Neurologic Functional Outcomes of Decompressive Hemicraniectomy Versus Conventional Treatment for Malignant Middle Cerebral Artery Infarction: A Systematic Review and Meta-Analysis

Role of decompressive craniectomy in the management of acute ischemic stroke (Review)

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.

Does erythropoietin affect the outcome and complication rates of patient with traumatic brain injury? A pooled-analysis

OBJECTIVE

The aim of this meta-analysis was to review the scientific literature published until April 18, 2021, to summarize existing knowledge on the efficacy and safety of erythropoietin (EPO) for traumatic brain injury (TBI).

METHODS

This systematic review followed PRISMA guidelines. Randomized controlled trials (RCTs) reporting on the efficacy and safety of EPO in the treatment of TBI were systematically searched in relevant electronic databases according to a pre-designed search strategy. The primary outcomes are the mortality; and secondary outcomes are the good functional outcome (GFO) and adverse events (AEs).

RESULTS

A total of 10 RCTs involving 2,402 participants fulfilled the inclusion criteria. The results showed that there is a significant difference in terms of the mortality (RR = 0.67, 95% CI = 0.54-0.84, P = 0.0003) and seizure rate (RR = 0.52, 95% CI = 0.29-0.96, P = 0.04) between the EPO groups compared to those in the control groups. However, compared with the control groups, the GFO in the EPO groups was not statistically significant (RR = 1.18, 95% CI = 0.93-1.48, P = 0.17).

CONCLUSIONS

Findings of the present meta-analysis suggest that the use of EPO could reduce mortality rate in patients with TBI, without increasing the incidence of AEs. EPO has potential research and application value in the treatment of TBI.

A Real-World Assessment of Outcomes, Health Resource Utilization, and Costs Associated with Cerebral Edema in US Patients with Large Hemispheric Infarction

BACKGROUND

Patients with large hemispheric infarction (LHI) are at risk of cerebral edema (CED). This study analyzed health resource use, costs, and outcomes during and after acute hospitalization for LHI in US patients with and without CED.

METHODS

Using IBM^® MarketScan^® Commercial, Medicaid, and Medicare databases, patients with incident hospitalization for LHI (International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes of I63.03x, I63.13x, I63.23x, I63.31x, I63.41x, I63.51x) from 31 March 2016 through 31 December 2018 were identified and further categorized by the presence or absence of CED based on related diagnosis codes or a procedure code of craniectomy. Health resource use, costs, and outcomes were compared in patients with and without CED during hospitalization and after discharge.

RESULTS

Of 7336 Commercial, 1946 Medicaid, and 5015 Medicare patients with LHI, 7.8%, 6.9%, and 4.3% had CED, respectively. After adjusting for age, sex, and baseline comorbidities, differences (95% confidence intervals) in mean total costs of the index hospitalization in patients with CED versus without CED were $65,572 ($56,506-$76,335), $44,395 ($26,442-$63,495), and $31,417 ($18,982-$48,543) in the Commercial, Medicaid, and Medicare groups, respectively. Similarly, the adjusted differences (95% confidence intervals) in mean lengths of stay between patients with CED and without CED were 11.75 (10.17-13.48), 10.84 (7.59-14.17), and 3.69 (2.40-5.19) days, respectively. Mortality during index hospitalization was 10-20 times greater in patients with CED versus without CED (p < 0.0001). In those patients who survived and had at least 30-days of follow-up after discharge, CED was also associated with higher post-discharge resource utilization and costs in the commercially insured population who were younger than Medicare patients, and had fewer comorbidities than Medicare and Medicaid patients. This indicates the effect of CED after discharge was particularly burdensome for younger individuals.

CONCLUSIONS

In this large cohort study, inpatient mortality, health resource utilization and costs were consistently higher in patients with LHI who developed CED than in those without CED. These findings underscore the need for greater awareness of CED among policymakers and healthcare practitioners.

Safety and efficacy of intravascular therapy in patients with progressive stroke caused by intracranial large vascular occlusion exceeding the time window of 24 hours

PURPOSE

To compare endovascular and drug therapies for efficacy and safety in patients with a progressive stroke caused by intracranial large vascular occlusion exceeding the time window of 24 hours.

PATIENTS AND METHODS

A total of 58 patients with progressive stroke caused by large intracranial vascular occlusion exceeding the time window of 24 hours treated in the stroke center of our hospital for three years were retrospectively analyzed . According to the applied therapy, 58 patients were divided into the endovascular (n = 19) and drug (n = 39) therapy groups. Then, modified Rankin scale (mRS) scores, symptomatic intracranial hemorrhage rates, mortality rates and adverse events were assessed in both groups within 90 days.

RESULTS

The 90-day good prognosis rate was significantly higher in the endovascular therapy group compared with the drug group (68.4% VS 38.5%, odds ratio [OR] = 0.29; 95% confidence interval [CI], 0.09-0.92; P = 0.032). The 90-day NIHSS scores were lower in the endovascular therapy group compared with the drug group (3.3 ± 2.6 VS 5.2 ± 3.0, OR = -1.89; 95%CI, -3.50 to -0.27; P = 0.023). Meanwhile, the proportion of patients with a Barthel index of 90-100 was significantly higher in the endovascular therapy group compared with the drug group (53.0% VS 25.6%, OR = 0.31; 95%CI, 0.10-0.98; P = 0.042). Finally, both groups showed similar rates of adverse events.

CONCLUSION

In patients with progressive stroke caused by large intracranial vascular occlusion exceeding 24 hours, endovascular therapy probably results in improved efficacy at 90 days compared with drug therapy, without increasing the rates of adverse effects.

Decompressive craniotomy for malignant middle cerebral artery infarction: The quest for an African perspective

Background:

Although associated with controversy, decompressive craniotomy (DC) for malignant middle cerebral artery infarction (MMCAI) is an unequivocally lifesaving intervention. DC for MMCAI is rarely performed in lower- to middle-income countries.

Methods:

A systemic review was performed in attempt to determine the rates of utilization and outcomes of DC on the African continent.

Results:

Only two African studies describing DC for MMCAI were found.

Conclusion:

DC for MMCAI is rarely performed and/or reported on the African continent. The African perspective for this needs to be urgently broadened.

European Stroke Organisation (ESO) guidelines on the management of space-occupying brain infarction

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.

Outcomes and resource use of patients with large hemispheric infarction and cerebral edema: analysis of real-world data

OBJECTIVE

Large hemispheric infarction (LHI) is associated with a high likelihood of the evolution of life-threatening edema. Few studies have assessed real-world clinical outcomes and management strategies among patients with LHI. The objective of this study was to describe the management, in-hospital outcomes, and direct healthcare resource burden of patients with LHI, as well as those of patients with subsequent cerebral edema.

METHODS

This observational, retrospective cohort study analyzed de-identified data from US adult patients using the IBM MarketScan Hospital Drug Database (Q4-2015 to Q4-2017). Patients were included in the "Possible LHI" or the "Other Ischemic Strokes" cohorts using ICD-10 diagnosis codes. Patients with possible LHI were further categorized into "LHI with Edema" and "LHI without Edema" subgroups using diagnosis and procedure codes. Select clinical and economic outcomes were compared between cohorts and subgroups using multivariable regressions.

RESULTS

Of 79,201 eligible encounters with ischemic strokes, 11,772 unique patients were assigned to the Possible LHI cohort while 67,429 were assigned to the Other Ischemic Strokes cohort. Among patients with possible LHI, 869 (7%) were assigned to the LHI with Edema subgroup and 10,903 (93%) were assigned to the LHI without Edema subgroup. Patients in the Possible LHI cohort had longer hospital stays (mean difference [MD] [95%CI] = 2.6 [2.4;2.8] days), higher total facility charges (MD [95%CI] = $28,656 [26,794;30,524]), and higher odds of death (odds ratio [95%CI] = 2.2 [2.0;2.4]) than the Other Ischemic Strokes cohort. Among patients with possible LHI, the incremental clinical and resource burden was further exacerbated in the subgroup of patients with edema (hospital days: MD [95%CI] = 5.0 [3.9;6.2] days; total facility charges: MD [95%CI] = $59,585 [50,816;67,583]; mortality: odds ratio [95%CI] = 10.3 [8.5;12.4]).

CONCLUSIONS

Among patients with ischemic strokes, LHI was associated with increased clinical management and direct healthcare resource burden in real-world hospital settings. The burden was substantially increased among patients who developed cerebral edema.

Net Water Uptake Calculated in Standardized and Blindly Outlined Regions of the Middle Cerebral Artery Territory Predicts the Development of Malignant Edema in Patients With Acute Large Hemispheric Infarction

Background and purpose: Previous studies have demonstrated that Net Water Uptake (NWU) is associated with the development of malignant edema (ME). The current study aimed to investigate whether NWU calculated in standardized and blindly outlined regions of the middle cerebral artery can predict the development of ME. Methods: We retrospectively included 119 patients suffering from large hemispheric infarction within onset of 24 h. The region of the middle cerebral artery territory was blindly outlined in a standard manner to calculate NWU. Patients were divided into two groups according to the occurrence of ME, which is defined as space-occupying infarct requiring decompressive craniotomy or death due to cerebral hernia in 7 days from onset. The clinical characteristics were analyzed, and the receiver operating characteristic curve (ROC curve) was used to assess the predictive ability of NWU and other factors for ME. Results: Multivariable analysis showed that NWU was an independent predictor of ME (OR 1.168, 95% CI 1.041-1.310). According to the ROC curve, NWU≥8.127% identified ME with good predictive power (AUC 0.734, sensitivity 0.656, specificity 0.862). Conclusions: NWU calculated in standardized and blindly outlined regions of the middle cerebral artery territory is also a good predictor for the development of ME in patients with large hemispheric infarction.

Long-Term Survival After Decompressive Craniectomy for Malignant Brain Infarction: A 10-Year Nationwide Study

BACKGROUND

Decompressive craniectomy (DC) has been shown to be an effective treatment for malignant cerebral infarction (MCI). There are limited nationwide studies evaluating outcome after craniectomy for MCI.

OBJECTIVE

To describe the evolution in DC practices for MCI, long-term survival, and associated prognostic factors.

METHODS

We searched the French medico-administrative national database to retrieve patients who underwent DC between 2008 and 2017.

RESULTS

A total of 1841 cases of DC were performed over 10 years in 51 centers. Mean age at procedure was 50.9 years, 18% were above 60 years, and 64.4% were male. There was a significant increase in DC for MCI over the 10 years (p < 0.001), and the annual volume of procedures more than doubled (95/year vs. 243/year). Early survival at one week and one month was 86%, _95%CI (84.5, 87.6) and 79.7%, _95%CI (77.8, 81.5), respectively. Long-term survival at 1 and 5 years were 73.6%, _95%CI (71.6, 75.7) and 68.9%, _95%CI (66.5, 71.4), respectively. Patients below 60 years at the time of DC (HR = 0.5; _95%CI [0.4, 0.7], p < 0.001), DC being performed in a center with a high surgical activity (HR = 0.8; _95%CI [0.6, 0.9], p = 0.002), and the patients having unimpaired consciousness (HR = 0.6; _95%CI [0.5, 0.8], p < 0.001) were associated with increased survival in both univariate and adjusted Cox regressions. 18.7% of the survivors had a cranioplasty inserted within 3 months and 57.8% within 6 months. The probability of having a cranioplasty at one year was 75.6%, _95%CI (77.9, 73.1).

CONCLUSION

Over the past 10 years in France, DC has been increasingly performed for MCI regardless of age. However, in-hospital mortality remains considerable, as about one quarter of patients died within the first weeks. For those who survive beyond 6 months, the risk of death significantly decreases. Early mortality is especially high for comatose patients above 60 years operated in inexperienced centers. Most of those who remain in good functional status tend to undergo a cranioplasty within the year following DC.

Clinical determination of serum nardilysin levels in predicting 30-day mortality among adults with malignant cerebral infarction

BACKGROUND

Nardilysin, a kind of metalloendopeptidase, plays an important role in numerous inflammatory diseases. Malignant cerebral infarction (Glasgow coma scale score of <9) is associated with a high mortality risk. Here, we intended to investigate the relationship between serum nardilysin levels and prognosis of patients with malignant cerebral infarction.

METHODS

Serum nardilysin concentrations were quantified at malignant cerebral infarction diagnosis moment in 105 patients and at study entrance in 105 healthy controls. Association of nardilysin concentrations with 30-day mortality and overall survival was estimated using multivariate analyses.

RESULTS

The patients exhibited substantially increased serum nardilysin concentrations, as compared to the controls. Nardilysin concentrations were in pronounced correlation with Glasgow coma scale scores and serum C-reactive protein concentrations. Serum nardilysin was independently predictive of 30-day mortality and overall survival. Under receiver operating characteristic curve, its high discriminatory ability was found.

CONCLUSIONS

Rising serum nardilysin concentrations following malignant cerebral infarction are strongly related to stroke severity, inflammatory extent and a higher risk of mortality, substantializing serum nardilysin as a potential prognostic biomarker for malignant cerebral infarction.

Conservative Treatment for Delayed Infection After Cranioplasty With Titanium Alloy

Cranioplasty (CP) is considered a low-risk operation in the field of neurosurgery following decompression craniectomy. Nevertheless, CP is still burdened by surgical complications, among which early or late infections are the most common outcome-threatening ones. Most of infection cases occur within a week after CP. Except that, implant-associated scalp infection is the most common complication, and leads to implant removal in many patients with refractory and recurrent infection. The authors reported a patient presenting with epidural infection about 3 months after titanium implant and cured by anti-infective treatment for 2 weeks.

Immunological, vascular, metabolic, and autonomic changes seen with aging possible implications for poor outcomes in the elderly following decompressive hemicraniectomy for malignant MCA stroke: a critical review

INTRODUCTION

Stroke is one of the leading causes of mortality and morbidity worldwide and requires rapid and intensive treatment to prevent adverse outcomes. Decompressive hemicraniectomy stands as the gold standard for surgical resolution of the intracranial swelling which accompanies cerebral infarction; however, the benefits of this procedure are not as well achieved in the elderly (age >65 years) compared to the younger population.

EVIDENCE ACQUISITION

This is a critical review performed on all available literature relating to middle cerebral artery (MCA) stroke in the elderly with emphasis on articles examining causality of adverse outcomes in this group over younger populations. Utilizing PRISMA guidelines, we initially identified 1462 articles.

EVIDENCE SYNTHESIS

After screening, four clear areas of physiological change associated with aging were identified and expounded upon as they relate to MCA stroke. These four areas include: immunological, autonomic, mitochondrial, and vascular changes. Elderly patients have a decreased and declining capacity to regulate the inflammation that develops postinfarction and this contributes to adverse outcomes from a neurological stand point. Additionally, aging decreases the ability of elderly patients to regulate their autonomic system resulting in aberrant blood pressures systemically post infarction. With age, the mitochondrial response to ischemia is exaggerated and causes greater local damage in elderly patients compared to younger populations. Finally, there are numerous vascular changes that occur with age including accumulation of homocysteine and atherosclerosis which together contributed to decreased structural integrity of the vasculature in the elderly and render decreased support to the recovery process post infarction.

CONCLUSIONS

We conclude that physiological changes inherent in the aging process serve to intensify adverse outcomes that are commonly associated with strokes in the elderly. Identification and subsequent minimization of these risk factors could allow for more effective management of elderly patients, post stroke, and promote better clinical outcomes.

A multiparameter model predicting in-hospital mortality in malignant cerebral infarction

The early identification of patients with large hemisphere infarctions (LHIs) at risk of fatal brain edema may result in better outcomes. A quantitative model using parameters obtained at admission may be a predictor of in-hospital mortality from LHI.This prospective study enrolled all patients with LHI involving >50% of the middle cerebral artery (MCA) admitted to our neurological intensive care unit within 48 hours of symptom onset. Early clinical and radiographic parameters and the baseline CHADS2 score (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke [double weight]) were analyzed regarding their ability to predict patient outcomes.Seventy-seven patients with LHIs were identified, 33 (42.9%) with complete MCA infarction (CMCA), and 44 (57.1%) with incomplete MCA infarction (IMCA). The predictors of CMCA score included: >1/3 early hypodensity in computed tomography findings, hyperdense MCA sign, brain edema, initial National Institutes of Health Stroke Scale (NIHSS) score ≥17, and stroke in progression during the 1st 5 days of admission. The cutoff CMCA score was 2, with a sensitivity of 81.8% and specificity of 70.5%. Mortality score 1, used for predicting in-hospital mortality from LHI, included CMCA and CHADS2 scores ≥4 (sensitivity 100.0%, specificity 57.4%), and mortality score 2 included CMCA and CHADS2 scores ≥4, and NIHSS score ≥26, during the 1st 5 days (sensitivity 100.0%, specificity 91.7%).Patients qualifying for a mortality score of 2 were at high-risk of in-hospital mortality from LHI. These findings may aid in identifying patients who may benefit from invasive therapeutic strategies, and in better describing the characteristics of those at risk of mortality.

Real-Time Distal, Multifocal, Repeated Lenticulostriate Bleeding Points during Thrombectomy in a Patient with Acute Variable M1 Occlusion: A Case Report and a Literature Review

BACKGROUND

Intracerebral hemorrhage can be classified as either primary or secondary to various conditions such as vascular anomalies or stroke. We present a case of real-time incident detected on digital subtraction angiography (DSA) during thrombectomy in a patient with acute variable M1 occlusion.

MATERIALS AND METHODS

A comprehensive literature search of the PubMed and Scopus databases was conducted: this is the first real-time visualization using DSA of a basal ganglia hematoma formation secondary to distal multifocal bleeding points just before a thrombectomy in a patient with acute variable M1 occlusion.

CONCLUSION

We suggest that the positions of the clot before and during the procedure be compared always.