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Moughal S, Trippier S, Al-Mousa A, Hainsworth AH, Pereira AC, Minhas PS, Shtaya A. Strokectomy for malignant middle cerebral artery infarction: experience and meta-analysis of current evidence. J Neurol 2022; 269:149-158. [PMID: 33340332 PMCID: PMC8739160 DOI: 10.1007/s00415-020-10358-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/25/2020] [Accepted: 12/04/2020] [Indexed: 11/05/2022]
Abstract
Strokectomy means surgical excision of infarcted brain tissue post-stroke with preservation of skull integrity, distinguishing it from decompressive hemicraniectomy. Both can mitigate malignant middle cerebral artery (MCA) syndrome but evidence regarding strokectomy is sparse. Here, we report our data and meta-analysis of strokectomy compared to hemicraniectomy for malignant MCA infarction. All malignant MCA stroke cases requiring surgical intervention in a large tertiary centre (January 2012-December 2017, N = 24) were analysed for craniotomy diameter, complications, length of follow-up and outcome measured using the modified Rankin score (mRS). Good outcome was defined as mRS 0-3 at 12 months. In a meta-analysis, outcome from strokectomy (pooled from our cohort and published strokectomy studies) was compared with hemicraniectomy (our cohort pooled with published DECIMAL, DESTINY and HAMLET clinical trial data). In our series (N = 24, 12/12 F/M; mean age: 45.83 ± 8.91, range 29-63 years), 4 patients underwent strokectomy (SC) and 20 hemicraniectomy (HC). Among SC patients, craniotomy diameter was smaller, relative to HC patients (86 ± 13.10 mm, 120 ± 4.10 mm, respectively; p = 0.003), complications were less common (25%, 55%) and poor outcomes were less common (25%, 70%). In the pooled data (N = 41 SC, 71 HC), strokectomy tended towards good outcome more than hemicraniectomy (OR 2.2, 95% CI 0.99-4.7; p = 0.051). In conclusion, strokectomy may be non-inferior, lower risk and cost saving relative to hemicraniectomy sufficiently to be worthy of further investigation and maybe a randomised trial.
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Affiliation(s)
- Saad Moughal
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, SW17 0RE, UK
- Atkinson Morley Neurosurgery Centre, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sarah Trippier
- Neurology Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Alaa Al-Mousa
- Department of Surgery, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Atticus H Hainsworth
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, SW17 0RE, UK
- Neurology Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Anthony C Pereira
- Neurology Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Pawanjit S Minhas
- Atkinson Morley Neurosurgery Centre, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Anan Shtaya
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, SW17 0RE, UK.
- Atkinson Morley Neurosurgery Centre, St George's University Hospitals NHS Foundation Trust, London, UK.
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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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Shim JW, Sandlund J, Hameed MQ, Blazer-Yost B, Zhou FC, Klagsbrun M, Madsen JR. Excess HB-EGF, which promotes VEGF signaling, leads to hydrocephalus. Sci Rep 2016; 6:26794. [PMID: 27243144 PMCID: PMC4886677 DOI: 10.1038/srep26794] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 05/10/2016] [Indexed: 01/19/2023] Open
Abstract
Heparin binding epidermal growth factor-like growth factor (HB-EGF) is an angiogenic factor mediating radial migration of the developing forebrain, while vascular endothelial growth factor (VEGF) is known to influence rostral migratory stream in rodents. Cell migratory defects have been identified in animal models of hydrocephalus; however, the relationship between HB-EGF and hydrocephalus is unclear. We show that mice overexpressing human HB-EGF with β-galactosidase reporter exhibit an elevated VEGF, localization of β-galactosidase outside the subventricular zone (SVZ), subarachnoid hemorrhage, and ventriculomegaly. In Wistar polycystic kidney rats with hydrocephalus, alteration of migratory trajectory is detected. Furthermore, VEGF infusions into the rats result in ventriculomegaly with an increase of SVZ neuroblast in rostral migratory stream, whereas VEGF ligand inhibition prevents it. Our results support the idea that excess HB-EGF leads to a significant elevation of VEGF and ventricular dilatation. These data suggest a potential pathophysiological mechanism that elevated HB-EGF can elicit VEGF induction and hydrocephalus.
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Affiliation(s)
- Joon W Shim
- Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA.,Department of Biology, Indiana University Purdue University, Indianapolis, IN 46202, USA.,Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Johanna Sandlund
- Vascular Biology Program, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA.,Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive L235, Stanford, CA 94305, USA.,Clinical Microbiology Laboratory, Stanford University Medical Center, 3375 Hillview Avenue Palo, Alto, CA 94304, USA
| | - Mustafa Q Hameed
- Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA.,Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Bonnie Blazer-Yost
- Department of Biology, Indiana University Purdue University, Indianapolis, IN 46202, USA
| | - Feng C Zhou
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Michael Klagsbrun
- Vascular Biology Program, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA.,Department of Surgery and Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Joseph R Madsen
- Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
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