mRS 0-3, defined as favourable, was observed in 9 (64.2%) patients 9 months after discharge. A functional outcome between mRS 4-6, defined as poor, was observed in 5 (35.7%) patients 9 months after discharge. CONCLUSIONS The obtained clinical results appear, however, substantially overlapping to decompressive craniectomy. Cisternostomy results in a favourable functional outcome after 9 months. This proposed technique permits that the patient no longer should be undergone cranioplasty thus avoiding the possible complications related to this procedure. The results are certainly interesting but higher case numbers are needed to reach definitive conclusions.
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Affiliation(s)
- Salvatore Massimiliano Cardali
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Maria Caffo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Gerardo Caruso
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Gianluca Scalia
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Nicola Gorgoglione
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Alfredo Conti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Sergio Lucio Vinci
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Neuroradiology, University of Messina, Messina, Italy
| | - Valeria Barresi
- Department of Diagnostics and Public Health, Section of Anatomic Pathology, University of Verona, Verona, Italy
| | - Francesca Granata
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Neuroradiology, University of Messina, Messina, Italy
| | - Giuseppe Ricciardo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Giada Garufi
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Giovanni Raffa
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Antonino Germanò
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
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Lim JX, Liu SJ, Cheong TM, Saffari SE, Han JX, Chen MW. Intracranial Pressure as an Objective Biomarker of Decompression Adequacy in Large Territory Infarction: A Multicenter Observational Study. Front Surg 2022; 9:823899. [PMID: 35769152 PMCID: PMC9235838 DOI: 10.3389/fsurg.2022.823899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 04/06/2022] [Indexed: 12/21/2022] Open
Abstract
Background Decompressive craniectomy (DC) improves the survival and functional outcomes in patients with malignant cerebral infarction. Currently, there are no objective intraoperative markers that indicates adequate decompression. We hypothesise that closure intracranial pressure (ICP) correlates with postoperative outcomes. Methods This is a multicentre retrospective review of all 75 DCs performed for malignant cerebral infarction. The patients were divided into inadequate ICP (iICP) and good ICP (gICP) groups based on a suitable ICP threshold determined with tiered receiver operating characteristic and association analysis. Multivariable logistic regression was performed for various postoperative outcomes. Results An ICP threshold of 7 mmHg was determined, with 36 patients (48.0%) and 39 patients (52.0%) in the iICP and gICP group, respectively. After adjustment, postoperative osmotherapy usage was more likely in the iICP group (OR 6.32, p = 0.003), and when given, was given for a longer median duration (iICP, 4 days; gICP, 1 day, p = 0.003). There was no difference in complications amongst both groups. When an ICP threshold of 11 mmHg was applied, there was significant difference in the duration on ventilator (ICP ≥11 mmHg, 3–9 days, ICP <11 mmHg, 3–5 days, p = 0.023). Conclusion Surgical decompression works complementarily with postoperative medical therapy to manage progressive cerebral edema in malignant cerebral infarctions. This is a retrospective study which showed that closure ICP, a novel objective intraoperative biomarker, is able to guide the adequacy of DC in this condition. Various surgical manoeuvres can be performed to ensure that this surgical aim is accomplished.
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Affiliation(s)
- Jia Xu Lim
- National Neuroscience Institute, Department of Neurosurgery, Singhealth, Singapore, Singapore
- Correspondence: Jia Xu Lim
| | - Sherry Jiani Liu
- National Neuroscience Institute, Department of Neurosurgery, Singhealth, Singapore, Singapore
| | - Tien Meng Cheong
- National Neuroscience Institute, Department of Neurosurgery, Singhealth, Singapore, Singapore
| | - Seyed Ehsan Saffari
- Center for Qualitative Medicine, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Julian Xinguang Han
- National Neuroscience Institute, Department of Neurosurgery, Singhealth, Singapore, Singapore
| | - Min Wei Chen
- National Neuroscience Institute, Department of Neurosurgery, Singhealth, Singapore, Singapore
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Volovici V, Vogels VI, Dammers R, Meling TR. Neurosurgical Evidence and Randomized Trials: The Fragility Index. World Neurosurg 2022; 161:224-229.e14. [DOI: 10.1016/j.wneu.2021.12.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/26/2021] [Indexed: 10/18/2022]
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Decompressive Craniectomy for Stroke: Who, When, and How. Neurol Clin 2022; 40:321-336. [DOI: 10.1016/j.ncl.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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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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Tian J, Zhang L, Di P, Liu H, Zhou Y, Liu L. Continuous Quantitative Electroencephalogram (EEG) Monitoring for Early Detection of Brain Herniation in Large Hemispheric Infarction (LHI): A Case Report. J Stroke Cerebrovasc Dis 2021; 31:106158. [PMID: 34688212 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 09/22/2021] [Accepted: 10/01/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Computer-assisted electroencephalography (EEG) systems may improve the likelihood of detecting abnormal EEGs in adult patients with severe disease. CASE PRESENTATION We implemented long-range EEG monitoring in a patient with large hemispheric infarction (LHI) and explored its real-time changes in reflecting the patient's brain function. The bands of Alpha, Beta, Delta, Theta, DAR (Delta/Alpha), DTABR (Delta+Theta/Alpha+Beta), and brain symmetry index (BSI) were calculated as a ratio of total power. The test results showed that this patient presents a progressive worsening trend and developed brain herniation. The sigh at the electrophysiological level of brain herniation could be seen 6 h in advance based on the quantitative EEG (QEEG) parameters test. We calculated QEEG at both C3 and C4, electrode locations simultaneously, and the results showed that the trend of QEEG at both electrodes was consistent with the global, affected, and unaffected side. CONCLUSIONS QEEG parameters can reflect the trend of LHI patients in real-time and may predict the occurrence of LHI brain herniation. For LHI patients, monitoring with fewer EEG electrodes can be tried to predict the changes in conditions.
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Affiliation(s)
- Jia Tian
- Neurocritical care unit, Department of Neurology, The Second Hospital of Hebei Medical University, 215 Heping West Road, Xinhua District, Shijiazhuang, Hebei 050000, China
| | - Luqing Zhang
- Department of Neurology, Shenze county hospital, Shijiazhuang, Hebei, China
| | - Pan Di
- Department of Neurology, Shenze county hospital, Shijiazhuang, Hebei, China
| | - Hu Liu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yi Zhou
- Neurocritical care unit, Department of Neurology, The Second Hospital of Hebei Medical University, 215 Heping West Road, Xinhua District, Shijiazhuang, Hebei 050000, China
| | - Lidou Liu
- Neurocritical care unit, Department of Neurology, The Second Hospital of Hebei Medical University, 215 Heping West Road, Xinhua District, Shijiazhuang, Hebei 050000, China.
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Garcia-Estrada E, Morales-Gómez JA, Romero-González M, Martínez-Ortíz RG, García-Hernández MA, Ramos-Delgado CA, López-Hernández PA, Palacios-Ortiz IJ, Martínez-Ponce de León AR. Decompressive Craniectomy for Hemispheric Infarction in a Low-Income Population. World Neurosurg 2021; 156:e152-e159. [PMID: 34517142 DOI: 10.1016/j.wneu.2021.09.013] [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: 07/25/2021] [Revised: 09/02/2021] [Accepted: 09/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Stroke is a worldwide leading cause of mortality and disability, and there are substantial economic costs for poststroke care. Disadvantaged populations show increased incidence, severity, and unfavorable outcomes. This study aimed to report the survival, functional outcome, and caregiver satisfaction of low-income patients diagnosed with a large hemispheric infarction (LHI) who underwent decompressive craniectomy (DC). METHODS A retrospective analysis was conducted in consecutive adult patients with an LHI who underwent DC at a single center between October 2015 and September 2019. Demographic, clinical, and radiologic data were reviewed. The primary outcomes were 1-year survival and favorable functional outcome. RESULTS Forty-nine patients were included; those <60 years of age showed a higher proportion of favorable functional outcomes (76% vs. 33%; P = 0.031) but similar survival (52% vs. 56%; P = 0.645) than older patients, respectively. Performing the craniectomy in <48 hours from stroke onset compared with ≥48 hours showed no statistically significant differences in survival (59% vs. 46%; P = 0.352) and favorable functional outcomes (56% vs. 70%; P = 0.683), respectively. In retrospective thinking, 79% of caregivers would decide to perform the surgery again. CONCLUSIONS Age group and time from stroke onset to craniectomy were not associated with survival; notwithstanding, a higher proportion of patients <60 years of age were associated with a favorable functional outcome compared with older patients. Additionally, if given the option, most caregivers would decide to perform the surgery again, independently of the grade of disability of the patient.
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Affiliation(s)
- Everardo Garcia-Estrada
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Jesús Alberto Morales-Gómez
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México.
| | - Mariana Romero-González
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Ricardo Gerardo Martínez-Ortíz
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Marco Antonio García-Hernández
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - César Alessandro Ramos-Delgado
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Paúl André López-Hernández
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Isaac Jair Palacios-Ortiz
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Angel Raymundo Martínez-Ponce de León
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
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Dower A, Mulcahy M, Maharaj M, Chen H, Lim CED, Sheridan M. Surgical decompression for malignant cerebral oedema after ischaemic stroke. Hippokratia 2021. [DOI: 10.1002/14651858.cd014989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Michael Mulcahy
- Department of Neurosurgery; John Hunter Hospital; Newcastle Australia
| | - Monish Maharaj
- Department of Neurosurgery; Waikato Hospital; Hamilton New Zealand
| | - Hui Chen
- School of Life Sciences; University of Technology Sydney; Sydney Australia
| | | | - Mark Sheridan
- Department of Neurosurgery; Liverpool Hospital, University of New South Wales; Sydney Australia
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van der Worp HB, Hofmeijer J, Jüttler E, Lal A, Michel P, Santalucia P, Schönenberger S, Steiner T, Thomalla G. European Stroke Organisation (ESO) guidelines on the management of space-occupying brain infarction. Eur Stroke J 2021; 6:XC-CX. [PMID: 34414308 PMCID: PMC8370072 DOI: 10.1177/23969873211014112] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/13/2021] [Indexed: 01/29/2023] Open
Abstract
Space-occupying brain oedema is a potentially life-threatening complication in the first days after large hemispheric or cerebellar infarction. Several treatment strategies for this complication are available, but the size and quality of the scientific evidence on which these strategies are based vary considerably. The aim of this Guideline document is to assist physicians in their management decisions when treating patients with space-occupying hemispheric or cerebellar infarction. These Guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. A working group identified 13 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence-based recommendations. An expert consensus statement was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high-quality evidence to recommend surgical decompression to reduce the risk of death and to increase the chance of a favourable outcome in adult patients aged up to and including 60 years with space-occupying hemispheric infarction who can be treated within 48 hours of stroke onset, and low-quality evidence to support this treatment in older patients. There is continued uncertainty about the benefit and risks of surgical decompression in patients with space-occupying hemispheric infarction if this is done after the first 48 hours. There is also continued uncertainty about the selection of patients with space-occupying cerebellar infarction for surgical decompression or drainage of cerebrospinal fluid. These Guidelines further provide details on the management of specific subgroups of patients with space-occupying hemispheric infarction, on the value of monitoring of intracranial pressure, and on the benefits and risks of medical treatment options. We encourage new high-quality studies assessing the risks and benefits of different treatment strategies for patients with space-occupying brain infarction.
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Affiliation(s)
- H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
- Department of Clinical Neurophysiology, University of Twente, Enschede, the Netherlands
| | - Eric Jüttler
- Department of Neurology, Kliniken Ostalb, Aalen, Germany
| | - Avtar Lal
- European Stroke Organisation, Basel, Switzerland
| | - Patrik Michel
- Centre Cérébrovasculaire, Service de Neurologie, Département des Neurosciences Cliniques CHUV, Lausanne, Switzerland
| | - Paola Santalucia
- Neurology-Stroke Unit, San Giuseppe Hospital-Multimedica, Milan, Italy
| | | | - Thorsten Steiner
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Götz Thomalla
- Department of Neurology, Center for Clinical Neurosciences, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Hong JH, Jeon I, Seo Y, Kim SH, Yu D. Radiographic predictors of clinical outcome in traumatic brain injury after decompressive craniectomy. Acta Neurochir (Wien) 2021; 163:1371-1381. [PMID: 33404876 DOI: 10.1007/s00701-020-04679-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/11/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Primary decompressive craniectomy (DC) is considered for traumatic brain injury (TBI) patients with clinical deterioration, presenting large amounts of high-density lesions on computed tomography (CT). Postoperative CT findings may be suitable for prognostic evaluation. This study evaluated the radiographic predictors of clinical outcome and survival using pre- and postoperative CT scans of such patients. METHODS We enrolled 150 patients with moderate to severe TBI who underwent primary DC. They were divided into two groups based on the 6-month postoperative Glasgow Outcome Scale Extended scores (1-4, unfavorable; 5-8, favorable). Radiographic parameters, including hemorrhage type, location, presence of skull fracture, midline shifting, hemispheric diameter, effacement of cisterns, parenchymal hypodensity, and craniectomy size, were reviewed. Stepwise logistic regression analysis was used to identify the prognostic factors of clinical outcome and 6-month mortality. RESULTS Multivariable logistic regression analysis revealed that age (odds ratio [OR] = 1.09; 95% confidence interval [CI] 1.032-1.151; p = 0.002), postoperative low density (OR = 12.58; 95% CI 1.247-126.829; p = 0.032), and postoperative effacement of the ambient cistern (OR = 14.52; 95% CI 2.234-94.351; p = 0.005) and the crural cistern (OR = 4.90; 95% CI 1.359-17.678; p = 0.015) were associated with unfavorable outcomes. Postoperative effacement of the crural cistern was the strongest predictor of 6-month mortality (OR = 8.93; 95% CI 2.747-29.054; p = 0.000). CONCLUSIONS Hemispheric hypodensity and effacement of the crural and ambient cisterns on postoperative CT after primary DC seems to associate with poor outcome in patients with TBI.
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Affiliation(s)
- Jung Ho Hong
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170, Hyeonchung street, Nam-Gu, Daegu, 42415, South Korea
| | - Ikchan Jeon
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170, Hyeonchung street, Nam-Gu, Daegu, 42415, South Korea
| | - Youngbeom Seo
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170, Hyeonchung street, Nam-Gu, Daegu, 42415, South Korea
| | - Seong Ho Kim
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170, Hyeonchung street, Nam-Gu, Daegu, 42415, South Korea
| | - Dongwoo Yu
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170, Hyeonchung street, Nam-Gu, Daegu, 42415, South Korea.
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Abstract
Large hemispheric infarcts occur in up to 10% of all ischemic strokes and can cause devastating disability. Significant research and clinical efforts have been made in hopes of mitigating the morbidity and mortality of this disease. Areas of interest include identifying predictors of malignant edema, optimizing medical and surgical techniques, selecting the patient population that would benefit most from decompressive hemicraniectomy, and studying the impact on quality of life of those who survive. Decompressive surgery can be a life-saving measure, and here we discuss the most up-to-date literature and provide a review on the surgical management of large hemispheric ischemic strokes.
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Affiliation(s)
- Jessica Lin
- Division of Neurocritical Care, Department of Neurology, New York University Langone Health (J.L., J.A.F.), New York, NY.,Department of Neurology, Bellevue Hospital Center (J.L.), New York, NY
| | - Jennifer A Frontera
- Division of Neurocritical Care, Department of Neurology, New York University Langone Health (J.L., J.A.F.), New York, NY
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31
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Fan L, Su Y, Zhang Y, Ye H, Chen W, Liu G. Decompressive craniectomy combined with mild hypothermia in patients with large hemispheric infarction: a randomized controlled trial. BMC Neurol 2021; 21:114. [PMID: 33711963 PMCID: PMC7953537 DOI: 10.1186/s12883-021-02142-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 03/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background The effect of hypothermia on large hemispheric infarction (LHI) remains controversial. Our study aimed to explore the therapeutic outcomes of decompressive craniectomy (DC) combined with hypothermia on LHI. Methods Patients were randomly divided into three groups: the DC group, the DC plus head surface cooling (DCSC) group and the DC plus endovascular hypothermia (DCEH) group. The DC group was maintained normothermia. The DCSC group received 24-h ice cap on the head for 7 days. While the DCEH group were given endovascular hypothermia (34 °C). Mortality and modified Rankin Scale (mRS) score at 6 months were evaluated. Results Thirty-four patients were included in the study. Mortality of the DC, DCSC and DCEH groups at discharge were 22.2% (2/9), 0% (0/14) and 9.1% (1/11), respectively. However, it increased to 44.4% (4/9), 21.4% (3/14) and 45.5% (5/11) at 6 months, respectively (p = 0.367). Pneumonia (8 cases) was the leading cause of death after discharge. Twelve cases (35.3%) achieved good neurological outcome (mRS 0–3) at 6 months. The proportions of good neurological outcome in the DC, DCSC and DCEH groups were 22.2% (2/9 cases), 42.9% (6/14 cases) and 36.4% (4/11), respectively. The DCSC group seemed to have higher proportion of good outcomes, but there was no significant difference between groups (p = 0.598). Among survivors, endovascular hypothermia had a higher proportion of good outcome (DC group, 2/5 cases, 40.0%; DCSC group, 6/11 cases, 54.5%; DCEH group, 4/6 cases, 66.7%; p = 0.696). The incidence of complications in the DCEH group was higher than those of the DC and DCSC groups (18.9%, 12.0%, and 12.1%, respectively; p = 0.025). Conclusions There is still no evidence to confirm that hypothermia further reduces long-term mortality and improves neurological outcomes in LHI patients with DC. However, there is a trend to benefit survivors from hypothermia. A local cooling method may be a better option for DC patients, which has little impact on systematic complications. Trial registration Decompressive Hemicraniectomy Combined Hypothermia in Malignant Middle Cerebral Artery Infarct, ChiCTR-TRC-12002698. Registered 11 Oct 2012- Retrospectively registered, URL: http://www.chictr.org.cn/showproj.aspx?proj=6854.
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Affiliation(s)
- Linlin Fan
- Department of Neurology, Xuanwu Hospital Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Yingying Su
- Department of Neurology, Xuanwu Hospital Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China.
| | - Yan Zhang
- Department of Neurology, Xuanwu Hospital Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Hong Ye
- Department of Neurology, Xuanwu Hospital Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Weibi Chen
- Department of Neurology, Xuanwu Hospital Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Gang Liu
- Department of Neurology, Xuanwu Hospital Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
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32
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Moody K, Santos D, Stein LK, Dhamoon MS. Decompressive Hemicraniectomy for Acute Ischemic Stroke in the US: Characteristics and Outcomes. J Stroke Cerebrovasc Dis 2021; 30:105703. [PMID: 33706194 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105703] [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: 12/11/2020] [Revised: 02/04/2021] [Accepted: 02/18/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVES Decompressive hemicraniectomy can be life-saving for malignant middle cerebral artery acute ischemic stroke (AIS). However, utilization and outcomes for hemicraniectomy in the US are not known. We sought to analyze baseline characteristics and outcomes of patients receiving hemicraniectomy for AIS in the US. MATERIALS AND METHODS We identified adults who received hemicraniectomy for AIS, identified with validated International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9) code in the Nationwide Readmissions Database 2014. We calculated 30-day readmission rates, reasons for readmission, and procedures performed. RESULTS 2850 of 531,896 AIS patients (0.54%) received hemicraniectomy. Although patients receiving hemicraniectomy were more likely to be younger (57.0, 95% CI 56.0-58.0; vs 70.9, 95% CI 70.6-71.2; p < 0.0001) and male (40% vs 51.2% female; p<0.0001), 46.3% of patients who received hemicraniectomy were age 60 years and older. Patients 60 years or older receiving hemicraniectomy were more likely to die (29.9% vs 21.9%, p = 0.0081). Hemicraniectomy was more frequently performed at large hospitals (75.3% vs 57.7%; p < 0.0001) in urban areas (99.1% vs 90.3%; p < 0.0001) designated as metropolitan teaching hospitals (88.3% vs 63.4%; p < 0.0001). 30-day readmissions were most commonly due to infection (31.5%), non-infectious medical complications (17.7%), and surgical complications (13.8%). These readmissions were critical. CONCLUSIONS Although hemicraniectomy is used more frequently in the treatment of younger, male, ischemic stroke patients, only half of the patients receiving hemicraniectomy in 2014 were <60 years old. Regardless of age, hemicraniectomy is a geographically segregated procedure, only being performed in large metropolitan teaching hospitals.
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Affiliation(s)
- Kate Moody
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Daniel Santos
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Laura K Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Reinink H, Jüttler E, Hacke W, Hofmeijer J, Vicaut E, Vahedi K, Slezins J, Su Y, Fan L, Kumral E, Greving JP, Algra A, Kappelle LJ, van der Worp HB, Neugebauer H. Surgical Decompression for Space-Occupying Hemispheric Infarction: A Systematic Review and Individual Patient Meta-analysis of Randomized Clinical Trials. JAMA Neurol 2021; 78:208-216. [PMID: 33044488 DOI: 10.1001/jamaneurol.2020.3745] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Importance In patients with space-occupying hemispheric infarction, surgical decompression reduces the risk of death and increases the chance of a favorable outcome. Uncertainties, however, still remain about the benefit of this treatment for specific patient groups. Objective To assess whether surgical decompression for space-occupying hemispheric infarction is associated with a reduced risk of death and an increased chance of favorable outcomes, as well as whether this association is modified by patient characteristics. Data Sources MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Stroke Trials Registry were searched from database inception to October 9, 2019, for English-language articles that reported on the results of randomized clinical trials of surgical decompression vs conservative treatment in patients with space-occupying hemispheric infarction. Study Selection Published and unpublished randomized clinical trials comparing surgical decompression with medical treatment alone were selected. Data Extraction and Synthesis Patient-level data were extracted from the trial databases according to a predefined protocol and statistical analysis plan. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and the Cochrane Collaboration's tool for assessing risk of bias were used. One-stage, mixed-effect logistic regression modeling was used for all analyses. Main Outcomes and Measures The primary outcome was a favorable outcome (modified Rankin Scale [mRS] score ≤3) at 1 year after stroke. Secondary outcomes included death, reasonable (mRS score ≤4) and excellent (mRS score ≤2) outcomes at 6 months and 1 year, and an ordinal shift analysis across all levels of the mRS. Variables for subgroup analyses were age, sex, presence of aphasia, stroke severity, time to randomization, and involved vascular territories. Results Data from 488 patients from 7 trials from 6 countries were available for analysis. The risk of bias was considered low to moderate for 6 studies. Surgical decompression was associated with a decreased chance of death (adjusted odds ratio, 0.16; 95% CI, 0.10-0.24) and increased chance of a favorable outcome (adjusted odds ratio, 2.95; 95% CI, 1.55-5.60), without evidence of heterogeneity of treatment effect across any of the prespecified subgroups. Too few patients were treated later than 48 hours after stroke onset to allow reliable conclusions in this subgroup, and the reported proportions of elderly patients reaching a favorable outcome differed considerably among studies. Conclusions and Relevance The results suggest that the benefit of surgical decompression for space-occupying hemispheric infarction is consistent across a wide range of patients. The benefit of surgery after day 2 and in elderly patients remains uncertain.
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Affiliation(s)
- Hendrik Reinink
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - Eric Jüttler
- Department of Neurology, University Hospital Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Werner Hacke
- Department of Neurology, University Hospital Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate, Arnhem, the Netherlands.,Faculty of Science and Technology, University of Twente, Enschede, the Netherlands
| | - Eric Vicaut
- Unité de Recherche Clinique, Assistance Publique-Hôpitaux de Paris, Lariboisière Hospital, Paris, France
| | - Katayoun Vahedi
- Department of Neurology, Assistance Publique-Hôpitaux de Paris, Lariboisière Hospital, Paris, France.,Neurology Centre, Ramsay-Générale de Sante, Hôpital Privé d'Antony, Antony, Paris, France
| | - Janis Slezins
- Neurosurgery Clinic, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Yingying Su
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Linlin Fan
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Emre Kumral
- Neurology Department, Medical School Hospital, Ege University, İzmir, Turkey
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center, Utrecht University, Utrecht, the Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center, Utrecht University, Utrecht, the Netherlands
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Jo K, Joo WI, Yoo DS, Park HK. Clinical Significance of Decompressive Craniectomy Surface Area and Side. J Korean Neurosurg Soc 2020; 64:261-270. [PMID: 33280352 PMCID: PMC7969045 DOI: 10.3340/jkns.2020.0149] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/02/2020] [Indexed: 11/27/2022] Open
Abstract
Objective Decompressive craniectomy (DC) can partially remove the unyielding skull vault and make affordable space for the expansion of swelling brain contents. The objective of this study was to compare clinical outcome according to DC surface area (DC area) and side.
Methods A total of 324 patients underwent different surgical methods (unilateral DC, 212 cases and bilateral DC, 112 cases) were included in this retrospective analysis. Their mean age was 53.4±16.6 years (median, 54 years). Neurological outcome (Glasgow outcome scale), ventricular intracranial pressure (ICP), and midline shift change (preoperative minus postoperative) were compared according to surgical methods and total DC area, DC surface removal rate (DC%) and side.
Results DC surgery was effective for ICP decrease (32.3±16.7 mmHg vs. 19.2±13.4 mmHg, p<0.001) and midline shift change (12.5±7.6 mm vs. 7.8±6.9 mm, p<0.001). The bilateral DC group showed larger total DC area (125.1±27.8 cm2 for unilateral vs. 198.2±43.0 cm2 for bilateral, p<0.001). Clinical outcomes were nonsignificant according to surgical side (favorable outcome, p=0.173 and mortality, p=0.470), significantly better when total DC area was over 160 cm2 and DC% was 46% (p=0.020 and p=0.037, respectively).
Conclusion DC surgery is effective in decrease the elevated ICP, decrease the midline shift and improve the clinical outcome in massive brain swelling patient. Total DC area and removal rate was larger in bilateral DC than unilateral DC but clinical outcome was not influenced by DC side. DC area more than 160 cm2 and DC surface removal rate more than 46% were more important than DC side.
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Affiliation(s)
- KwangWook Jo
- Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won Il Joo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do Sung Yoo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hae-Kwan Park
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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35
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Mrosk F, Hecht N, Vajkoczy P. Decompressive hemicraniectomy in ischemic stroke. J Neurosurg Sci 2020; 65:249-258. [PMID: 33252206 DOI: 10.23736/s0390-5616.20.05103-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Malignant hemispheric stroke (MHS) is a life-threatening event, associated with high morbidity and mortality. Decompressive hemicraniectomy (DHS) is the treatment of choice to relieve the emerging space-occupying brain edema. This review details the pathophysiological and scientific background, considerations for clinical decision making, surgical treatment and impact on the patients' outcome. Although surgery reduces mortality significantly, the probability for unfavorable outcome is still high in selected cases. While former randomized controlled studies aimed for the prevention of the primary cause, the current research focuses on the treatment and prevention of secondary neurological injury.
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Affiliation(s)
- Friedrich Mrosk
- Department of Neurosurgery, Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany -
| | - Peter Vajkoczy
- Department of Neurosurgery, Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
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36
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Comparison of equiosmolar doses of 10% hypertonic saline and 20% mannitol for controlling intracranial hypertention in patients with large hemispheric infarction. Clin Neurol Neurosurg 2020; 200:106359. [PMID: 33246252 DOI: 10.1016/j.clineuro.2020.106359] [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: 10/24/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We conducted this prospective self-crossover controlled trial to compare the efficacy and safety of 10 % hypertonic saline (HS) and 20 % mannitol in doses of similar osmotic burden for the treatment of increased intracranial pressure (ICP) in patients with large hemispheric infarction (LHI). PATIENTS AND METHODS Patients with LHI were enrolled from January 2017 to January 2018. We used an alternating treatment protocol to compare the effects of HS with mannitol given for episodes of increased ICP in patients with LHI. Indicators such as ICP, mean arterial pressure (MAP) and cerebral perfusion pressure (CPP) were continuously monitored at regular intervals for 240 min after initiation of infusion. Electrolytes, plasma osmolality and renal functions were measured before and 240 min after initiation of infusion to compare the efficacy and safety of the two drugs. RESULTS A total of 49 episodes of increased ICP occurred in 14 patients with LHI, of which 24 were infused with 10 % HS and 25 with 20 % mannitol. Both the treatments were equally effective in reducing ICP (P < 0.01). The differences in the duration and degree of reduction were not significant between the groups (P > 0.05). Although both the osmolar agents decreased MAP, the degree was greater in the mannitol group (P < 0.05) at T120. The increase in CPP was greater in the HS group compared with the mannitol group (P < 0.05) at T120. However, HS was associated with faster heart rate (HR) and higher serum chloride levels (P < 0.05). Changes in serum sodium levels and osmolality were not significant between the groups in spite of being higher in the HS group. CONCLUSIONS Both the drugs can serve as first-line agents for treating intracranial hypertension caused by LHI and should be selected rationally according to the differences in efficacy and adverse effects.
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Li J, Gu Y, Li G, Wang L, Cheng X, Wang M, Zhao M. The Role of Hypothermia in Large Hemispheric Infarction: A Systematic Review and Meta-Analysis. Front Neurol 2020; 11:549872. [PMID: 33192981 PMCID: PMC7653189 DOI: 10.3389/fneur.2020.549872] [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: 04/07/2020] [Accepted: 09/18/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Hypothermia is used in the treatment of large hemispheric infarction (LHI); however, its role in outcomes for LHI patients remains ambiguous. This systematic review and meta-analysis was conducted to evaluate the effect of hypothermia on the outcomes of LHI patients. Methods: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, China Biological Medicine Database, and clinical trials registers before September 21, 2018, and then scanned the reference lists. Randomized controlled trials that compared hypothermia with normothermia in LHI patients were included. Primary outcomes that we reviewed were mortality and neurological outcome. Adverse events during treatment were defined as secondary outcomes. We performed a meta-analysis to calculate pooled risk ratios (RRs), standardized mean differences (SMDs), and 95% confidence intervals (CIs) using fixed-effect models. Results: Three randomized controlled trials involving 131 participants were included. No statistically significant association was revealed between hypothermia and mortality (RR, 1.12; 95% CI, 0.76-1.65). There was significant association between hypothermia and good neurological outcome as assessed by modified Rankin Scale score (mRS of 0-3) of survivors (RR, 2.09; 95% CI, 1.14-3.82), and with neurological outcome by mRS (SMD, -0.54; 95% CI, -1.07 to -0.01). However, significant associations were found between hypothermia and gastrointestinal bleeding, gastric retention, electrolyte derangement, and shivering. No significant differences were detected in the incidence of developing herniation in the rewarming process, pneumonia, cardiac arrhythmia, hemorrhagic transformation, hyperglycemia, hypotension, acute kidney injury, and venous thrombotic events in LHI patients who underwent hypothermia compared with those who had normothermia. Conclusions: This meta-analysis suggested that hypothermia was not associated with mortality in LHI patients. However, it was associated with the improvement of neurological outcome, but with a higher risk of adverse events during treatment. Future studies are needed to demonstrate the efficacy and safety of hypothermia for LHI. The protocol for this systematic review was obtained from PROSPERO (registration number: CRD42018111761).
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Affiliation(s)
- Jing Li
- Department of Intensive Care Unit, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Yanghui Gu
- Department of Cardiology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Gang Li
- Department of Intensive Care Unit, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Lixin Wang
- Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaobin Cheng
- Department of Intensive Care Unit, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Min Wang
- Department of Intensive Care Unit, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Min Zhao
- Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Parish JM, Asher AM, Pfortmiller D, Smith MD, Clemente JD, Stetler WR, Bernard JD. Outcomes After Decompressive Craniectomy for Ischemic Stroke: A Volumetric Analysis. World Neurosurg 2020; 145:e267-e273. [PMID: 33065347 DOI: 10.1016/j.wneu.2020.10.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Decompressive hemicraniectomy (DHC) is a treatment of space-occupying hemispheric infarct. Current surgical guidelines use criteria of age <60 years and surgery within 48 hours of stroke onset. OBJECTIVE The purpose of this study was to evaluate the neurologic outcome after DHC and evaluate the relationship of stroke volume and outcomes. METHODS A retrospective review was performed of patients undergoing DHC for cerebral infarct from 2016 to 2019. Unfavorable outcome was defined as modified Rankin Scale (mRS) score >3. Patients with precraniectomy magnetic resonance imaging were selected as a subset for volumetric stroke volume analysis using RAPID software (iSchemaView, Redwood City, California), with stroke volume defined as apparent diffusion coefficient <620 on diffusion-weighted imaging. RESULTS Fifty-two patients met the inclusion criteria. At 90 days, favorable outcome was achieved in 11 patients (21.2%), and 41 patients (78.8%) had unfavorable outcomes (15 [29%] died). Surgery after 48 hours, age >60 years, and multivessel distribution did not significantly affect 90-day mRS score (P = 0.091, 0.111, and 0.664, respectively). In volumetric subset analysis, 10 patients of 41 (31.3%) achieved favorable outcomes, and no patients with volume of infarct >280 mL had a favorable outcome. There was a trend of lower volumes associated with favorable outcomes, but this did not meet significance (favorable 207 ± 68.7 vs. unfavorable 262 ± 117.1; P = 0.163). CONCLUSIONS Outcomes after DHC for malignant hemispheric infarct were not affected by current accepted guidelines. Volume of infarct may have an effect on outcome after DHC. Further research to aid in predicting which patients benefit from decompressive craniectomy is warranted.
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Affiliation(s)
- Jonathan M Parish
- Department of Neurological Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA.
| | - Anthony M Asher
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | | | - Mark D Smith
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
| | | | - William R Stetler
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
| | - Joe D Bernard
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
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Goedemans T, Verbaan D, Coert BA, Kerklaan B, van den Berg R, Coutinho JM, van Middelaar T, Nederkoorn PJ, Vandertop WP, van den Munckhof P. Outcome After Decompressive Craniectomy for Middle Cerebral Artery Infarction: Timing of the Intervention. Neurosurgery 2020; 86:E318-E325. [PMID: 31943069 PMCID: PMC7061200 DOI: 10.1093/neuros/nyz522] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 09/29/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Based on randomized controlled trials (RCTs), clinical guidelines for the treatment of space-occupying hemispheric infarct employ age (≤60 yr) and time elapsed since stroke onset (≤48 h) as decisive criteria whether to perform decompressive craniectomy (DC). However, only few patients in these RCTs underwent DC after 48 h. OBJECTIVE To study the association between the timing of DC and (un)favorable outcome in patients with space-occupying middle cerebral artery (MCA) infarct undergoing DC. METHODS We performed a single-center cohort study from 2007 to 2017. Unfavorable outcome at 1 yr was defined as a Glasgow outcome scale 1 to 3. Additionally, we systematically reviewed the literature up to November 2018, including studies reporting on the timing of DC and other predictors of outcome. We performed Firth penalized likelihood and random-effects meta-analysis with odds ratio (OR) on unfavorable outcome. RESULTS A total of 66 patients were enrolled. A total of 26 (39%) patients achieved favorable and 40 (61%) unfavorable outcomes (13 [20%] died). DC after 48 h since stroke diagnosis did not significantly increase the risk of unfavorable outcome (OR 0.8, 95% CI 0.3-2.3). Also, in the meta-analysis, DC after 48 h of stroke onset was not associated with a higher risk of unfavorable outcome (OR 1.11; 95% CI 0.89-1.38). CONCLUSION The outcome of DC performed after 48 h in patients with malignant MCA infarct was not worse than the outcome of DC performed within 48 h. Contrary to current guidelines, we, therefore, advocate not to set a restriction of ≤48 h on the time elapsed since stroke onset in the decision whether to perform DC.
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Affiliation(s)
- Taco Goedemans
- Neurosurgical Centre Amsterdam, Amsterdam Medical Centre, Amsterdam University Medical Centres (UMC), University of Amsterdam, Amsterdam, the Netherlands
| | - Dagmar Verbaan
- Neurosurgical Centre Amsterdam, Amsterdam Medical Centre, Amsterdam University Medical Centres (UMC), University of Amsterdam, Amsterdam, the Netherlands
| | - Bert A Coert
- Neurosurgical Centre Amsterdam, Amsterdam Medical Centre, Amsterdam University Medical Centres (UMC), University of Amsterdam, Amsterdam, the Netherlands
| | - Bertjan Kerklaan
- Department of Neurology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, and Zaans Medical Centre (ZMC), Zaandam, the Netherlands
| | - René van den Berg
- Department of Radiology, Amsterdam Medical Centre, Amsterdam UMC, Amsterdam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam Medical Centre, Amsterdam UMC, Amsterdam, the Netherlands
| | - Tessa van Middelaar
- Department of Neurology, Amsterdam Medical Centre, Amsterdam UMC, Amsterdam, the Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam Medical Centre, Amsterdam UMC, Amsterdam, the Netherlands
| | - W Peter Vandertop
- Neurosurgical Centre Amsterdam, Amsterdam Medical Centre, Amsterdam University Medical Centres (UMC), University of Amsterdam, Amsterdam, the Netherlands
| | - Pepijn van den Munckhof
- Neurosurgical Centre Amsterdam, Amsterdam Medical Centre, Amsterdam University Medical Centres (UMC), University of Amsterdam, Amsterdam, the Netherlands
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Adeeb N, Terrell DL, Whipple SG, Thakur JD, Griessenauer CJ, Adeeb A, Aslan A, Mamilly A, Mortazavi MM, Dossani RH, Guthikonda B, Ogilvy CS, Thomas AJ, Moore JM. The Reproducibility of Cerebrovascular Randomized Controlled Trials. World Neurosurg 2020; 140:e46-e52. [PMID: 32437984 DOI: 10.1016/j.wneu.2020.04.106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/12/2020] [Accepted: 04/13/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Numerous randomized controlled trials (RCTs) relevant to the cerebrovascular field have been performed. The fragility index was recently developed to complement the P value and measure the robustness and reproducibility of clinical findings of RCTs. OBJECTIVE In this study, we evaluate the fragility index for key surgical and endovascular cerebrovascular RCTs and propose a novel RCT classification system based on the fragility index. METHODS Cerebrovascular RCTs reported between 2000 and 2018 were reviewed. Six key areas were specifically targeted in relation to stroke, carotid stenosis, cerebral aneurysms, and subarachnoid hemorrhage. The correlation between fragility index, number of patients lost to follow-up, and fragility quotient were evaluated to propose a classification system for the robustness of the studies. RESULTS A total of 20 RCTs that reported significant differences between both study groups in terms of the primary outcome were included. The median fragility index for the trials was 5.5. An additional 30 randomly selected RCTs were added to propose a classification system with high reliability. The difference between the number of patients lost to follow-up and fragility index inversely correlated with the fragility quotient and was used to divide the robustness of the RCTs into 3 classes reflecting the reproducibility of the trial. CONCLUSIONS Neurosurgeons and neurointerventionalists should exercise caution with interpreting the results of cerebrovascular RCTs, especially when the sample size and events numbers are small and there is a high number of patients who were lost to follow-up, as quantitatively identified using the proposed classification system.
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Affiliation(s)
- Nimer Adeeb
- Department of Neurosurgery, Ochsner LSU Medical Center, Louisiana State University, Shreveport, Louisiana, USA.
| | - Danielle L Terrell
- Department of Neurosurgery, Ochsner LSU Medical Center, Louisiana State University, Shreveport, Louisiana, USA
| | - Stephen Garrett Whipple
- Department of Neurosurgery, Ochsner LSU Medical Center, Louisiana State University, Shreveport, Louisiana, USA
| | - Jai Deep Thakur
- Department of Neurosurgery, Ochsner LSU Medical Center, Louisiana State University, Shreveport, Louisiana, USA
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania, USA; Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Abdallah Adeeb
- School of Medicine, An-Najah University, Nablus, Palestine
| | - Asala Aslan
- School of Medicine, An-Najah University, Nablus, Palestine
| | - Ahmed Mamilly
- Department of Radiology, Ochsner LSU Medical Center, Louisiana State University, Shreveport, Louisiana, USA
| | | | - Rimal H Dossani
- Department of Neurosurgery, Ochsner LSU Medical Center, Louisiana State University, Shreveport, Louisiana, USA
| | - Bharat Guthikonda
- Department of Neurosurgery, Ochsner LSU Medical Center, Louisiana State University, Shreveport, Louisiana, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Cui LL, Zhang Y, Chen ZY, Su YY, Liu Y, Boltze J. Early neutrophil count relates to infarct size and fatal outcome after large hemispheric infarction. CNS Neurosci Ther 2020; 26:829-836. [PMID: 32374521 PMCID: PMC7366744 DOI: 10.1111/cns.13381] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 02/02/2023] Open
Abstract
AIMS To investigate the relationship between peripheral leukocyte dynamics and the outcome of large hemispheric infarction (LHI) patients. METHODS Patients with acute LHI admitted to the neuro-intensive care unit of Xuanwu Hospital from 2013 to 2017 were prospectively enrolled and followed up for 6 months after LHI. RESULTS A total of 84 LHI patients were included, 38 patients suffered brain herniation and 20 patients died from stroke. Compared to patients with benign course, LHI patients with fatal outcome showed larger infarcts and more severe brain edema (P < .01), as well as increased WBC and neutrophil counts throughout the first week after stroke (P < .05). Correlation analysis revealed that neutrophil counts on D2 after LHI positively correlated with infarct and edema volumes measured from CT/MRI (R2 = 0.22 and R2 = 0.15, P < .01) and negatively correlated with Glasgow Coma Scale (ρ = -0.234, P < .05). Patients with D2 neutrophils > 7.14 × 109 /L had higher risk of brain herniation [odds ratio (OR) = 7.5, 95% CI: 2.0-28.1, P = .001], and patients with D2 neutrophils > 7.79 × 109 /L had a higher risk of death (OR = 5.8, 95% CI: 1.2-27.0, P = .015). CONCLUSION Early peripheral neutrophil count after stroke relates to infarct size and the fatal outcome of LHI patients, which might help guiding acute LHI management such as reduction of intracranial pressure and potential antiinflammatory therapy in the future.
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Affiliation(s)
- Li-Li Cui
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhong-Yun Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ying-Ying Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yawu Liu
- Department of Neurology and Clinical Radiology, University of Eastern Finland, Kuopio, Finland
| | - Johannes Boltze
- School of Life Sciences, University of Warwick, Coventry, UK
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Wei H, Jia FM, Yin HX, Guo ZL. Decompressive hemicraniectomy versus medical treatment of malignant middle cerebral artery infarction: a systematic review and meta-analysis. Biosci Rep 2020; 40:BSR20191448. [PMID: 31854446 PMCID: PMC6944664 DOI: 10.1042/bsr20191448] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 11/23/2019] [Accepted: 12/18/2019] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES To estimate evidence for decompressive hemicraniectomy (DHC) versus medical treatment effects on survival rate and favorable functional recovery among patients of malignant middle cerebral artery infarction (MMCAI) in randomized controlled trials (RCTs). DESIGN The present study is a systematic review and meta-analysis of RCTs. SETTING The MEDLINE/PubMed, EMBASE, Springer, Cochrane Collaboration database, China National Knowledge Infrastructure (CNKI) database, and Wanfang database were comprehensively searched for RCTs regarding the effects of DHC versus medical treatment among patients of MMCAI in these English and Chinese electronic databases from inception to 1 June 2019. Two reviewers independently retrieved RCTs and extracted relevant information. The methodological quality of the included trials was estimated using the Cochrane risk of bias tool. Review Manager5.3.5 software was used for statistical analyses. The statistical power of meta-analysis was estimated by Power and Precision, version 4 software. PARTICIPANTS Nine RCTs with a total of 425 patients with MMCAI, containing 210 cases in the DHC group and 215 cases in the medical treatment group, met the inclusion criteria were included. Primary outcomes were measured by survival rate, defined as modified Rankin scale (mRS) score 0-5 and favorable functional recovery as mRS score 0-3. The follow-up time of all studies was at 6-12months. RESULTS First, compared with the medical treatment group, DHC was associated with a statistically significant increase survival rate (RR: 1.96, 95%CI 1.61-2.38, P < 0.00001) and favorable functional recovery (RR: 1.62, 95%CI 1.11-2.37, P = 0.01). Second, subgroup analysis: (1) Compared with the medical treatment group among patients age ≤60 years, DHC was associated with a statistically significant increase survival rate (RR = 2.20, 95%CI 1.60-3.04, P < 0.00001); (2) Compared with the medical treatment group among patients of age >60 years, DHC was also associated with a statistically significant increase survival rate (RR: 1.93, 95%CI 1.45-2.59, P < 0.00001); (3) Compared with the medical treatment group, the time of DHC was preformed within 48 h from the onset of stroke that could statistically significant increase survival rate (RR: 2.16, 95%CI 1.69-2.75, P < 0.00001). Third, sensitivity analyses that measured the results were consistent, indicating that the results were stable. Fourth, the results of statistical power analysis were ≥80%. Finally, the funnel plot of the survival rate included nine RCTs showed no remarkable publication bias. CONCLUSIONS Our study results indicated that DHC could increase survival rate and favorable functional recovery among patients age ≤60 or >60 years. The optimal time for DHC might be no more than 48 h from the onset of symptoms. However, due to the limitations of this research, it is necessary to design high quality, large-scale RCTs to further evaluate these findings.
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Affiliation(s)
- Heng Wei
- Department of Neurology, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Hubei University of Chinese Medicine, Wuhan 430000, China
| | - Fu-Min Jia
- Department of Neurology, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Hubei University of Chinese Medicine, Wuhan 430000, China
| | - Hong-Xiang Yin
- Department of Neurology, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Hubei University of Chinese Medicine, Wuhan 430000, China
| | - Zhen-Li Guo
- Department of Neurology, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Hubei University of Chinese Medicine, Wuhan 430000, China
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Schwake M, Schipmann S, Müther M, Stögbauer L, Hanning U, Sporns PB, Ewelt C, Dziewas R, Minnerup J, Holling M, Stummer W. Second-look strokectomy of cerebral infarction areas in patients with severe herniation. J Neurosurg 2020; 132:1-9. [PMID: 30611135 DOI: 10.3171/2018.8.jns18692] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/14/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Decompressive craniectomies (DCs) are performed on patients suffering large cerebral infarctions. The efficacy of this procedure has been demonstrated in several trials. In some cases, however, this procedure alone is not sufficient and patients still suffer refractory elevations of intracranial pressure (ICP). The goal of this study was to determine whether resection of infarcted tissue, termed strokectomy, performed as a second-look procedure after DC, improves outcome in selected cases. METHODS The authors retrospectively evaluated data of patients who underwent a DC due to a cerebral infarction at their institution from 2009 to 2016, including patients who underwent a strokectomy procedure after DC. Clinical records, imaging data, outcome scores, and neurological symptoms were analyzed, and clinical outcomes and mortality rates in the strokectomy group were compared to those for similar patients in recently published randomized controlled trials. RESULTS Of 198 patients who underwent DC due to cerebral infarction, 12 patients underwent strokectomy as a second surgical procedure, with a median National Institutes of Health Stroke Scale (NIHSS) score of 19 for patients with versus 16 for those without secondary strokectomy (p = 0.029). Either refractory increases of ICP > 20 mm Hg or dilated pupils in addition to herniation visible on CT images were triggers for strokectomy surgery. Ten of 12 (83%) patients had infarctions in more than one territory (p < 0.001). After 12 months, 43% of patients had a good outcome according to the modified Rankin Scale (mRS) score (≤ 3). In the subgroup of patients suffering infarctions in more than one vascular territory, functional outcome after 12 months was better (mRS ≤ 3 in 40% of patients in comparison to 9%; p = 0.027). A 1:3 case-control analysis matched to age, side of infarction, sex, and vascular territory confirmed these results (mRS ≤ 3, 42% in comparison to 11%; p = 0.032). Age, NIHSS score on admission, and number of vascular territories involved were identified as risk factors in multivariate analysis (p < 0.05). Patients in the strokectomy group had more infections (p < 0.001). According to these results, the authors developed a scale (Münster Stroke Score, 0-6 points) to predict whether patients might benefit from additional strokectomy. Receiver-operating characteristic (ROC) curve analysis revealed an area under the curve (AUC) of 0.86 (p < 0.001). The authors recommend a Münster Stroke Score of ≥ 3 as a cutoff, with a sensitivity of 92% and specificity of 66%, for predicting benefit from strokectomy. CONCLUSIONS In this study in comparison to former studies, mortality rates were lower and clinical outcome was comparable to that of previously published trials regarding large cerebral infarctions. Second surgery including strokectomy may help achieve better outcomes, especially in cases of infarction of more than one vascular territory.
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Affiliation(s)
- Michael Schwake
- 1Department of Neurosurgery, University Hospital Münster, Münster
| | | | - Michael Müther
- 1Department of Neurosurgery, University Hospital Münster, Münster
| | - Louise Stögbauer
- 1Department of Neurosurgery, University Hospital Münster, Münster
| | - Uta Hanning
- 2Institute for Clinical Radiology, Münster
- 3Department of Diagnostic and Interventional Neuroradiology, University of Hamburg, Hamburg; and
| | | | - Christian Ewelt
- 1Department of Neurosurgery, University Hospital Münster, Münster
| | - Rainer Dziewas
- 4Department of Neurology, University Hospital Münster, Münster, Germany
| | - Jens Minnerup
- 4Department of Neurology, University Hospital Münster, Münster, Germany
| | - Markus Holling
- 1Department of Neurosurgery, University Hospital Münster, Münster
| | - Walter Stummer
- 1Department of Neurosurgery, University Hospital Münster, Münster
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Sun W, Li G, Liu Z, Miao J, Yang Z, Zhou Q, Liu R, Zhu S, Zhu Z. A nomogram for predicting the in-hospital mortality after large hemispheric infarction. BMC Neurol 2019; 19:347. [PMID: 31884967 PMCID: PMC6935484 DOI: 10.1186/s12883-019-1571-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 12/12/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Large hemispheric infarction (LHI) is a severe form of stroke with high mortality and disability rates. The purpose of this study was to explore predictive indicators of the in-hospital mortality of LHI patients treated conservatively without decompressive hemicraniectomy. METHOD We performed a retrospective study of 187 consecutive patients with LHI between January 1, 2016 to May 31, 2019. The receiver operating curves were preformed to evaluate predictive performance of demographics factors, biomarkers and radiologic characteristics. Significant prognostic factors were combined to build a nomogram to predict the risk of in-hospital death of individual patients. RESULT One hundred fifty-eight patients with LHI were finally enrolled, 58 of which died. Through multivariate logistic regression analysis, we identified that independent prognostic factors for in-hospital death were age (adjusted odds ratio [aOR] = 1.066; 95% confidence interval [CI], 1.025-1.108; P = 0.001), midline shift (MLS, aOR = 1.330, 95% CI, 1.177-1.503; P < 0.001), and neutrophil-to-lymphocyte ratio (NLR, aOR = 3.319, 95% CI, 1.542-7.144; P = 0.002). NLR may serve as a better predictor than white blood count (WBC) and neutrophil counts. Lastly, we used all of the clinical characteristics to establish a nomogram for predicting the prognosis, area under the curve (AUC) of this nomogram was 0.858 (95% CI, 0.794-0.908). CONCLUSION This study shows that age, MLS, and admission NLR value are independent predictors of in-hospital mortality in patients with LHI. Moreover, nomogram, serve as a precise and convenient tool for the prognosis of LHI patients.
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Affiliation(s)
- Wenzhe Sun
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Guo Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Ziqiang Liu
- Department of Geriatrics, Taikang Tongji Hospital, No.233 SiXin North Road, Wuhan, 430030, China
| | - Jinfeng Miao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Zhaoxia Yang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Qiao Zhou
- Department of Geriatrics, Taikang Tongji Hospital, No.233 SiXin North Road, Wuhan, 430030, China
| | - Run Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Suiqiang Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China.
| | - Zhou Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China.
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Wu J, Wei W, Gao YH, Liang FT, Gao YL, Yu HG, Huang QL, Long XQ, Zhou YF. Surgical Decompression versus Conservative Treatment in Patients with Malignant Infarction of the Middle Cerebral Artery: Direct Comparison of Death-Related Complications. World Neurosurg 2019; 135:e366-e374. [PMID: 31816452 DOI: 10.1016/j.wneu.2019.11.170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/28/2019] [Accepted: 11/29/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Surgical decompression and conservative treatment are routinely used in the treatment of patients with malignant infarction of the middle cerebral artery (MIMCA). However, efficacy and safety are controversial. The purpose of this study is to systematically compare the clinical outcomes between surgical decompression and conservative treatment in patients with MIMCA. METHODS This study retrieved available academic randomized controlled trials (RCTs) comparing the clinical outcomes between surgical decompression and conservative treatment in patients with MIMCA from the databases of ScienceDirect, Cochrane Library, Embase, and PubMed. The references of previous reviews and related clinical studies were manually checked to retrieve potential literature that was not involved in our electronic search results. RESULTS A total of 7 RCTs were included in the study. The overall number of participants in the surgical decompression group was 165, whereas it was 173 in the conservative treatment group. The results revealed that the surgical decompression group was related to a lower incidence of 1-year death (odds ratio [OR], 0.192; 95% confidence interval [CI], 0.119-0.309; P < 0.001), 1-year death in patients >60 years of age (OR, 0.202; 95% CI, 0.097-0.421; P < 0.001), 1-year death in patients <60 years of age (OR, 0.145; 95% CI, 0.069-0.301; P < 0.001), 1-year death in patients treated within 48 hours of stroke onset (OR, 0.159; 95% CI, 0.090-0.282; P < 0.001), and modified Rankin Scale (mRS) score ≤3 (OR, 2.082; 95% CI, 1.185-3.658; P < 0.001). CONCLUSIONS Based on current evidence for patients with MIMCA, decompressive surgery not only is a life-saving therapy but also reduces the incidence of mortality without increasing the risk of severe disability.
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Affiliation(s)
- Jun Wu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (The First People's Hospital of Fuzhou), Fuzhou, Jiangxi, China
| | - Wei Wei
- Department of Neurology, Mianyang Central Hospital, Sichuan, R.P. China
| | - Yue-Hua Gao
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, R.P. China
| | - Fang-Te Liang
- Department of Anesthesiology, Guangxi Medical University, Nanning, Guangxi, R.P. China
| | - Yun-Long Gao
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (The First People's Hospital of Fuzhou), Fuzhou, Jiangxi, China
| | - Hai-Guang Yu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (The First People's Hospital of Fuzhou), Fuzhou, Jiangxi, China
| | - Qing-Liang Huang
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (The First People's Hospital of Fuzhou), Fuzhou, Jiangxi, China
| | - Xin-Quan Long
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (The First People's Hospital of Fuzhou), Fuzhou, Jiangxi, China
| | - Yu-Fan Zhou
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (The First People's Hospital of Fuzhou), Fuzhou, Jiangxi, China.
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Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50:e344-e418. [PMID: 31662037 DOI: 10.1161/str.0000000000000211] [Citation(s) in RCA: 3408] [Impact Index Per Article: 681.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.
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Outcomes of therapeutic hypothermia in patients treated with decompressive craniectomy for malignant Middle cerebral artery infarction: A systematic review and meta-analysis. Clin Neurol Neurosurg 2019; 188:105569. [PMID: 31710882 DOI: 10.1016/j.clineuro.2019.105569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 10/17/2019] [Accepted: 10/20/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The beneficial effects of therapeutic hypothermia (TH) after decompressive craniectomy (DC) for malignant middle cerebral artery (MCA) infarction are controversial. We conducted a systematic review and meta-analysis to assess the clinical efficacy of TH in aforementioned patients. PATIENTS AND METHODS A systematic literature search was conducted to find articles published up to April 2019 evaluating the effect of combining TH and DC on short-term (≤30 days) and long-term (>6 months) mortality and neurological outcomes in patients with malignant MCA infarction. Pooled relative risk (RRs) with 95% confidence interval (CI) were calculated using the Mantel-Haenszel fixed-effects model or the DerSimonian-Laird random-effects. RESULTS Patient data was analyzed for a total of 289 patients from four selected studies and two abstracts. Compared to DC alone, combining DC and TH had a tendency to reduce short-term mortality (RR = 0.52, 95% CI 0.26 to 1.05, P = 0.07, I2 = 0%) but had no significant effects on long-term mortality (RR = 1.26, 95% CI 0.58 to 2.76, P = 0.56, I2 = 68%) or neurological outcomes (RR = 0.81, 95% CI 0.53 to 1.24, P = 0.34, I2 = 30%). CONCLUSION Using TH in tandem with DC did not show definite short- or long-term survival benefits in our study, but may tend to reduce the short-term mortality of patients with malignant MCA infarction.
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Tartara F, Colombo EV, Bongetta D, Pilloni G, Bortolotti C, Boeris D, Zenga F, Giossi A, Ciccone A, Sessa M, Cenzato M. Strokectomy and Extensive Cisternal CSF Drain for Acute Management of Malignant Middle Cerebral Artery Infarction: Technical Note and Case Series. Front Neurol 2019; 10:1017. [PMID: 31616366 PMCID: PMC6775199 DOI: 10.3389/fneur.2019.01017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/09/2019] [Indexed: 01/01/2023] Open
Abstract
Background and Purpose: Ischemic stroke is a major cause of death and disability worldwide. Large MCA stroke may evolve as malignant space occupying lesion and mortality rate reaches 80% despite maximal medical therapy. Early decompressive craniectomy is effective in reducing mortality and improving the functional outcome but is an extended and invasive surgical approach burdened with a significant complication rate. We report a surgical treatment based on partial strokectomy and basal cisterns opening with massive CSF drain. Materials and Methods: We retrospectively collected 15 cases of massive middle cerebral artery stroke treated with strokectomy between 2010 and 2017: nine males and six females, mean age 61.73 ± 9.5 years. The right side was affected in 66.7%. All patients show clinical deterioration despite standard medical therapy and indication for surgery was placed after collegiate evaluation by neurologists and neurosurgeons based on clinical and radiological data. Results: Surgical procedure was performed 24–96 h after the stroke onset. All the 15 patients survived the intervention, one patient died 20 days after the admission for massive lung embolism. Mean GCS and NIHSS at admission were 12.6 ± 1.18 (range 9–15) and 19.7 ± 2.3 (range 18–23), respectively. Mean mRS at 12 months was 3.6 ± 1.1 (range 2–6). Mean follow-up was 18.1 months (range 12–34). The outcome was evaluated as satisfactory (mRs ≤ 3) in 8 patients (53.3%). Mortality at 1 year was 6.7%. No patients developed hydrocephalus and 1 presented seizures. According to mRs outcome evaluation (mRs ≤ 3 vs. mRs ≥ 4) no quantitative variable resulted significantly different between the two groups, whereas the concomitant use of iv rTPA significantly differed (P < 0.05). Conclusion: Supratentorial strokectomy seems to be safe and could be a potential alternative to decompressive craniectomy for the acute management of malignant MCA stroke. Advantages of this approach could be low complication rate, avoidance of bone reconstruction procedure, and reduced occurrence of hydrocephalus or seizures. A co-operative multicentric, prospective pilot study will be necessary to validate this technical approach.
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Affiliation(s)
- Fulvio Tartara
- UO Neurochirurgia, Azienda Ospedaliero-Universitaria, Parma, Italy
| | | | | | - Giulia Pilloni
- UO Neurochirurgia, Azienda Ospedaliero-Universitaria, Parma, Italy
| | - Carlo Bortolotti
- UO Neurochirurgia, Istituto Delle Scienze Neurologiche-Ospedale Bellaria, Bologna, Italy
| | - Davide Boeris
- UO Neurochirurgia, IRCCS Ospedale Niguarda Ca' Granda, Milan, Italy
| | - Francesco Zenga
- UO Neurochirurgia, AOU Città Della Salute e Della Scienza, Turin, Italy
| | - Alessia Giossi
- SC Neurologia, Dipartimento Interaziendale Neuroscienze Cremona-Mantova, ASST Cremona, Cremona, Italy
| | - Alfonso Ciccone
- SC Neurologia, Dipartimento Interaziendale Neuroscienze Cremona-Mantova, ASST Mantova, Mantua, Italy
| | - Maria Sessa
- SC Neurologia, Dipartimento Interaziendale Neuroscienze Cremona-Mantova, ASST Cremona, Cremona, Italy
| | - Marco Cenzato
- UO Neurochirurgia, IRCCS Ospedale Niguarda Ca' Granda, Milan, Italy
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Li J, Zhang P, Wu S, Wang Y, Zhou J, Yi X, Wang C. Stroke-related complications in large hemisphere infarction: incidence and influence on unfavorable outcome. Ther Adv Neurol Disord 2019; 12:1756286419873264. [PMID: 31516557 PMCID: PMC6719470 DOI: 10.1177/1756286419873264] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 08/11/2019] [Indexed: 02/05/2023] Open
Abstract
Objective: Neurological and medical complications are major causes of morbidity and mortality after ischemic stroke. This study aimed to identify the incidence of stroke-related complications following large hemisphere infarction (LHI) and to explore their influence on unfavorable outcome in LHI patients. Methods: We prospectively enrolled consecutive patients with LHI. The unfavorable outcome was defined as an modified Rankin Scale (mRS) score of 4–6 at 3 months. Multivariate logistic regression analysis was employed to identify the stroke-related complications associated with unfavorable outcome. Results: Of the 256 cases with LHI included, 41 (16.0%) died during hospitalization, 94 (36.7%) died and 140 (55.3%) patients had unfavorable outcome at 3 months. A total of 194 (75.8%) had at least one complication. The three most common medical complications were pneumonia (53.5%), electrolyte disorder (30.9%), and urinary incontinence (18.4%), and the three most common neurological complications were malignant brain edema (31.2%), hemorrhagic transformation (27.7%), and poststroke seizures (7.0%). Overall, LHI patients with unfavorable outcome had more frequent stroke-related complications (91.4% versus 55.8%, p < 0.001) than patients with favorable outcome. After adjusting for age, baseline National Institutes of Health Stroke Scale score, and other confounders, only malignant brain edema [odds ratios (OR) 19.76, 95% confidence interval (CI) 4.73–82.45] and pneumonia (OR 2.45, 95% CI 1.11–5.40) were independently associated with 3-month unfavorable outcome in patients with LHI. Conclusions: More than three-quarters of LHI patients have at least one stroke-related complication. LHI patients with the unfavorable outcome had stroke-related complications more frequently, whereas only malignant brain edema and pneumonia are independently associated with 3-month unfavorable outcome.
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Affiliation(s)
- Jie Li
- Department of Neurology, People's Hospital of Deyang City, Deyang, PR China
| | - Ping Zhang
- Department of Neurology, People's Hospital of Deyang City, Deyang, PR China
| | - Simiao Wu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Yanfen Wang
- Department of Neurology, People's Hospital of Deyang City, Deyang, PR China
| | - Ju Zhou
- Department of Neurology, People's Hospital of Deyang City, Deyang, PR China
| | - Xingyang Yi
- Department of Neurology, People's Hospital of Deyang City, Deyang, PR China
| | - Chun Wang
- Department of Neurology, People's Hospital of Deyang City, No.173, North Taishan Road, Deyang 618000, Sichuan Province, PR China
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Whitney E, Mahato D, Odell T, Khan YR, Siddiqi J. The 100-most Cited Articles About Craniectomy and Hemicraniectomy: A Bibliometric Analysis. Cureus 2019; 11:e5524. [PMID: 31687299 PMCID: PMC6819074 DOI: 10.7759/cureus.5524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Craniectomy is a life-saving procedure used in the setting of traumatic brain injury, stroke and increased intracranial pressure. The purpose of this study was to analyze and determine the most influential articles and authors in the field of craniectomy. Our study presents an analysis of the articles that include the word "craniectomy" or "hemicraniectomy" in the title and a detailed analysis of the top 100-cited articles in that selection. This search provided insight into how this procedure was initially documented and how it has been utilized over the years. We used the SCOPUS database to search “craniectomy OR hemicraniectomy” in the article title. We then sorted the top 100 most-cited articles. Bibliometric analysis was performed. An H-index was presented with each author. The citation count ranged from 71 to 5310. The most published author was Werner Hacke, a German researcher (n=6). The highest quantity of influential work was published in 2006 and 2007 (n=9/yr). The United States published the most articles (n=42). The Journal of Neurosurgery published 21 of the top 100 most-cited articles. The chronological timeline shows the evolution of decompression as it related to both stroke and trauma. It demonstrated that well-cited articles acted as turning points to direct further scientific endeavors while highlighting the hard work of certain authors. There is, to the best of our knowledge, a shortage of literature on a bibliometric analysis regarding the term craniectomy. Thus, the current bibliometric study was undertaken to highlight the work of authors who have advanced knowledge about this procedure. It provides an analysis of the top 100-cited articles with craniectomy in the title with dates ranging from 1892 to 2016. A review of its publication history shows how interventions in this field have advanced over the last several decades.
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Affiliation(s)
- Eric Whitney
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | | | - Tiffany Odell
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | - Yasir R Khan
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | - Javed Siddiqi
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
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