Hemicraniectomy and durotomy for malignant middle cerebral artery infarction

Craniectomy for malignant cerebral infarction: prevalence and outcomes in US hospitals

Object

Randomized trials have demonstrated the efficacy of craniectomy for the treatment of malignant cerebral edema following ischemic stroke. We sought to determine the prevalence and outcomes related to this by using a national database.

Methods

Patient discharges with ischemic stroke as the primary diagnosis undergoing craniectomy were queried from the US Nationwide Inpatient Sample from 1999 to 2008. A subpopulation of patients was identified that underwent thrombolysis. Two primary end points were examined: in-hospital mortality and discharge to home/routine care. To facilitate interpretations, adjusted prevalence was calculated from the overall prevalence and two age-specific logistic regression models. The predictive margin was then generated using a multivariate logistic regression model to estimate the probability of in-hospital mortality after adjustment for admission type, admission source, length of stay, total hospital charges, chronic comorbidities, and medical complications.

Results

After excluding 71,996 patients with the diagnosis of intracranial hemorrhage and posterior intracranial circulation occlusion, we identified 4,248,955 adult hospitalizations with ischemic stroke as a primary diagnosis. The estimated rates of hospitalizations in craniectomy per 10,000 hospitalizations with ischemic stroke increased from 3.9 in 1999–2000 to 14.46 in 2007–2008 (p for linear trend<0.001). Patients 60+ years of age had in-hospital mortality of 44% while the 18–59 year old group was found to be 24%(p = 0.14). Outcomes were comparable if recombinant tissue plasminogen activator had been administered.

Conclusions

Craniectomy is being increasingly performed for malignant cerebral edema following large territory cerebral ischemia. We suspect that the increase in the annual incidence of DC for malignant cerebral edema is directly related to the expanding collection of evidence in randomized trials that the operation is efficacious when performed in the correct patient population. In hospital mortality is high for all patients undergoing this procedure.

Nationwide study of decompressive surgery for malignant supratentorial infarction in the Czech Republic: utilization and outcome predictors. Clinical article

OBJECT

Decompressive surgery within 48 hours in patients younger than 60 years of age reduces mortality and morbidity from malignant supratentorial infarction. The goal of this study was to characterize the utilization of decompressive surgery in the Czech Republic in 2006.

METHODS

This nationwide study was undertaken from September to December 2007 using a questionnaire sent to all neurosurgery departments in the Czech Republic. Diagnosis of brain infarction and decompressive surgery was based on discharge codes. Patient data were retrieved from hospital charts. Favorable outcome was defined as a modified Rankin scale score ≤4 on the day of discharge from the hospital.

RESULTS

Data were obtained from 15 of the 16 neurosurgery departments in the Czech Republic (94%) and from 39 patients (11 female [28%]). The average patient age was 52 +/-14 years (11 patients > 60), median time to surgery was 48 hours (interquartile range [IQR] 26-67 hours; 15 patients > 48 hours), median National Institutes of Health Stroke Scale score was 22 (IQR 16-30), median infarct volume was 341 cm³ (IQR 243-375 cm³), mean shift from the midline was 9.9 +/- 4.1 mm, median duration of hospitalization was 19 days (IQR 13-30 days), and mean bone flap surface area was 75 cm² (IQR 70-97 cm²). A favorable outcome was achieved in 19 patients (49%). The median number of procedures per site in 2006 was 1.5 (range 0-13 procedures). Five sites (31%) serving one-third of the entire population did not perform any decompressive surgery. No variable was a significant predictor of outcome in a multiple regression model.

CONCLUSIONS

In 2006 decompressive surgery was underutilized and occurred late in the clinical course in the Czech Republic. Revision of national guidelines is necessary to incorporate the latest data and ensure that the patients who can benefit most receive treatment.

Blood pressure treatment in acute ischemic stroke: a review of studies and recommendations

PURPOSE OF REVIEW

Elevated blood pressure (BP) is frequent in patients with acute ischemic stroke. Pathophysiological data support its usefulness to maintain adequate perfusion of the ischemic penumba. This review article aims to summarize the available evidence from clinical studies that examined the prognostic role of BP during the acute phase of ischemic stroke and intervention studies that assessed the efficacy of active BP alteration.

RECENT FINDINGS

We found 34 observational studies (33,470 patients), with results being inconsistent among the studies; most studies reported a negative association between increased levels of BP and clinical outcome, whereas a few studies showed clinical improvement with higher BP levels, clinical deterioration with decreased BP, or no association at all. Similarly, the conclusions drawn by the 18 intervention studies included in this review (1637 patients) were also heterogeneous. Very recent clinical data suggest a possible beneficial effect of early treatment with some antihypertensives on late clinical outcome.

SUMMARY

Observational and interventional studies of management of acute poststroke hypertension yield conflicting results. We discuss different explanations that may account for this and discuss the current guidelines and pathophysiological considerations for the management of acute poststroke hypertension.