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Fotakopoulos G, Gatos C, Georgakopoulou VE, Lempesis IG, Spandidos DA, Trakas N, Sklapani P, Fountas KN. Role of decompressive craniectomy in the management of acute ischemic stroke (Review). Biomed Rep 2024; 20:33. [PMID: 38273901 PMCID: PMC10809310 DOI: 10.3892/br.2024.1721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 12/07/2023] [Indexed: 01/27/2024] Open
Abstract
The application of decompressive craniectomy (DC) is thoroughly documented in the management of brain edema, particularly following traumatic brain injury. However, an increasing amount of concern is developing among the universal medical community as regards the application of DC in the treatment of other causes of brain edema, such as subarachnoid hemorrhage, cerebral hemorrhage, sinus thrombosis and encephalitis. Managing stroke continues to remain challenging, and demands the aggressive and intensive consulting of a number of medical specialties. Middle cerebral artery (MCA) infarcts, which consist of 1-10% of all supratentorial infarcts, are often associated with mass effects, and high mortality and morbidity rates. Over the past three decades, a number of neurosurgical medical centers have reported their experience with the application of DC in the treatment of malignant MCA infarction with varying results. In addition, over the past decade, major efforts have been dedicated to multicenter randomized clinical trials. The present study reviews the pertinent literature to outline the use of DC in the management of malignant MCA infarction. The PubMed database was systematically searched for the following terms: 'Malignant cerebral infarction', 'surgery for stroke', 'DC for cerebral infarction', and all their combinations. Case reports were excluded from the review. The articles were categorized into a number of groups; the majority of these were human clinical studies, with a few animal experimental clinical studies. The surgical technique involved was DC, or hemicraniectomy. Other aspects that were included in the selection of articles were methodological characteristics and the number of patients. The multicenter randomized trials were promising. The mortality rate has unanimously decreased. As for the functional outcome, different scales were employed; the Glasgow Outcome Scale Extended was not sufficient; the Modified Rankin Scale and Bathel index, as well as other scales, were applied. Other aspects considered were demographics, statistics and the very interesting radiological ones. There is no doubt that DC decreases mortality rates, as shown in all clinical trials. Functional outcome appears to be the goal standard in modern-era neurosurgery, and quality of life should be further discussed among the medical community and with patient consent.
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Affiliation(s)
- George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | - Charalambos Gatos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | | | - Ioannis G. Lempesis
- Department of Pathophysiology, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Pagona Sklapani
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Kostas N. Fountas
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
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Beucler N, Dagain A. Decompressive craniectomy: keep it simple! Acta Neurochir (Wien) 2023; 165:2377-2379. [PMID: 35717427 DOI: 10.1007/s00701-022-05280-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, 2 boulevard Sainte-Anne, 83800, Toulon Cedex 9, France.
- Ecole du Val-de-Grâce, French Military Health Service Academy, 1 place Alphonse Laveran, 75230, Paris Cedex 5, France.
| | - Arnaud Dagain
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, 2 boulevard Sainte-Anne, 83800, Toulon Cedex 9, France
- Val-de-Grâce Military Academy, 1 place Alphonse Laveran, 75230, Paris Cedex 5, France
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Ndiaye Sy EHC, Cisse Y, Thiam AB, Barry LF, Mbaye M, Diop A, Thioub M, Faye M, Fahad A, Ndongo MM, Soilihi AA, Doumbia N, Codé Ba M, Badiane SB. Decompressive craniectomy: indications and results of 24 cases at the neurosurgery clinic of Fann university hospital of Dakar. Pan Afr Med J 2021; 38:399. [PMID: 34381543 PMCID: PMC8325445 DOI: 10.11604/pamj.2021.38.399.27571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/22/2021] [Indexed: 11/28/2022] Open
Abstract
Decompressive craniectomy is a surgical technique considered to be the last step in the management of intracranial hypertension. The objective of our study was to evaluate our results in the management of intracranial hypertension by decompressive craniectomy. This was a retrospective study of 24 cases of decompressive craniectomy performed over a 9-year period (from January 2010 to December 2019) at the Fann Neurosurgery Clinic. The mean age of the patients was 33.82 years, there was a male predominance with a sex ratio of 2.42. The most frequent indication was severe cranioencephalic trauma with 50%. The cerebral computed tomography (CT) scan was the key examination and was performed in all our patients. Complications were entirely infectious and were the cause of 73.33% of deaths. Thirty-five percent of the patients had received prior treatment before the decompressive craniectomy. The functional prognosis was good in 44.44% of cases, moderate in 33.33% of cases, 1 (11.11%) patient had a severe disability and 1 (11.11%) patient was in a vegetative state. Mortality rate was 62.5% of patients in our study series. Despite the lack of sophisticated techniques for diagnosis and monitoring of intracranial hypertension, our results remain acceptable with 37.5% survival. The early completion of this surgery allows us to be more efficient with a significant reduction in morbidity and mortality.
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Affiliation(s)
| | - Yakhya Cisse
- Neurosurgery Department, Fann University Hospital Center, Dakar, Senegal
| | | | | | - Maguette Mbaye
- Neurosurgery Department, Fann University Hospital Center, Dakar, Senegal
| | - Abdoulaye Diop
- Neurosurgery Unit, Ziguinchor Regional Hospital, Ziguinchor, Senegal
| | - Mbaye Thioub
- Neurosurgery Department, Fann University Hospital Center, Dakar, Senegal
| | - Mohameth Faye
- Neurosurgery Department, Idrissa Pouye General Hospital, Dakar, Senegal
| | - Attoumane Fahad
- Neurosurgery Department, Fann University Hospital Center, Dakar, Senegal
| | | | | | - Nantenin Doumbia
- Neurosurgery Department, Fann University Hospital Center, Dakar, Senegal
| | - Momar Codé Ba
- Neurosurgery Department, Fann University Hospital Center, Dakar, Senegal
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Coccolini F, Improta M, Picetti E, Vergano LB, Catena F, de ’Angelis N, Bertolucci A, Kirkpatrick AW, Sartelli M, Fugazzola P, Tartaglia D, Chiarugi M. Timing of surgical intervention for compartment syndrome in different body region: systematic review of the literature. World J Emerg Surg 2020; 15:60. [PMID: 33087153 PMCID: PMC7579897 DOI: 10.1186/s13017-020-00339-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/07/2020] [Indexed: 12/28/2022] Open
Abstract
Compartment syndrome can occur in many body regions and may range from homeostasis asymptomatic alterations to severe, life-threatening conditions. Surgical intervention to decompress affected organs or area of the body is often the only effective treatment, although evidences to assess the best timing of intervention are lacking. Present paper systematically reviewed the literature stratifying timings according to the compartmental syndromes which may beneficiate from immediate, early, delayed, or prophylactic surgical decompression. Timing of decompression have been stratified into four categories: (1) immediate decompression for those compartmental syndromes whose missed therapy would rapidly lead to patient death or extreme disability, (2) early decompression with the time burden of 3-12 h and in any case before clinical signs of irreversible deterioration, (3) delayed decompression identified with decompression performed after 12 h or after signs of clinical deterioration has occurred, and (4) prophylactic decompression in those situations where high incidence of compartment syndrome is expected after a specific causative event.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100 Pisa, Italy
| | - Mario Improta
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | | | - Fausto Catena
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Nicola de ’Angelis
- Unit of Digestive and Hepato-biliary-pancreatic Surgery, Henri Mondor Hospital and University Paris-Est Créteil (UPEC), Créteil, France
| | - Andrea Bertolucci
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100 Pisa, Italy
| | - Andrew W. Kirkpatrick
- Departments of Surgery and Critical Care Medicine, Foothills Medical Centre, Calgary, Canada
| | | | - Paola Fugazzola
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Dario Tartaglia
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100 Pisa, Italy
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100 Pisa, Italy
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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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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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Shah A, Almenawer S, Hawryluk G. Timing of Decompressive Craniectomy for Ischemic Stroke and Traumatic Brain Injury: A Review. Front Neurol 2019; 10:11. [PMID: 30740085 PMCID: PMC6355668 DOI: 10.3389/fneur.2019.00011] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 01/07/2019] [Indexed: 11/23/2022] Open
Abstract
While studies have demonstrated that decompressive craniectomy after stroke or TBI improves mortality, there is much controversy regarding when decompressive craniectomy is optimally performed. The goal of this paper is to synthesize the data regarding timing of craniectomy for malignant stroke and traumatic brain injury (TBI) based on studied time windows and clinical correlates of herniation. In stroke patients, evidence supports that early decompression performed within 24 h or before clinical signs of herniation may improve overall mortality and functional outcomes. In adult TBI patients, published results demonstrate that early decompressive craniectomy within 24 h of injury may reduce mortality and improve functional outcomes when compared to late decompressive craniectomy. In contrast to the stroke data, preliminary TBI data have demonstrated that decompressive craniectomy after radiographic signs of herniation may still lead to improved functional outcomes compared to medical management. In pediatric TBI patients, there is also evidence for better functional outcomes when treated with decompressive craniectomy, regardless of timing. More high quality data are needed, particularly that which incorporates a broader set of metrics into decision-making surrounding cranial decompression. In particular, advanced neuromonitoring and imaging technologies may be useful adjuncts in determining the optimal time for decompression in appropriate patients.
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Affiliation(s)
- Aatman Shah
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Saleh Almenawer
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Gregory Hawryluk
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, United States
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Shim HK, Yu SH, Kim BC, Lee JH, Choi HJ. Relationship between Clinical Outcomes and Superior Sagittal Sinus to Bone Flap Distance during Unilateral Decompressive Craniectomy in Patients with Traumatic Brain Injury: Experience at a Single Trauma Center. Korean J Neurotrauma 2018; 14:99-104. [PMID: 30402426 PMCID: PMC6218355 DOI: 10.13004/kjnt.2018.14.2.99] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/03/2018] [Accepted: 08/10/2018] [Indexed: 01/21/2023] Open
Abstract
Objective This retrospective study was conducted to investigate the relationship between the superior sagittal sinus (SSS) to bone flap distance and clinical outcome in patients with traumatic brain injury (TBI) who underwent decompressive craniectomy (DC). Methods A retrospective review of medical records identified 255 adult patients who underwent DC with hematoma removal to treat TBI at our hospital from 2016 through 2017; of these, 68 patients met the inclusion criteria and underwent unilateral DC. The nearest SSS to bone flap distances were measured on postoperative brain computed tomography images, and patients were divided into groups A (distance ≥20 mm) and B (distance <20 mm). The estimated blood loss (EBL) and operation time were evaluated using anesthesia records, and the time spent in an intensive care unit (ICU) was obtained by chart review. The clinical outcome was rated using the extended Glasgow Outcome Scale (GOS-E) at 3 and 6 months postoperatively. Results The male to female ratio was 15:2 and the mean subject age was 55.12 years (range, 18–79 years). The mean EBL and operation times were significantly different between groups A and B (EBL: 655.26 vs. 1803.33 mL, p<0.001; operation time: 125.92 vs. 144.83 min, p<0.001). The time spent in the ICU and GOS-E scores did not differ significantly between the groups. Conclusion We recommend that when DC is indicated due to TBI, an SSS to bone flap distance of at least 20 mm should be maintained, considering the EBL, operation time, and other outcomes.
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Affiliation(s)
- Hyuk Ki Shim
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Seung Han Yu
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Byung Chul Kim
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Jung Hwan Lee
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Hyuk Jin Choi
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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Li J, Zhang P, Wu S, Yi X, Wang C, Liu M. Factors associated with favourable outcome in large hemispheric infarctions. BMC Neurol 2018; 18:152. [PMID: 30236075 PMCID: PMC6149207 DOI: 10.1186/s12883-018-1148-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/07/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Large hemispheric infarction (LHI) is a devastating condition with high mortality and poor functional outcome in most conservatively treated patients. The purpose of this study was to explore factors associated with favorable outcome in patients with LHI. METHODS We prospectively enrolled consecutive patients with LHI. Favorable outcome was defined as a modified Rankin Scale (mRS) score of 0 to 3 at 90 days. Multivariate logistic regression analysis was employed to identify the independent factors associated with favorable outcome. RESULTS Two hundred fifty-six cases with LHI were identified: 41 (16.0%) died during hospitalization, 94 (36.7%) died at 3 month, and 113 (44.1%) survived with favorable outcome at day 90. Compared with patients with unfavorable outcome, the favorable cases were younger (55.8 ± 14.7 vs. 66.2 ± 14.1), had less history of hypertension (38.9% vs. 59.3%), lower baseline NIHSS score (median NIHSS score 11 vs. 17), lower blood pressure on admission (systolic 134.7 ± 24.9 vs. 145.1 ± 26.1 mmHg; diastolic 80.2 ± 14.9 vs. 86.9 ± 16.2 mmHg; respectively), lower level of baseline serum glucose (7.2 ± 3.3 vs. 8.2 ± 3.3 mmol/L), a lower frequency of stroke-related complications (55.8% vs. 91.4%), more use of antiplatelets (93.8% vs. 57.1%) and statins (46.9% vs. 25.7%) in the acute phase of stroke, but less use of osmotic agents (69.9% vs. 89.3%), mechanical ventilation (1.8% vs. 20.0%) or decompressive hemicraniectomy (1.8% vs. 15.7%). Multivariable analysis identified the following factors associated with favorable outcome: age (odds ratio, OR 0.95, 95% confidence interval [CI] 0.92-0.98, p < 0.001), baseline NIHSS score (OR 0.90, 95% CI 0.84-0.96, p = 0.002), statins used in acute phase (OR 2.49, 95% CI 1.10-5.65, p = 0.029), brain edema (OR 0.05, 95% CI 0.01-0.21, p < 0.001) and pneumonia (OR 0.42, 95% CI 0.19-0.93, p = 0.032). CONCLUSION More than one third of patients with LHI have relatively favorable clinical outcomes at 90 days. Younger age, lower baseline NIHSS score, absence of brain edema and pneumonia, and statins used in the acute phase were associated with favorable outcome of patients with LHI at 90 days.
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Affiliation(s)
- Jie Li
- Department of Neurology, People's Hospital of Deyang City, No.173, North Taishan Road, Deyang, 618000, Sichuan Province, People's Republic of China
| | - Ping Zhang
- Department of Neurology, People's Hospital of Deyang City, No.173, North Taishan Road, Deyang, 618000, Sichuan Province, People's Republic of China
| | - Simiao Wu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, No. 37, GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Xingyang Yi
- Department of Neurology, People's Hospital of Deyang City, No.173, North Taishan Road, Deyang, 618000, Sichuan Province, People's Republic of China
| | - Chun Wang
- Department of Neurology, People's Hospital of Deyang City, No.173, North Taishan Road, Deyang, 618000, Sichuan Province, People's Republic of China.
| | - Ming Liu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, No. 37, GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China.
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Revisiting Hemicraniectomy: Late Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke and the Role of Infarct Growth Rate. Stroke Res Treat 2017; 2017:2507834. [PMID: 28409051 PMCID: PMC5376465 DOI: 10.1155/2017/2507834] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 02/22/2017] [Indexed: 11/25/2022] Open
Abstract
Objective and Methods. The outcome in late decompressive hemicraniectomy in malignant middle cerebral artery stroke and the optimal timings of surgery has not been addressed by the randomized trials and pooled analysis. Retrospective, multicenter, cross-sectional study to measure outcome following DHC under 48 or over 48 hours using the modified Rankin scale [mRS] and dichotomized as favorable ≤4 or unfavorable >4 at three months. Results. In total, 137 patients underwent DHC. Functional outcome analyzed as mRS 0–4 versus mRS 5-6 showed no difference in this split between early and late operated on patients [P = 0.140] and mortality [P = 0.975]. Multivariate analysis showed that age ≥ 55 years, MCA with additional infarction, septum pellucidum deviation ≥1 cm, and uncal herniation were independent predictors of poor functional outcome at three months. In the “best” multivariate model, second infarct growth rate [IGR2] >7.5 ml/hr, MCA with additional infarction, and patients with temporal lobe involvement were independently associated with surgery under 48 hours. Both first infarct growth rate [IGR1] and second infarct growth rate [IGR2] were nearly double [P < 0.001] in patients with early surgery [under 48 hours]. Conclusions. The outcome and mortality in malignant middle cerebral artery stroke patients operated on over 48 hours of stroke onset were comparable to those of patients operated on less than 48 hours after stroke onset. Our data identifies IGR, temporal lobe involvement, and middle cerebral artery with additional infarct as independent predictors for early surgery.
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Maier IL, Behme D, Schnieder M, Tsogkas I, Schregel K, Bähr M, Knauth M, Liman J, Psychogios MN. Early computed tomography-based scores to predict decompressive hemicraniectomy after endovascular therapy in acute ischemic stroke. PLoS One 2017; 12:e0173737. [PMID: 28282456 PMCID: PMC5345861 DOI: 10.1371/journal.pone.0173737] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 02/24/2017] [Indexed: 11/18/2022] Open
Abstract
Background Identification of patients requiring decompressive hemicraniectomy (DH) after endovascular therapy (EVT) is crucial as clinical signs are not reliable and early DH has been shown to improve clinical outcome. The aim of our study was to identify imaging-based scores to predict the risk for space occupying ischemic stroke and DH. Methods Prospectively derived data from patients with acute large artery occlusion within the anterior circulation and EVT was analyzed in this monocentric study. Predictive value of non-contrast cranial computed tomography (ncCT) and cerebral blood volume (CBV) Alberta Stroke Program Early CT score (ASPECTS) were investigated for DH using logistic regression models and Receiver Operating Characteristic Curve analysis. Results From 218 patients with EVT, DH was performed in 20 patients (9.2%). Baseline- (7 vs. 9; p = 0.009) and follow-up ncCT ASPECTS (1 vs. 7, p<0.001) as well as baseline CBV ASPECTS (5 vs. 7, p<0.001) were significantly lower in patients with DH. ncCT (baseline: OR 0.71, p = 0.018; follow-up: OR 0.32, p = <0.001) and CBV ASPECTS (OR 0.63, p = 0.008) predicted DH. Cut-off ncCT-ASPECTS on baseline was 7-, ncCT-ASPECTS on follow-up was 4- and CBV ASPECTS on baseline was 5 points. Conclusions ASPECTS could be useful to early identify patients requiring DH after EVT for acute large vessel occlusion.
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Affiliation(s)
- Ilko L Maier
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Daniel Behme
- Department of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Marlena Schnieder
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Ioannis Tsogkas
- Department of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Katharina Schregel
- Department of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Mathias Bähr
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Michael Knauth
- Department of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Jan Liman
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
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12
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Abstract
Decompressive craniectomy (DC) has been used for many years in the management of patients with elevated intracranial pressure and cerebral edema. Ongoing clinical trials are investigating the clinical and cost effectiveness of DC in trauma and stroke. While DC has demonstrable efficacy in saving life, it is accompanied by a myriad of non-trivial complications that have been inadequately highlighted in prospective clinical trials. Missing from our current understanding is a comprehensive analysis of all potential complications associated with DC. Here, we review the available literature, we tabulate all reported complications, and we calculate their frequency for specific indications. Of over 1500 records initially identified, a final total of 142 eligible records were included in our comprehensive analysis. We identified numerous complications related to DC that have not been systematically reviewed. Complications were of three major types: (1) Hemorrhagic (2) Infectious/Inflammatory, and (3) Disturbances of the CSF compartment. Complications associated with cranioplasty fell under similar major types, with additional complications relating to the bone flap. Overall, one of every ten patients undergoing DC may suffer a complication necessitating additional medical and/or neurosurgical intervention. While DC has received increased attention as a potential therapeutic option in a variety of situations, like any surgical procedure, DC is not without risk. Neurologists and neurosurgeons must be aware of all the potential complications of DC in order to properly advise their patients.
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13
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Stokum JA, Gerzanich V, Simard JM. Molecular pathophysiology of cerebral edema. J Cereb Blood Flow Metab 2016; 36:513-38. [PMID: 26661240 PMCID: PMC4776312 DOI: 10.1177/0271678x15617172] [Citation(s) in RCA: 357] [Impact Index Per Article: 44.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 10/21/2015] [Accepted: 10/22/2015] [Indexed: 12/25/2022]
Abstract
Advancements in molecular biology have led to a greater understanding of the individual proteins responsible for generating cerebral edema. In large part, the study of cerebral edema is the study of maladaptive ion transport. Following acute CNS injury, cells of the neurovascular unit, particularly brain endothelial cells and astrocytes, undergo a program of pre- and post-transcriptional changes in the activity of ion channels and transporters. These changes can result in maladaptive ion transport and the generation of abnormal osmotic forces that, ultimately, manifest as cerebral edema. This review discusses past models and current knowledge regarding the molecular and cellular pathophysiology of cerebral edema.
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Affiliation(s)
- Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, USA
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, USA Department of Pathology, University of Maryland School of Medicine, Baltimore, USA Department of Physiology, University of Maryland School of Medicine, Baltimore, USA
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14
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Hao Z, Chang X, Zhou H, Lin S, Liu M. A Cohort Study of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction: A Real-World Experience in Clinical Practice. Medicine (Baltimore) 2015; 94:e1039. [PMID: 26107675 PMCID: PMC4504625 DOI: 10.1097/md.0000000000001039] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Decompressive hemicraniectomy with malignant middle cerebral artery (MCA) infarction is effective but remains underutilized. The aim of this study was to observe the utilization of this intervention in mainland China.We included patients with malignant MCA infarction who admitted in West China Hospital between December 2007 to March 2011. The outcomes were death and favorable outcome (mRS < 4) at 1 month and 1 year. The multivariate logistic regression model was used to identify the independent predictors for outcomes.Ten percent (219/2174) of patients with acute ischemic stroke had malignant MCA infarction and 31.1% (68/219) patients meet the criteria that ≤60 years of age and the timing to hospital <48 hours after stroke onset. Of them, 18 patients (26.5%) underwent to decompressive hemicraniectomy. In total, 31 patients (14.2%) underwent the decompressive surgery. The average age was 53 ± 12 years; median NIHSS score was 21. The case fatality rate of patients in surgery group was significantly lower than those of in nonsurgery group at 1 month and 1 year follow-ups (32.3% and 38.7% vs. 51.1% and 61.2%, respectively, P < 0.05). Patients in surgery group had a higher proportion of good outcome at 1 year follow-up (32.2% vs. 13.3%, P = 0.006). After adjusting for confounders including age, sex, NIHSS score, and GCS score on admission, decompressive hemicraniectomy was an independent predictor of good outcome for 1 year (OR = 3.44, 95% CI, 1.27-9.31).This study shows better outcomes in the surgical group, which are consistent with findings in previous prospective randomized trials. However, this beneficial intervention remains underutilized in clinical settings.
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Affiliation(s)
- Zilong Hao
- From the Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (ZH, XC, HZ, ML); and Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (SL). Zilong Hao and Xueli Chang contributed equally to this study
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15
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Schneider AL, Jordan KG. Regional Attenuation WithOut Delta (RAWOD): A distinctive EEG pattern that can aid in the diagnosis and management of severe acute ischemic stroke. ACTA ACUST UNITED AC 2015. [DOI: 10.1080/1086508x.2005.11079517] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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16
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Raffiq MAM, Haspani MSM, Kandasamy R, Abdullah JM. Decompressive craniectomy for malignant middle cerebral artery infarction: Impact on mortality and functional outcome. Surg Neurol Int 2014; 5:102. [PMID: 25101197 PMCID: PMC4123249 DOI: 10.4103/2152-7806.135342] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Accepted: 05/13/2014] [Indexed: 12/03/2022] Open
Abstract
Background: Malignant middle cerebral artery (MCA) infarction is a devastating clinical entity affecting about 10% of stroke patients. Decompressive craniectomy has been found to reduce mortality rates and improve outcome in patients. Methods: A retrospective case review study was conducted to compare patients treated with medical therapy and decompressive surgery for malignant MCA infarction in Hospital Kuala Lumpur over a period of 5 years (from January 2007 to December 2012). A total of 125 patients were included in this study; 90 (72%) patients were treated with surgery, while 35 (28%) patients were treated with medical therapy. Outcome was assessed in terms of mortality rate at 30 days, Glasgow Outcome Score (GOS) on discharge, and modified Rankin scale (mRS) at 3 and 6 months. Results: Decompressive craniectomy resulted in a significant reduction in mortality rate at 30 days (P < 0.05) and favorable GOS outcome at discharge (P < 0.05). Good functional outcome based on mRS was seen in 48.9% of patients at 3 months and in 64.4% of patients at 6 months (P < 0.05). Factors associated with good outcome include infarct volume of less than 250 ml, midline shift of less than 10 mm, absence of additional vascular territory involvement, good preoperative Glasgow Coma Scale (GCS) score, and early surgical intervention (within 24 h) (P < 0.05). Age and dominant hemisphere infarction had no significant association with functional outcome. Conclusion: Decompressive craniectomy achieves good functional outcome in, young patients with good preoperative GCS score and favorable radiological findings treated with surgery within 24 h of ictus.
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Affiliation(s)
| | | | - Regunath Kandasamy
- Department of Neurosciences, Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Jafri Malin Abdullah
- Department of Neurosciences, Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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17
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Rahmanian A, Seifzadeh B, Razmkon A, Petramfar P, Kivelev J, Alibai EA, Hernesniemi J. Outcome of decompressive craniectomy in comparison to nonsurgical treatment in patients with malignant MCA infarction. SPRINGERPLUS 2014; 3:115. [PMID: 24711983 PMCID: PMC3977016 DOI: 10.1186/2193-1801-3-115] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 01/13/2014] [Indexed: 11/17/2022]
Abstract
Background Malignant cerebral infarction is a well-recognized disease, comprising 10-15% of all cases with cerebral infarction and causing herniation and death in 80% of cases. In this study, we compare the effects of decompressive craniectomy versus conventional medical treatment on mortality rate and functional and neurological outcome in patients with malignant MCA infarction. Methods We performed a prospective case–control study on 60 patients younger than 80years of age suffering malignant MCA cerebral infarction. The case group underwent decompressive craniectomy in addition to routine aggressive medical care; while the control group received routine medical treatment. Patient outcome was assessed using Glasgow outcome scale and modified Rankin scale within three months of follow-up. The data were analyzed by SPSS version 16.0 software using Chi Square, One-way ANOVA and Mann–Whitney tests. Results There were 27 male and 33 female patients with a mean age of 60.6 years (SD = 12.3). Glasgow outcome scale score averaged 2.93 in the surgical versus 1.53 in the medical group; this difference was significant (p = 0.001). Outcome in modified Rankin scale was also significantly lower in the surgical (3.27) versus medical (5.27) group (p < 0.001). Surgery could decrease the mortality rate about 47%. Conclusion In this study, decompressive craniectomy could decrease mortality rate, and improve neurological and functional outcome, and decrease long-term disability in patients with malignant MCA infarction.
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Affiliation(s)
- Abdolkarim Rahmanian
- Department of Neurosurgery, Shiraz University of Medical Sciences, Nemazee Hospital, P.O. Box: 71937-11351, Shiraz, Iran
| | - Babak Seifzadeh
- Department of Neurosurgery, Shiraz University of Medical Sciences, Nemazee Hospital, P.O. Box: 71937-11351, Shiraz, Iran
| | - Ali Razmkon
- Department of Neurosurgery, Shiraz University of Medical Sciences, Nemazee Hospital, P.O. Box: 71937-11351, Shiraz, Iran ; Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Peyman Petramfar
- Department of Neurology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Juri Kivelev
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260 Helsinki, Finland
| | - Ehsan-Ali Alibai
- Department of Neurosurgery, Shiraz University of Medical Sciences, Nemazee Hospital, P.O. Box: 71937-11351, Shiraz, Iran
| | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260 Helsinki, Finland
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18
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Kano T, Kurosaki S, Wada H. Retrospective analysis of hinge technique for head trauma or stroke. Neurol Med Chir (Tokyo) 2013. [PMID: 23183076 DOI: 10.2176/nmc.52.816] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Hinge technique is a new method for cerebral decompression that allows the bone flap to move outward in response to brain swelling and essentially allows reconstruction of the cranial vault as a minor procedure under local anesthesia. This retrospective study assessed outcomes following the use of this new decompressive technique. During an approximately 7-year period (June 2004 to March 2011), 58 patients who had suffered head trauma or stroke underwent cerebral decompression using the hinge technique or conventional decompressive craniectomy. Patients were assessed with the Glasgow Coma Scale (GCS), the Glasgow Outcome Scale (GOS), and the modified Rankin scale (mRS). Twenty-one patients (16 males, 5 females; age range, 21-78 yrs; mean age, 57.4 ± 15.5 yrs) underwent cerebral decompression using the hinge technique, and 37 patients (18 males, 19 females; age range, 5-83 yrs; mean age, 54.1 ± 20.9 yrs) underwent conventional decompressive craniectomy. There was no significant difference in preoperative GCS or postoperative GOS or mRS between the two groups. Six patients in the decompressive craniectomy group and none of the patients in the hinge technique group developed bone flap infection (p = 0.02). The bone flap was removed in two cases in the hinge technique group due to low cerebral perfusion pressure as well as elevated intracranial pressure (ICP). The hinge technique with ICP monitoring was effective and safe for management for head trauma or stroke and was not associated with bone flap infection.
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Affiliation(s)
- Tomoaki Kano
- Department of Neurosurgery, Fukaya Red Cross Hospital, Fukaya, Saitama.
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19
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Zhao J, Su YY, Zhang Y, Zhang YZ, Zhao R, Wang L, Gao R, Chen W, Gao D. Decompressive hemicraniectomy in malignant middle cerebral artery infarct: a randomized controlled trial enrolling patients up to 80 years old. Neurocrit Care 2012; 17:161-71. [PMID: 22528280 DOI: 10.1007/s12028-012-9703-3] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Decompressive hemicraniectomy (DHC) has proven efficacious for the treatment of malignant middle cerebral artery infarction (mMCAI) only in patients less than 60 years. This study aimed to assess the effectiveness of DHC in patients up to 80. METHODS This is a prospective, randomized, controlled trail comparing the outcomes with or without DHC in patients aged 18-80 with mMCAI (ChiCTR-TRC-11001757). The primary outcome measure was the modified Rankin Scale (mRS) scores at 6 months. The secondary outcome measures included the 6- and 12-month mortality and the mRS scores after 1 year. The prognosis of patients was evaluated independently by two blinded investigators. In addition, subgroup analyses were done for those above 60 years of age. All analyses were by intention-to-treat. RESULTS A significant reduction in the poor outcome (mRS > 4) following DHC was reached after 36 patients had completed the follow-up period of 6 months. The trial was then terminated when 47 participants (24 in the surgical group vs. 23 in the medical group) had been recruited. The final analysis, based on the outcome data of the 47 patients, showed that DHC significantly reduced mortality at 6 and 12 months (12.5 vs. 60.9 %, P = 0.001 and 16.7 vs. 69.6 %, P < 0.001, respectively), and significantly fewer patients had a mRS score >4 after surgery (33.3 vs. 82.6 %, P = 0.001 and 25.0 vs. 87.0 %, P < 0.001, respectively). Similar results were present in the subgroup analyses of elderly participants CONCLUSIONS For patients up to 80 years who suffered mMCAI, DHC within 48 h of stroke onset not only is a life-saving treatment, but also increases the possibility of surviving without severe disability (mRS = 5).
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Affiliation(s)
- Jingwei Zhao
- Division of Neurocritical Care, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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20
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Nizami FA, Ramzan AU, Wani AA, Wani MA, Malik NK, Shah PA, Asimi R. Decompressive hemicraniectomy in supra-tentorial malignant infarcts. Surg Neurol Int 2012; 3:29. [PMID: 22439120 PMCID: PMC3307248 DOI: 10.4103/2152-7806.93410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 01/02/2012] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Decompressive hemicraniectomy not only reduces the intracranial pressure but has been demonstrated to increase survival and decrease the morbidity in patients with supratentorial malignant brain infarcts (STMBI). The aim of this study was to assess the efficacy of surgical decompression to decrease the mortality and morbidity in patients with STMBI refractory to medical therapy and to compare the results with those of the medically managed patients. METHODS All the 24 consecutive patients with clinical and radiological diagnosis of STMBI, refractory to medical management in 2 years, were included. Option of surgical decompression after explaining the outcome, risk and benefits of the procedure was given to the attendants/relatives of all patients who were fulfilling the inclusion criteria. The patient group, whose attendants/relatives were not willing to undergo surgery, were subjected to the same medical therapy and they were taken as the "control group." RESULTS Supratentorial malignant infarcts were more common in the age group of 41-60 years. Mean age of presentation was 42.16 ± 16.2 years and the mean GCS on admission was 7.83 ± 2.1. Mortality was 16.7% in the surgically and 25.0% in the medically managed group. Patients operated early (<48 h), age ≤60 years, midline shift <5 mm and size of infarct less than 2/3(rd) of the vascular territory involved showed good prognosis. The functional outcome revealed by modified Rankin Score (mRS) and Glasgow Outcome Score (GOS) was better in surgically managed patients. Results of the Zung Self-Rating Depression Score were better in surgically managed patients at 1 year. Barthal Index in the surgically managed group showed statistically significant results. CONCLUSIONS Decompressive hemicraniectomy with duroplasty if performed early in STMBI not only decreases the mortality but also increases the functional outcome when compared with patients who were managed conservatively with medical therapy only.
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Affiliation(s)
- Furqan A Nizami
- Department of Neurosurgery, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Soura, Jammu and Kashmir, India
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21
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Simard JM, Sahuquillo J, Sheth KN, Kahle KT, Walcott BP. Managing malignant cerebral infarction. Curr Treat Options Neurol 2011; 13:217-29. [PMID: 21190097 DOI: 10.1007/s11940-010-0110-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OPINION STATEMENT Managing patients with malignant cerebral infarction remains one of the foremost challenges in medicine. These patients are at high risk for progressive neurologic deterioration and death due to malignant cerebral edema, and they are best cared for in the intensive care unit of a comprehensive stroke center. Careful initial assessment of neurologic function and of findings on MRI, coupled with frequent reassessment of clinical and radiologic findings using CT or MRI are mandatory to promote the prompt initiation of treatments that will ensure the best outcome in these patients. Significant deterioration in either neurologic function or radiologic findings or both demand timely treatment using the best medical management, which may include osmotherapy (mannitol or hypertonic saline), endotracheal intubation, and mechanical ventilation. Under appropriate circumstances, decompressive craniectomy may be warranted to improve outcome or to prevent death.
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Affiliation(s)
- J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
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22
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Eghwrudjakpor PO, Allison AB. Decompressive craniectomy following brain injury: factors important to patient outcome. Libyan J Med 2010; 5:10.4176/091104. [PMID: 21483545 PMCID: PMC3066780 DOI: 10.4176/091104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Accepted: 10/20/2009] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Decompressive craniectomy (DC) is often performed as an empirical lifesaving measure to protect the injured brain from the damaging effects of propagating oedema and intracranial hypertension. However, there are no clearly defined indications or specified guidelines for patient selection for the procedure. AIMS To evaluate outcome determinants and factors important in patient selection for the procedure. METHODS We reviewed the literature on DC, including single case reports and reported case series, to identify factors affecting outcome following the procedure, as well as its pitfalls and associated complications. RESULTS Glasgow coma score of 8 and above, age less than 50 years and early intervention were found to be among the most significant determinants of prognosis. CONCLUSION Improving patient selection for DC may be expected to further improve the outcome following the procedure in severely brain-injured patients.
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Affiliation(s)
- Patrick O. Eghwrudjakpor
- Patrick O. Eghwrudjakpor, Department of Surgery, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria.
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23
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Huttner HB, Jüttler E, Schwab S. Hemicraniectomy for middle cerebral artery infarction. Curr Neurol Neurosci Rep 2008; 8:526-33. [PMID: 18957191 DOI: 10.1007/s11910-008-0083-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The space-occupying so-called "malignant" middle cerebral artery infarction is-besides acute basilar artery occlusion-the most devastating form of ischemic stroke. Until recently, there was no proven treatment. In 2007, results from randomized controlled trials provided evidence for the benefit of early hemicraniectomy with respect to mortality after 3 months. This review focuses on current treatment options for malignant ischemic brain infarction, especially hemicraniectomy. Moreover, major unsolved problems and open questions regarding the disease are discussed, and perspective is given on future clinical studies.
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Affiliation(s)
- Hagen B Huttner
- Department of Neurology, University of Erlangen, Erlangen, Germany
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24
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Abstract
Decompressive Craniectomy (DC) is used to treat elevated intracranial pressure that is unresponsive to conventional treatment modalities. The underlying cause of intracranial hypertension may vary and consequently there is a broad range of literature on the uses of this procedure. Traumatic brain injury (TBI), middle cerebral artery (MCA) infarction, and aneurysmal subarachnoid hemorrhage (SAH) are three conditions for which DC has been predominantly used in the past. Despite an increasing number of reports supportive of DC, the controversy over the suitability of the procedure and criteria for patient selection remains unresolved. Although the majority of published studies is retrospective, the recent publication of several randomized prospective studies prompts a reevaluation of the utility of DC. We review the literature concerning the use of DC in TBI, MCA infarction, and SAH and address the evidence regarding common questions pertaining to the timing of and laterality of the procedure. We conclude that at the time of this review, there still remains insufficient data to support the routine use of DC in TBI, stroke or SAH. There is evidence that early and aggressive use of DC in good-grade patients may improve outcome, but the notion that DC is indicated in these patients is contentious. At this point, the indication for DC should be individualized and its potential implications on long-term outcomes should be comprehensively discussed with the caregivers.
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25
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Simard JM, Kent TA, Chen M, Tarasov KV, Gerzanich V. Brain oedema in focal ischaemia: molecular pathophysiology and theoretical implications. Lancet Neurol 2007; 6:258-68. [PMID: 17303532 PMCID: PMC2725365 DOI: 10.1016/s1474-4422(07)70055-8] [Citation(s) in RCA: 567] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Focal cerebral ischaemia and post-ischaemic reperfusion cause cerebral capillary dysfunction, resulting in oedema formation and haemorrhagic conversion. There are substantial gaps in understanding the pathophysiology, especially regarding early molecular participants. Here, we review physiological and molecular mechanisms involved. We reaffirm the central role of Starling's principle, which states that oedema formation is determined by the driving force and the capillary "permeability pore". We emphasise that the movement of fluids is largely driven without new expenditure of energy by the ischaemic brain. We organise the progressive changes in osmotic and hydrostatic conductivity of abnormal capillaries into three phases: formation of ionic oedema, formation of vasogenic oedema, and catastrophic failure with haemorrhagic conversion. We suggest a new theory suggesting that ischaemia-induced capillary dysfunction can be attributed to de novo synthesis of a specific ensemble of proteins that determine osmotic and hydraulic conductivity in Starling's equation, and whose expression is driven by a distinct transcriptional program.
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Affiliation(s)
- J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.
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26
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Jüttler E, Schellinger PD, Aschoff A, Zweckberger K, Unterberg A, Hacke W. Clinical review: Therapy for refractory intracranial hypertension in ischaemic stroke. Crit Care 2007; 11:231. [PMID: 18001491 PMCID: PMC2556730 DOI: 10.1186/cc6087] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The treatment of patients with large hemispheric ischaemic stroke accompanied by massive space-occupying oedema represents one of the major unsolved problems in neurocritical care medicine. Despite maximum intensive care, the prognosis of these patients is poor, with case fatality rates as high as 80%. Therefore, the term 'malignant brain infarction' was coined. Because conservative treatment strategies to limit brain tissue shift almost consistently fail, these massive infarctions often are regarded as an untreatable disease. The introduction of decompressive surgery (hemicraniectomy) has completely changed this point of view, suggesting that mortality rates may be reduced to approximately 20%. However, critics have always argued that the reduction in mortality may be outweighed by an accompanying increase in severe disability. Due to the lack of conclusive evidence of efficacy from randomised trials, controversy over the benefit of these treatment strategies remained, leading to large regional differences in the application of this procedure. Meanwhile, data from randomised trials confirm the results of former observational studies, demonstrating that hemicraniectomy not only significantly reduces mortality but also significantly improves clinical outcome without increasing the number of completely dependent patients. Hypothermia is another promising treatment option but still needs evidence of efficacy from randomised controlled trials before it may be recommended for clinical routine use. This review gives the reader an integrated view of the current status of treatment options in massive hemispheric brain infarction, based on the available data of clinical trials, including the most recent data from randomised trials published in 2007.
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Affiliation(s)
- Eric Jüttler
- Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany
| | - Peter D Schellinger
- Department of Neurology, University of Erlangen, Schwabachanlage 6, D-91054 Erlangen, Germany
| | - Alfred Aschoff
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany
| | - Klaus Zweckberger
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany
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Cheung A, Telaghani CK, Wang J, Yang Q, Mosher TJ, Reichwein RK, Cockroft KM. Neurological recovery after decompressive craniectomy for massive ischemic stroke. Neurocrit Care 2006; 3:216-23. [PMID: 16377832 DOI: 10.1385/ncc:3:3:216] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Decompressive craniectomy has demonstrated efficacy in reducing morbidity and mortality in critically ill patients with massive hemispheric cerebral infarction. However, little is known about the patterns of functional recovery that exist in patients after decompressive craniectomy, and controversy still exists as to whether craniotomy and infarct resection ("strokectomy") are appropriate alternatives to decompression alone. We therefore used functional magnetic resonance imaging (f-MRI) to assess the extent and location of functional recovery in patients after decompressive craniectomy for massive ischemic stroke. METHODS f-MRI was obtained in three patients with massive nondominant cerebral infarction who had undergone decompressive craniectomy for severe cerebral edema 13 to 26 months previously. Brain activation was triggered by hand-gripping or foot- movement tasks. Imaging results were combined with periodic clinical follow-up to determine the extent of neurological recovery. RESULTS Activation of the contralateral hemisphere was seen in the sensorimotor cortex, premotor, and supplementary motor areas. Lesser activation patterns were seen in equivalent regions of the infarcted hemisphere. Peri-infarct activation foci were seen in two of the three patients, but no activation occurred within the area of infarction as defined by the initial stroke seen on diffusion-weighted MRI. All three patients demonstrated some corresponding neurological improvement. CONCLUSION After massive hemispheric cerebral infarction requiring decompressive craniectomy, patients may experience functional recovery as a result of activation in both the infarcted and contralateral hemispheres. The evidence of functional recovery in peri-infarct regions suggests that decompression alone may be preferable to strokectomy where the risk of damage to adjacent nonischemic brain may be greater.
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Affiliation(s)
- Arnold Cheung
- Department of Neurological Surgery, Pennsylvania State University College of Medicine, M. S. Hershey Medical Center, Hershey, PA 17033, USA
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Els T, Oehm E, Voigt S, Klisch J, Hetzel A, Kassubek J. Safety and Therapeutical Benefit of Hemicraniectomy Combined with Mild Hypothermia in Comparison with Hemicraniectomy Alone in Patients with Malignant Ischemic Stroke. Cerebrovasc Dis 2006; 21:79-85. [PMID: 16330868 DOI: 10.1159/000090007] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2004] [Accepted: 04/14/2005] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Both for hemicraniectomy and for hypothermia, several reports describe a beneficial effect in patients with malignant supratentorial cerebral ischemia. We compared the safety and the clinical outcome in patients with a malignant supratentorial infarction who were treated with hemicraniectomy alone (HA) or received a combination therapy with hemicraniectomy and hypothermia of 35 degrees C (HH), respectively. METHODS In a prospective and randomized study, 25 consecutive patients were treated after an ischemic infarction of more than two thirds of one hemisphere by HA (n=13 patients) or the HH combination therapy (n=12 patients). Safety parameters were compared between both treatment groups, the clinical outcome was assessed during treatment and after 6 months. RESULTS Age, cranial CT or MRI findings, initial National institutes of Health Stroke Scale Score (NIHSSS) and level of consciousness were not significantly different between both groups. Hemicraniectomy was performed within 15+/- 6 h after the ischemic event. Hypothermia was induced immediately after surgery. Overall mortality was 12% (2/13 vs. 1/12 in the two groups), but none of these 3 patients died due to treatment-related complications. There were no severe side effects of hypothermia. Duration of need for intensive care or for mechanical ventilation and infectious status did not differ significantly between both groups, but the need for catecholamine application was increased in the HH group. The clinical outcome showed a tendency for a better outcome in the HH compared with the HA group with respect to status after 6 months, as assessed by the NIHSSS (10+/-1 vs. 11+/-3, p<0.08). DISCUSSION The present study suggests that a combined therapy of mild hypothermia and hemicraniectomy in malignant brain infarction does not imply additional risks by side effects and improves functional outcome as compared with hemicraniectomy alone.
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Affiliation(s)
- Thomas Els
- Department of Neurology and Neurophysiology, Albert Ludwig University, Freiburg, Germany.
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Jieyong B, Zhong W, Shiming Z, Dai Z, Kato Y, Kanno T, Sano H. Decompressive craniectomy and mild hypothermia reduces infarction size and counterregulates Bax and Bcl-2 expression after permanent focal ischemia in rats. Neurosurg Rev 2006; 29:168-72. [PMID: 16402275 DOI: 10.1007/s10143-005-0010-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2005] [Revised: 08/12/2005] [Accepted: 08/25/2005] [Indexed: 10/25/2022]
Abstract
Both mild hypothermia (MH) and decompressive craniectomy (CE) have been shown to have neuroprotective effects in brain ischemia. We investigated a possible effect of MH and a combination of CE and MH (CE + MH) on the changes of infarction size, DNA fragmentation, and immunoreactivities for Bcl-2 and Bax after 24 h of permanent middle cerebral artery occlusion (MCAO) in rats. For the estimation of ischemic brain injury, we calculated the infarct size of the MCA region at 24 h after the MCAO. Terminal deoxynucleotidyl transferase-mediated dUTP-biotin in situ nick labeling (TUNEL) staining was performed for the detection of DNA fragmentation. Immunoreactivities for Bcl-2 and Bax were stained. Infarction size after permanent MCAO was significantly reduced by CE+MH treatment (P < 0.01). Infarction size did not change significantly by application of MH alone (P > 0.05). TUNEL staining was remarkably reduced both in MH-treated animals and in CE + MH-treated animals. Immunoreactivity for Bcl-2 was greatly induced both in MH-treated animals and in CE + MH-treated animals. Induction of immunoreactivity for Bcl-2 was obviously inhibited both in MH-treated animals and in CE + MH-treated animals. It suggests that temporary MH delays infarct evolution and ameliorates neuron apoptosis but does not significantly reduce definite infarction size. CE + MH not only ameliorates neuron apoptosis but also remarkably reduces infarction size.
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Affiliation(s)
- Bian Jieyong
- Neurosurgery Department, The First Affliated Hospital to Suzhou University, People's Republic of China.
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