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Xu H, Zheng M, Liu W, Peng W, Qiu J, Huang W, Zhang J, Xin E, Xia N, Lin R, Qiu C, Cao G, Chen W, Yang Y, Qian Y, Chen J. Enhanced Prediction of Malignant Cerebral Edema in Large Vessel Occlusion with Successful Recanalization Through Automated Weighted Net Water Uptake. World Neurosurg 2024; 188:e312-e319. [PMID: 38796145 DOI: 10.1016/j.wneu.2024.05.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Accepted: 05/16/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Malignant cerebral edema (MCE) is associated with both net water uptake (NWU) and infarct volume. We hypothesized that NWU weighted by the affected Alberta Stroke Program Early Computed Tomography Score (ASPECTS) regions could serve as a quantitative imaging biomarker of aggravated edema development in acute ischemic stroke with large vessel occlusion (LVO). The aim of this study was to evaluate the performance of weighted NWU (wNWU) to predict MCE in patients with mechanical thrombectomy (MT). METHODS We retrospectively analyzed consecutive patients who underwent MT due to LVO. NWU was computed from nonenhanced computed tomography scans upon admission using automated ASPECTS software. wNWU was derived by multiplying NWU with the number of affected ASPECTS regions in the ischemic hemisphere. Predictors of MCE were assessed through multivariate logistic regression analysis and receiver operating characteristic curves. RESULTS NWU and wNWU were significantly higher in MCE patients than in non-MCE patients. Vessel recanalization status influenced the performance of wNWU in predicting MCE. In patients with successful recanalization, wNWU was an independent predictor of MCE (adjusted odds ratio 1.61; 95% confidence interval [CI] 1.24-2.09; P < 0.001). The model integrating wNWU, National Institutes of Health Stroke Scale, and collateral score exhibited an excellent performance in predicting MCE (area under the curve 0.80; 95% CI 0.75-0.84). Among patients with unsuccessful recanalization, wNWU did not influence the development of MCE (adjusted odds ratio 0.99; 95% CI 0.60-1.62; P = 0.953). CONCLUSIONS This study revealed that wNWU at admission can serve as a quantitative predictor of MCE in LVO with successful recanalization after MT and may contribute to the decision for early intervention.
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Affiliation(s)
- Haoli Xu
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu, China; Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Mo Zheng
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wenhui Liu
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Weili Peng
- Cancer Center, Department of Interventional Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Jiamei Qiu
- Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Wangle Huang
- Department of Nuclear Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jiaqi Zhang
- Cancer Center, Department of Interventional Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Enhui Xin
- Department of Research and Development, Shanghai United Imaging Intelligence Co., Ltd., Shanghai, China
| | - Nengzhi Xia
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ru Lin
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Chaomin Qiu
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Guoquan Cao
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Weijian Chen
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yunjun Yang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; Department of Nuclear Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yinfeng Qian
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jun Chen
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu, China; Cancer Center, Department of Interventional Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China.
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Kowoll CM, Schumm L, Gieffers A, Lemale CL, Major S, Dohmen C, Fink GR, Brinker G, von Pidoll T, Dömer P, Dreier JP, Hecht N, Woitzik J. Duration of spreading depression is the electrophysiological correlate of infarct growth in malignant hemispheric stroke. J Cereb Blood Flow Metab 2024:271678X241262203. [PMID: 38902207 DOI: 10.1177/0271678x241262203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
Spreading depolarizations (SD) contribute to lesion progression after experimental focal cerebral ischemia while such correlation has never been shown in stroke patients. In this prospective, diagnostic study, we investigate the association of SDs and secondary infarct progression after malignant hemispheric stroke. SDs were continuously monitored for 3-9 days with electrocorticography after decompressive hemicraniectomy for malignant hemispheric stroke. To ensure valid detection and analysis of SDs, a threshold based on the electrocorticographic baseline activity was calculated to identify valid electrocorticographic recordings. Subsequently SD characteristics were analyzed in association to infarct progression based on serial MRI. Overall, 62 patients with a mean stroke volume of 289.6 ± 68 cm3 were included. Valid electrocorticographic recordings were found in 44/62 patients with a mean recording duration of 139.6 ± 26.5 hours and 52.5 ± 39.5 SDs per patient. Infarct progression of more than 5% was found in 21/44 patients. While the number of SDs was similar between patients with and without infarct progression, the SD-induced depression duration per day was significantly longer in patients with infarct progression (593.8 vs. 314.1 minutes; *p = 0.046). Therefore, infarct progression is associated with a prolonged SD-induced depression duration. Real-time analysis of electrocorticographic recordings may identify secondary stroke progression and help implementing targeted management strategies.
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Affiliation(s)
- Christina M Kowoll
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Department of Neurology, Märkische Kliniken Lüdenscheid, Lüdenscheid, Germany
| | - Leonie Schumm
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Alexandra Gieffers
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Coline L Lemale
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christian Dohmen
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Department of Neurology, LVR-Klinik Bonn, Bonn, Germany
| | - Gereon R Fink
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Cognitive Neuroscience, Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich, Jülich, Germany
| | - Gerrit Brinker
- Department of Neurosurgery, University of Cologne, Cologne, Germany
| | - Tilmann von Pidoll
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Department of Trauma Surgery, SANA-Dreifaltigkeitskrankenhaus Cologne, Cologne, Germany
| | - Patrick Dömer
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
- Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Jens P Dreier
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Bernstein Centre for Computational Neuroscience Berlin, Berlin, Germany
- Einstein Centre for Neurosciences Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
- Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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Rodríguez-Vázquez A, Laredo C, Reyes L, Dolz G, Doncel-Moriano A, Llansó L, Rudilosso S, Llull L, Renú A, Amaro S, Torné R, Urra X, Chamorro Á. Computed tomography perfusion as an early predictor of malignant cerebral infarction. Eur Stroke J 2024:23969873241260965. [PMID: 38872264 DOI: 10.1177/23969873241260965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024] Open
Abstract
INTRODUCTION Malignant middle cerebral artery infarction (MCI) needs rapid intervention. This study aimed to enhance the prediction of MCI using computed tomography perfusion (CTP) with varied quantitative benchmarks. MATERIALS AND METHODS We retrospectively analyzed 253 patients from a single-center registry presenting with acute, severe, proximal large vessel occlusion studied with whole-brain CTP imaging at hospital arrival within the first 24 h of symptoms-onset. MCI was defined by clinical and imaging criteria, including decreased level of consciousness, anisocoria, death due to cerebral edema, or need for decompressive craniectomy, together with midline shift ⩾6 mm, or infarction of more than 50% of the MCA territory. The predictive accuracy of baseline ASPECTS and CTP quantifications for MCI was assessed by receiver operating characteristic (ROC) area under the curve (AUC) while F-score was calculated as an indicator of precision and sensitivity. RESULTS Sixty-three out of 253 patients (25%) fulfilled MCI criteria and had worse clinical and imaging results than the non-MCI group. The capacity to predict MCI was lower for baseline ASPECTS (AUC 0.83, F-score 0.52, Youden's index 6), than with perfusion-based measures: relative cerebral blood volume threshold <40% (AUC 0.87, F-score 0.71, Youden's index 34 mL) or relative cerebral blood flow threshold <35% (AUC 0.87, F-score 0.62, Youden's index 67 mL). CTP based on rCBV measurements identified twice as many MCI as baseline CT ASPECTS. DISCUSSION AND CONCLUSION CTP-based quantifications may offer enhanced predictive capabilities for MCI compared to non-contrast baseline CT ASPECTS, potentially improving the monitoring of severe ischemic stroke patients at risk of life-threatening edema and its treatment.
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Affiliation(s)
- Alejandro Rodríguez-Vázquez
- Department of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació de Recerca Clínic Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
| | - Carlos Laredo
- Fundació de Recerca Clínic Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
| | - Luis Reyes
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Guillem Dolz
- Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Laura Llansó
- Department of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Salvatore Rudilosso
- Department of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació de Recerca Clínic Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
| | - Laura Llull
- Department of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació de Recerca Clínic Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Arturo Renú
- Department of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació de Recerca Clínic Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
| | - Sergio Amaro
- Department of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació de Recerca Clínic Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Ramón Torné
- Fundació de Recerca Clínic Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Xabier Urra
- Department of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació de Recerca Clínic Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Ángel Chamorro
- Department of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
- Fundació de Recerca Clínic Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
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Comer AR, Jawed A, Roeder H, Kramer N. The impact of sex and gender on advanced stroke interventions and end-of-life outcomes after stroke. J Stroke Cerebrovasc Dis 2024; 33:107820. [PMID: 38876458 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 06/16/2024] Open
Abstract
OBJECTIVES In this review, we examine the impact of sex and gender on advanced stroke interventions and end-of-life outcomes after stroke and discuss the current theories, available evidence, and gaps in the literature. METHODS A scoping review of the literature was conducted to determine gender differences on advanced stroke interventions and end-of-life outcomes after stroke. The study team utilized PubMed to conduct a review of the literature and included research studies related to sex, gender, advanced stroke interventions, and end-of-life outcomes after stroke. The PRISMA process for conducting a scoping review was followed. RESULTS This review found that although evidence regarding gender differences in advanced stroke interventions and end-of-life care after stroke is disparate, some gender differences do indeed exist. Women are less likely to receive thrombectomy or alteplase, women are more likely to receive palliative care intervention, hospice, and women experience stroke mortality at higher rates. CONCLUSIONS Gender differences in end-of-life care after stroke are apparent with women experiencing lower rates of life sustaining interventions, and higher rates of mortality, palliative and hospice care. More research is needed to identify variables associated with or responsible for gender differences during advance interventions and end-of-life care after stroke.
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Affiliation(s)
- Amber R Comer
- American Medical Association, Indiana University, United States.
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5
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Mee H, Harris JM, Korhonen T, Anwar F, Wahba AJ, Martin M, Whiting G, Viaroli E, Timofeev I, Helmy A, Kolias AG, Hutchinson PJ. Decompressive craniectomy to cranioplasty: a retrospective observational study using Hospital Episode Statistics in England. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2024; 6:e000253. [PMID: 38835401 PMCID: PMC11149159 DOI: 10.1136/bmjsit-2023-000253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 05/13/2024] [Indexed: 06/06/2024] Open
Abstract
Objectives To investigate the longitudinal trends of decompressive craniectomy (DC) following traumatic brain injury (TBI) or stroke and explore whether the timing of cranial reconstruction affected revision or removal rates using Hospital Episode Statistics (HES) between 2014 and 2019. Design Retrospective observational cohort study using HES. The time frame definitions mirror those often used in clinical practice. Setting HES data from neurosurgical centres in England. Participants HES data related to decompressive craniectomy procedures and cranioplasty following TBI or stroke between 2014 and 2019. Main outcome measures The primary outcome was the timing and rate of revision/removal compared with cranioplasty within <12 weeks to ≥12 weeks. Results There were 4627 DC procedures, of which 1847 (40%) were due to head injury, 1116 (24%) were due to stroke, 728 (16%) were due to other cerebrovascular diagnoses, 317 (7%) had mixed diagnosis and 619 (13%) had no pre-specified diagnoses. The number of DC procedures performed per year ranged from 876 in 2014-2015 to 967 in 2018-2019. There were 4466 cranioplasty procedures, with 309 (7%) revisions and/or removals during the first postoperative year. There was a 33% increase in the overall number of cranioplasty procedures performed within 12 weeks, and there were 1823 patients who underwent both craniectomy and cranioplasty during the study period, with 1436 (79%) having a cranioplasty within 1 year. However, relating to the timing of cranial reconstruction, there was no evidence of any difference in the rate of revision or removal surgery in the early timing group (6.5%) compared with standard care (7.9%) (adjusted HR 0.93, 95% CIs 0.61 to 1.43; p=0.75). Conclusions Overall number of craniectomies and the subsequent requirements for cranioplasty increased steadily during the study period. However, relating to the timing of cranial reconstruction, there was no evidence of an overall difference in the rate of revision or removal surgery in the early timing group.
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Affiliation(s)
- Harry Mee
- Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | - T Korhonen
- Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Neurosurgery, University of Oulu, Oulu, Finland
| | - F Anwar
- Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | - G Whiting
- Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - E Viaroli
- Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - I Timofeev
- Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - A Helmy
- Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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6
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Beck J, Fung C, Strbian D, Bütikofer L, Z'Graggen WJ, Lang MF, Beyeler S, Gralla J, Ringel F, Schaller K, Plesnila N, Arnold M, Hacke W, Jüni P, Mendelow AD, Stapf C, Al-Shahi Salman R, Bressan J, Lerch S, Hakim A, Martinez-Majander N, Piippo-Karjalainen A, Vajkoczy P, Wolf S, Schubert GA, Höllig A, Veldeman M, Roelz R, Gruber A, Rauch P, Mielke D, Rohde V, Kerz T, Uhl E, Thanasi E, Huttner HB, Kallmünzer B, Jaap Kappelle L, Deinsberger W, Roth C, Lemmens R, Leppert J, Sanmillan JL, Coutinho JM, Hackenberg KAM, Reimann G, Mazighi M, Bassetti CLA, Mattle HP, Raabe A, Fischer U. Decompressive craniectomy plus best medical treatment versus best medical treatment alone for spontaneous severe deep supratentorial intracerebral haemorrhage: a randomised controlled clinical trial. Lancet 2024; 403:2395-2404. [PMID: 38761811 DOI: 10.1016/s0140-6736(24)00702-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 03/16/2024] [Accepted: 04/04/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND It is unknown whether decompressive craniectomy improves clinical outcome for people with spontaneous severe deep intracerebral haemorrhage. The SWITCH trial aimed to assess whether decompressive craniectomy plus best medical treatment in these patients improves outcome at 6 months compared to best medical treatment alone. METHODS In this multicentre, randomised, open-label, assessor-blinded trial conducted in 42 stroke centres in Austria, Belgium, Finland, France, Germany, the Netherlands, Spain, Sweden, and Switzerland, adults (18-75 years) with a severe intracerebral haemorrhage involving the basal ganglia or thalamus were randomly assigned to receive either decompressive craniectomy plus best medical treatment or best medical treatment alone. The primary outcome was a score of 5-6 on the modified Rankin Scale (mRS) at 180 days, analysed in the intention-to-treat population. This trial is registered with ClincalTrials.gov, NCT02258919, and is completed. FINDINGS SWITCH had to be stopped early due to lack of funding. Between Oct 6, 2014, and April 4, 2023, 201 individuals were randomly assigned and 197 gave delayed informed consent (96 decompressive craniectomy plus best medical treatment, 101 best medical treatment). 63 (32%) were women and 134 (68%) men, the median age was 61 years (IQR 51-68), and the median haematoma volume 57 mL (IQR 44-74). 42 (44%) of 95 participants assigned to decompressive craniectomy plus best medical treatment and 55 (58%) assigned to best medical treatment alone had an mRS of 5-6 at 180 days (adjusted risk ratio [aRR] 0·77, 95% CI 0·59 to 1·01, adjusted risk difference [aRD] -13%, 95% CI -26 to 0, p=0·057). In the per-protocol analysis, 36 (47%) of 77 participants in the decompressive craniectomy plus best medical treatment group and 44 (60%) of 73 in the best medical treatment alone group had an mRS of 5-6 (aRR 0·76, 95% CI 0·58 to 1·00, aRD -15%, 95% CI -28 to 0). Severe adverse events occurred in 42 (41%) of 103 participants receiving decompressive craniectomy plus best medical treatment and 41 (44%) of 94 receiving best medical treatment. INTERPRETATION SWITCH provides weak evidence that decompressive craniectomy plus best medical treatment might be superior to best medical treatment alone in people with severe deep intracerebral haemorrhage. The results do not apply to intracerebral haemorrhage in other locations, and survival is associated with severe disability in both groups. FUNDING Swiss National Science Foundation, Swiss Heart Foundation, Inselspital Stiftung, and Boehringer Ingelheim.
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Affiliation(s)
- Jürgen Beck
- Department of Neurosurgery, University of Bern, Bern, Switzerland; Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Christian Fung
- Department of Neurosurgery, University of Bern, Bern, Switzerland; Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Lukas Bütikofer
- Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Werner J Z'Graggen
- Department of Neurosurgery, University of Bern, Bern, Switzerland; Department of Neurology, University of Bern, Bern, Switzerland
| | - Matthias F Lang
- University Institute of Diagnostic and Interventional Neuroradiology, University of Bern, Bern, Switzerland
| | - Seraina Beyeler
- Department of Neurology, University of Bern, Bern, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University of Bern, Bern, Switzerland
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| | - Karl Schaller
- Department of Neurosurgery, University of Geneva, Geneva, Switzerland
| | - Nikolaus Plesnila
- Institute for Stroke and Dementia Research, LMU University Hospital, Munich, Germany
| | - Marcel Arnold
- Department of Neurosurgery, University of Bern, Bern, Switzerland
| | - Werner Hacke
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Jüni
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Christian Stapf
- Department of Neurosciences, Université de Montréal, and Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences and Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Jenny Bressan
- Department of Neurology, University of Bern, Bern, Switzerland; Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Stefanie Lerch
- Department of Neurology, University of Bern, Bern, Switzerland; Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Arsany Hakim
- University Institute of Diagnostic and Interventional Neuroradiology, University of Bern, Bern, Switzerland
| | | | - Anna Piippo-Karjalainen
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gerrit A Schubert
- Department of Neurosurgery, RWTH Aachen, University Hospital Aachen, Aachen, Germany; Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Anke Höllig
- Department of Neurosurgery, RWTH Aachen, University Hospital Aachen, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen, University Hospital Aachen, Aachen, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Philip Rauch
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Dorothee Mielke
- Department of Neurosurgery, University Hospital Goettingen, Goettingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Hospital Goettingen, Goettingen, Germany
| | - Thomas Kerz
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| | - Eberhard Uhl
- Department of Neurosurgery, Justus-Liebig-Universität Gießen, Gießen, Germany
| | - Enea Thanasi
- Department of Neurosurgery, Justus-Liebig-Universität Gießen, Gießen, Germany
| | - Hagen B Huttner
- Department of Neurology, Justus-Liebig-Universität Gießen, Gießen, Germany; Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - L Jaap Kappelle
- Department of Neurology, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Christian Roth
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - Robin Lemmens
- University Hospitals Leuven, Department of Neurology, Leuven, Belgium
| | - Jan Leppert
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jose L Sanmillan
- Department of Neurosurgery, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Location AMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, Netherlands
| | - Katharina A M Hackenberg
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Gernot Reimann
- Klinikum Dortmund, Klinikum der Universität Witten-Herdecke, Dortmund, Germany
| | - Mikael Mazighi
- Department of Neurology, Lariboisière University Hospital and Department of Interventional Neuroradiology, Rothschild Foundation Hospital, FHU Neurovasc, INSERM 1144, Paris Cité Université, Paris, France; Department of Neurointensive Care, Rothschild Foundation Hospital, Paris France
| | | | | | - Andreas Raabe
- Department of Neurosurgery, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University of Bern, Bern, Switzerland; Department of Neurology, Basel University Hospital, University of Basel, Basel, Switzerland.
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Ellens NR, Albert GP, Bender MT, George BP, McHugh DC. Trends and predictors of decompressive craniectomy in acute ischemic stroke, 2011-2020. J Stroke Cerebrovasc Dis 2024; 33:107713. [PMID: 38583545 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 03/29/2024] [Accepted: 04/04/2024] [Indexed: 04/09/2024] Open
Abstract
INTRODUCTION Rates of decompressive craniectomy (DC) in acute ischemic stroke (AIS) have been reported to decline over time, attributed to an increase in endovascular therapy (EVT) preventing the development of malignant cerebral edema. We sought to characterize trends in DC in AIS between 2011 and 2020. MATERIAL AND METHODS We performed a retrospective observational study of U.S. AIS hospitalizations using the National Inpatient Sample, 2011 to 2020. We calculated rates of DC per 10,000 AIS among all AIS hospitalizations, as well as AIS hospitalizations undergoing invasive mechanical ventilation (IMV). A logistic regression to determine predictors of DC was performed. RESULTS Of ∼4.4 million AIS hospitalizations, 0.5 % underwent DC; of ∼300,000 AIS with IMV, 5.8 % underwent DC. From 2011 to 2020, the rate of DC increased from 37.4 to 59.1 per 10,000 AIS (p < 0.001). The rate of DC in patients undergoing IMV remained stable at ∼550 per 10,000 (p = 0.088). The most important factors predicting DC were age (OR 4.88, 95 % CI 4.53-5.25), hospital stroke volume (OR 2.61, 95 % CI 2.17-3.14), hospital teaching status (OR 1.54, 95 % CI 1.36-1.75), and transfer status (OR 1.53, 95 % CI 1.41-1.66); EVT status did not predict DC. CONCLUSIONS The rate of DC in AIS has increased between 2011 and 2020. Our findings are contrary to prior reports of decreasing DC rates over time. Increasing EVT rates do not seem to be preventing the occurrence of DC. Future research should focus on the decision-making process for both clinicians and surrogates regarding DC with consideration of long-term outcomes.
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Affiliation(s)
- Nathaniel R Ellens
- Department of Neurological Surgery, University of Rochester Medical Center, Rochester, NY, United States
| | - George P Albert
- Department of Neurology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 673, Rochester, NY 14642, United States
| | - Matthew T Bender
- Department of Neurological Surgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Benjamin P George
- Department of Neurology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 673, Rochester, NY 14642, United States
| | - Daryl C McHugh
- Department of Neurology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 673, Rochester, NY 14642, United States.
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Leslie-Mazwi TM. Neurocritical Care for Patients With Ischemic Stroke. Continuum (Minneap Minn) 2024; 30:611-640. [PMID: 38830065 DOI: 10.1212/con.0000000000001427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Management of stroke due to large vessel occlusion (LVO) has undergone unprecedented change in the past decade. Effective treatment with thrombectomy has galvanized the field and led to advancements in all aspects of care. This article provides a comprehensive examination of neurologic intensive care unit (ICU) management of patients with stroke due to LVO. The role of the neurocritical care team in stroke systems of care and the importance of prompt diagnosis, initiation of treatment, and continued monitoring of patients with stroke due to LVO is highlighted. LATEST DEVELOPMENTS The management of complications commonly associated with stroke due to LVO, including malignant cerebral edema and respiratory failure, are addressed, stressing the importance of early identification and aggressive treatment in mitigating negative effects on patients' prognoses. In the realm of medical management, this article discusses various medical therapies, including antithrombotic therapy, blood pressure management, and glucose control, outlining evidence-based strategies for optimizing patient outcomes. It further emphasizes the importance of a multidisciplinary approach to provide a comprehensive care model. Lastly, the critical aspect of family communication and prognostication in the neurologic ICU is addressed. ESSENTIAL POINTS This article emphasizes the multidimensional aspects of neurocritical care in treating patients with stroke due to LVO.
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Sarikaya-Seiwert S, Shabo E, Schievelkamp AH, Born M, Wispel C, Haberl H. Decompressive craniotomy in split-technique (DCST) for TBI in infants: introducing a new surgical technique to prevent long-term complications. Childs Nerv Syst 2024:10.1007/s00381-024-06445-1. [PMID: 38789688 DOI: 10.1007/s00381-024-06445-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION Decompressive craniectomy (DC) is rarely required in infants. These youngest patients are vulnerable to blood loss, and cranial reconstruction can be challenging due to skull growth and bone flap resorption. On the other hand, infants have thin and flexible bone and osteogenic potential. MATERIAL AND METHODS: We propose a new technique called DCST, which makes use of these unique aspects by achieving decompression using the circumstance of the thin and flexible bone. We describe the surgical technique and the follow-up course over a period of 13 months. RESULTS AND CONCLUSION In our study, DCST achieved adequate decompression and no further repeated surgeries in accordance with decompressive craniectomy were needed afterwards.
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Affiliation(s)
- Sevgi Sarikaya-Seiwert
- Section of Pediatric Neurosurgery, Department of Neurosurgery, Medical Faculty, Rheinische Friedrich Wilhelms University, Venusberg Campus 1, Bonn, D-53127, Bonn, Germany.
| | - Ehab Shabo
- Section of Pediatric Neurosurgery, Department of Neurosurgery, Medical Faculty, Rheinische Friedrich Wilhelms University, Venusberg Campus 1, Bonn, D-53127, Bonn, Germany.
| | - Arndt-Hendrik Schievelkamp
- Department of Neuroradiology, University Hospital Bonn, 53127, Bonn, Germany
- Department of Neuroradiology, University Hospital Koeln, Koeln, Germany
| | - Mark Born
- Section of Pediatric Radiology, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Christian Wispel
- Section of Pediatric Neurosurgery, Department of Neurosurgery, Medical Faculty, Rheinische Friedrich Wilhelms University, Venusberg Campus 1, Bonn, D-53127, Bonn, Germany
| | - Hannes Haberl
- Department of Neurosurgery, Schoen Clinic Vogtareuth, Munich, Germany
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Figueroa-Sanchez JA, Martinez HR, Riaño-Espinoza M, Avalos-Montes PJ, Moran-Guerrero JA, Solorzano-Lopez EJ, Perez-Martinez LE, Flores-Salcido RE. Partial Cranial Reconstruction Using Titanium Mesh after Craniectomy: An Antiadhesive and Protective Barrier with Improved Aesthetic Outcomes. World Neurosurg 2024; 185:207-215. [PMID: 38403012 DOI: 10.1016/j.wneu.2024.02.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/16/2024] [Accepted: 02/17/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVE Describe a new, safe, technique that uses titanium mesh to partially cover skull defects immediately after decompressive craniectomy (DC). METHODS This study is a retrospective review of 8 patients who underwent DC and placement of a titanium mesh. The mesh partially covered the defect and was placed between the temporalis muscle and the dura graft. The muscle was sutured to the mesh. All patients underwent cranioplasty at a later time. The study recorded and analyzed demographic information, time between surgeries, extra-axial fluid collections, postoperative infections, need for reoperation, cortical hemorrhages, and functional and aesthetic outcomes. RESULTS After craniectomy, all patients underwent cranioplasty within an average of 112.5 days (30-240 days). One patient reported temporalis muscle atrophy, which was the only complication observed. During the cranioplasties, no adhesions were found between temporalis muscle, titanium mesh, and underlying dura. None of the patients showed complications in the follow-up computerized tomography scans. All patients had favorable aesthetic and functional results. CONCLUSIONS Placing a titanium mesh as an extra step during DC could have antiadhesive and protective properties, facilitating subsequent cranioplasty by preventing adhesions and providing a clear surgical plane between the temporalis muscle and intracranial tissues. This technique also helps preserve the temporalis muscle and enhances functional and aesthetic outcomes postcranioplasty. Therefore, it represents a safe alternative to other synthetic anti-adhesive materials. Further studies are necessary to draw definitive conclusions and elucidate long-term outcomes, however, the results obtained hold great promise for the safety and efficacy of this technique.
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Affiliation(s)
- Jose A Figueroa-Sanchez
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico; Instituto de Neurologia y Neurocirugia, Centro Médico Zambrano Hellion TecSalud, Monterrey, Mexico
| | - Hector R Martinez
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico; Instituto de Neurologia y Neurocirugia, Centro Médico Zambrano Hellion TecSalud, Monterrey, Mexico.
| | | | - Pablo J Avalos-Montes
- Instituto de Neurologia y Neurocirugia, Centro Médico Zambrano Hellion TecSalud, Monterrey, Mexico
| | - Jose A Moran-Guerrero
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico; Instituto de Neurologia y Neurocirugia, Centro Médico Zambrano Hellion TecSalud, Monterrey, Mexico
| | - E J Solorzano-Lopez
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
| | - Luis E Perez-Martinez
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico; Instituto de Neurologia y Neurocirugia, Centro Médico Zambrano Hellion TecSalud, Monterrey, Mexico
| | - Rogelio E Flores-Salcido
- Instituto de Neurologia y Neurocirugia, Centro Médico Zambrano Hellion TecSalud, Monterrey, Mexico
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Pohlmann JE, Kim ISY, Brush B, Sambhu KM, Conti L, Saglam H, Milos K, Yu L, Cronin MFM, Balogun O, Chatzidakis S, Zhang Y, Trinquart L, Huang Q, Smirnakis SM, Benjamin EJ, Dupuis J, Greer DM, Ong CJ. Association of large core middle cerebral artery stroke and hemorrhagic transformation with hospitalization outcomes. Sci Rep 2024; 14:10008. [PMID: 38693282 PMCID: PMC11063151 DOI: 10.1038/s41598-024-60635-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 04/25/2024] [Indexed: 05/03/2024] Open
Abstract
Historically, investigators have not differentiated between patients with and without hemorrhagic transformation (HT) in large core ischemic stroke at risk for life-threatening mass effect (LTME) from cerebral edema. Our objective was to determine whether LTME occurs faster in those with HT compared to those without. We conducted a two-center retrospective study of patients with ≥ 1/2 MCA territory infarct between 2006 and 2021. We tested the association of time-to-LTME and HT subtype (parenchymal, petechial) using Cox regression, controlling for age, mean arterial pressure, glucose, tissue plasminogen activator, mechanical thrombectomy, National Institute of Health Stroke Scale, antiplatelets, anticoagulation, temperature, and stroke side. Secondary and exploratory outcomes included mass effect-related death, all-cause death, disposition, and decompressive hemicraniectomy. Of 840 patients, 358 (42.6%) had no HT, 403 (48.0%) patients had petechial HT, and 79 (9.4%) patients had parenchymal HT. LTME occurred in 317 (37.7%) and 100 (11.9%) had mass effect-related deaths. Parenchymal (HR 8.24, 95% CI 5.46-12.42, p < 0.01) and petechial HT (HR 2.47, 95% CI 1.92-3.17, p < 0.01) were significantly associated with time-to-LTME and mass effect-related death. Understanding different risk factors and sequelae of mass effect with and without HT is critical for informed clinical decisions.
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Affiliation(s)
- Jack E Pohlmann
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, MA, 02118, USA
- Department of Epidemiology, School of Public Health, Boston University, 715 Albany St, Boston, MA, 02118, USA
| | - Ivy So Yeon Kim
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, MA, 02118, USA
| | - Benjamin Brush
- Department of Neurology, NYU Langone Medical Center, 550 1st Ave, New York, NY, 10016, USA
| | - Krishna M Sambhu
- Department of Neurology, Boston University School of Medicine, Chobanian and Avedisian School of Medicine, 85 E Concord St., Suite 1116, Boston, MA, 02118, USA
| | - Lucas Conti
- Department of Neurology, Boston University School of Medicine, Chobanian and Avedisian School of Medicine, 85 E Concord St., Suite 1116, Boston, MA, 02118, USA
| | - Hanife Saglam
- Department of Neurology, Brigham & Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Katie Milos
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, MA, 02118, USA
| | - Lillian Yu
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, MA, 02118, USA
| | - Michael F M Cronin
- Department of Neurology, Boston University School of Medicine, Chobanian and Avedisian School of Medicine, 85 E Concord St., Suite 1116, Boston, MA, 02118, USA
| | - Oluwafemi Balogun
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, MA, 02118, USA
| | - Stefanos Chatzidakis
- Department of Neurology, Brigham & Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Yihan Zhang
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, MA, 02118, USA
| | - Ludovic Trinquart
- Department of Epidemiology, School of Public Health, Boston University, 715 Albany St, Boston, MA, 02118, USA
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Boston, MA, 02111, USA
- Tufts Clinical and Translational Science Institute, Tufts University, 419 Boston, Ave, Medford, MA, 02155, USA
| | - Qiuxi Huang
- Department of Epidemiology, School of Public Health, Boston University, 715 Albany St, Boston, MA, 02118, USA
| | - Stelios M Smirnakis
- Department of Neurology, Brigham & Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
- Department of Neurology, Jamaica Plain Veterans Administration Medical Center, 150 S Huntington Ave, Boston, MA, 02130, USA
| | - Emelia J Benjamin
- Department of Epidemiology, School of Public Health, Boston University, 715 Albany St, Boston, MA, 02118, USA
- Department of Cardiology, Boston Medical Center and Boston University Chobanian and Avedisian School of Medicine, 85 E Concord St, Boston, MA, 02118, USA
| | - Josée Dupuis
- Department of Epidemiology, School of Public Health, Boston University, 715 Albany St, Boston, MA, 02118, USA
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 2001 McGill College, Montreal, QC, Canada
| | - David M Greer
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, MA, 02118, USA
- Department of Neurology, Boston University School of Medicine, Chobanian and Avedisian School of Medicine, 85 E Concord St., Suite 1116, Boston, MA, 02118, USA
| | - Charlene J Ong
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, MA, 02118, USA.
- Department of Neurology, Boston University School of Medicine, Chobanian and Avedisian School of Medicine, 85 E Concord St., Suite 1116, Boston, MA, 02118, USA.
- Department of Neurology, Brigham & Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA.
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12
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Aaron S, Ferreira JM, Coutinho JM, Canhão P, Conforto AB, Arauz A, Carvalho M, Masjuan J, Sharma VK, Putaala J, Uyttenboogaart M, Werring DJ, Bazan R, Mohindra S, Weber J, Coert BA, Kirubakaran P, Sanchez van Kammen M, Singh P, Aguiar de Sousa D, Ferro JM. Outcomes of Decompressive Surgery for Patients With Severe Cerebral Venous Thrombosis: DECOMPRESS2 Observational Study. Stroke 2024; 55:1218-1226. [PMID: 38572636 DOI: 10.1161/strokeaha.123.045051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 02/28/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Decompressive neurosurgery is recommended for patients with cerebral venous thrombosis (CVT) who have large parenchymal lesions and impending brain herniation. This recommendation is based on limited evidence. We report long-term outcomes of patients with CVT treated by decompressive neurosurgery in an international cohort. METHODS DECOMPRESS2 (Decompressive Surgery for Patients With Cerebral Venous Thrombosis, Part 2) was a prospective, international cohort study. Consecutive patients with CVT treated by decompressive neurosurgery were evaluated at admission, discharge, 6 months, and 12 months. The primary outcome was death or severe disability (modified Rankin Scale scores, 5-6) at 12 months. The secondary outcomes included patient and caregiver opinions on the benefits of surgery. The association between baseline variables before surgery and the primary outcome was assessed by multivariable logistic regression. RESULTS A total of 118 patients (80 women; median age, 38 years) were included from 15 centers in 10 countries from December 2011 to December 2019. Surgery (115 craniectomies and 37 hematoma evacuations) was performed within a median of 1 day after diagnosis. At last assessment before surgery, 68 (57.6%) patients were comatose, fixed dilated pupils were found unilaterally in 27 (22.9%) and bilaterally in 9 (7.6%). Twelve-month follow-up data were available for 113 (95.8%) patients. Forty-six (39%) patients were dead or severely disabled (modified Rankin Scale scores, 5-6), of whom 40 (33.9%) patients had died. Forty-two (35.6%) patients were independent (modified Rankin Scale scores, 0-2). Coma (odds ratio, 2.39 [95% CI, 1.03-5.56]) and fixed dilated pupil (odds ratio, 2.22 [95% CI, 0.90-4.92]) were predictors of death or severe disability. Of the survivors, 56 (78.9%) patients and 61 (87.1%) caregivers expressed a positive opinion on surgery. CONCLUSIONS Two-thirds of patients with severe CVT were alive and more than one-third were independent 1 year after decompressive surgery. Among survivors, surgery was judged as worthwhile by 4 out of 5 patients and caregivers. These results support the recommendation to perform decompressive neurosurgery in patients with CVT with impending brain herniation.
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Affiliation(s)
- Sanjit Aaron
- Neurology Unit, Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu, India (S.A., P.K., P.S.)
| | - Jorge M Ferreira
- Serviço de Neurologia, Centro Hospitalar Universitário Lisboa Central, Portugal (Jorge M. Ferreira)
| | - Jonathan M Coutinho
- Department of Neurology (J.M.C., M.S.v.K.), Amsterdam University Medical Centers, University of Amsterdam, the Netherlands
| | - Patrícia Canhão
- Serviço de Neurologia, Departamento de Neurociências e Saúde Mental, Centro Hospitalar Universitário Lisboa Norte, Portugal (P.C.)
- Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Portugal (P.C., D.A.d.S., José M. Ferro)
| | | | - Antonio Arauz
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico (A.A.)
| | - Marta Carvalho
- Serviço de Neurologia, Unidade Local de Saúde São João (M.C.)
- Departamento de Neurociências Clínicas e Saúde Mental, Faculdade de Medicina da Universidade do Porto, Portugal (M.C.)
| | - Jaime Masjuan
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Instituto Ramon y Cajal de Investigación Sanitaria (IRYCIS), Departamento de Medicina, Universidad de Alcalá. Red Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS), Madrid, Spain (J.M.)
| | - Vijay K Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (V.K.S.)
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Finland (J.P.)
| | - Maarten Uyttenboogaart
- Department of Neurology and Medical Imaging Center, University Medical Center Groningen, University of Groningen, the Netherlands (M.U.)
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, United Kingdom (D.J.W.)
| | - Rodrigo Bazan
- Faculdade de Medicina Campus de Botucatu, Universidade Estadual Paulista Julio de Mesquita Filho, Botucatu, São Paulo, Brazil (R.B.)
| | - Sandeep Mohindra
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India (S.M.)
| | - Jochen Weber
- Department of Neurosurgery, Steinenberg Clinic, Reutlingen, Germany (J.W.)
| | - Bert A Coert
- Department of Neurosurgery (B.A.C.). Amsterdam University Medical Centers, University of Amsterdam, the Netherlands
| | - Prabhu Kirubakaran
- Neurology Unit, Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu, India (S.A., P.K., P.S.)
| | - Mayte Sanchez van Kammen
- Department of Neurology (J.M.C., M.S.v.K.), Amsterdam University Medical Centers, University of Amsterdam, the Netherlands
| | - Pankaj Singh
- Neurology Unit, Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu, India (S.A., P.K., P.S.)
| | - Diana Aguiar de Sousa
- Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Portugal (P.C., D.A.d.S., José M. Ferro)
- Stroke Center, Lisbon Central University Hospital, Portugal (D.A.d.S.)
| | - José M Ferro
- Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Portugal (P.C., D.A.d.S., José M. Ferro)
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Luo X, Yang B, Yuan J, An H, Xie D, Han Q, Zhou S, Yue C, Sang H, Qiu Z, Kong Z, Shi Z. Decompressive craniectomy for patients with malignant infarction of the middle cerebral artery: A pooled analysis of two randomized controlled trials. J Stroke Cerebrovasc Dis 2024; 33:107719. [PMID: 38604351 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 04/06/2024] [Accepted: 04/08/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Decompressive craniectomy (DC) reduces mortality without increasing the risk of very severe disability among patients with life-threatening massive cerebral infarction. However, its efficacy was demonstrated before the era of endovascular thrombectomy trials. It remains uncertain whether DC improves the prognosis of patients with malignant middle cerebral artery (MCA) infarction receiving endovascular therapy. METHODS We pooled data from two trials (DEVT and RESCUE BT studies in China) and patients with malignant MCA infarction were included to assess outcomes and heterogeneity of DC therapy effect. Patients with herniation were dichotomized into DC and conservative groups according to their treatment strategy. The primary outcome was the rate of mortality at 90 days. Secondary outcomes included disability level at 90 days as measured by the modified Rankin Scale score (mRS) and quality-of-life score. The associations of DC with clinical outcomes were performed using multivariable logistic regression. RESULTS Of 98 patients with herniation, 37 received DC surgery and 61 received conservative treatment. The median (interquartile range) was 70 (62-76) years and 40.8% of the patients were women. The mortality rate at 90 days was 59.5% in the DC group compared with 85.2% in the conservative group (adjusted odds ratio, 0.31 [95% confidence interval (CI), 0.10-0.94]; P=0.04). There were 21.6% of patients in the DC group and 6.6% in the conservative group who had a mRS score of 4 (moderately severe disability); and 10.8% and 4.9%, respectively, had a score of 5 (severe disability). The quality-of-life score was higher in the DC group (0.00 [0.00-0.14] vs 0.00 [0.00-0.00], P=0.004), but DC treatment was not associated with better quality-of-life score in multivariable analyses (adjusted β Coefficient, 0.02 [95% CI, -0.08-0.11]; p=0.75). CONCLUSIONS DC was associated with decreased mortality among patients with malignant MCA infarction who received endovascular therapy. The majority of survivors remained moderately severe disability and required improvement on quality of life. CLINICAL TRIAL REGISTRATION The DEVT trial: http://www.chictr.org. Identifier, ChiCTR-IOR-17013568. The RESCUE BT trial: URL: http://www.chictr.org. Identifier, ChiCTR-INR-17014167.
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Affiliation(s)
- Xiaojun Luo
- Department of Cerebrovascular Diseases, Guangyuan Central Hospital, Guangyuan, China
| | - Bo Yang
- Department of Neurology, The First Affiliated Hospital of Henan Polytechnic University (Jiaozuo Second People's Hospital), Jiaozuo, China
| | - Junjie Yuan
- Department of Neurology, The 925th Hospital of The People's Liberation Army, Guiyang, China; Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Huijie An
- Department of Pharmacy, General Hospital of Southern Theatre Command, PLA, Guangzhou, China
| | - Dongjing Xie
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Qin Han
- Department of Neurology, The 903rd Hospital of The People's Liberation Army, Hangzhou, China
| | - Simin Zhou
- Department of Neurosurgery, The 904th Hospital of The People's Liberation Army, Wuxi, China
| | - Chengsong Yue
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Hongfei Sang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhenyu Kong
- Department of Neurology, The First Affiliated Hospital of Henan Polytechnic University (Jiaozuo Second People's Hospital), Jiaozuo, China
| | - Zhonghua Shi
- Department of Neurosurgery, The 904th Hospital of The People's Liberation Army, 101 North Xinyuan Road, Wuxi, China.
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14
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In YN, Kim HI, Park JS, Kang C, You Y, Min JH, Lee D, Lee IH, Jeong HS, Lee BK, Lee JK. Association between quantitative analysis of cerebral edema using CT imaging and neurological outcomes in cardiac arrest survivors. Am J Emerg Med 2024; 78:22-28. [PMID: 38181542 DOI: 10.1016/j.ajem.2023.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 12/10/2023] [Accepted: 12/22/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND To determine if the density distribution proportion of Hounsfield unit (HUdp) in head computed tomography (HCT) images can be used to quantitatively measure cerebral edema in survivors of out-of-hospital cardiac arrest (OHCA). METHODS This retrospective observational study included adult comatose OHCA survivors who underwent HCT within 6 h (first) and 72-96 h (second), all performed using the same CT scanner. Semi-automated quantitative analysis was used to identify differences in HUdp at specific HU ranges across the intracranial component based on neurological outcome. Cerebral edema was defined as the increased displacement of the sum of HUdp values (ΔHUdp) at a specific range between two HCT scans. Poor neurological outcome was defined as cerebral performance categories 3-5 at 6 months after OHCA. RESULTS Twenty-three (42%) out of 55 patients had poor neurological outcome. Significant HUdp differences were observed between good and poor neurological outcomes in the second HCT scan at HU = 1-14, 23-35, and 39-56 (all P < 0.05). Only the ΔHUdp = 23-35 range showed a significant increase and correlation in the poor neurological outcome group (4.90 vs. -0.72, P < 0.001) with the sum of decreases in the other two ranges (r = 0.97, P < 0.001). Multivariate logistic regression analysis demonstrated a significant association between ΔHUdp = 23-35 range and poor neurological outcomes (adjusted OR, 1.12; 95% CI: 1.02-1.24; P = 0.02). CONCLUSION In this cohort study, the increased displacement in ΔHUdp = 23-35 range is independently associated with poor neurological outcome and provides a quantitative assessment of cerebral edema formation in OHCA survivors.
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Affiliation(s)
- Yong Nam In
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea; Department of Emergency Medicine, Chungnam National University Sejong Hospital, Daejoen, Republic of Korea
| | - Ho Il Kim
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Jung Soo Park
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea; Department of Emergency Medicine, Chungnam National University Hospital, Daejoen, Republic of Korea.
| | - Changshin Kang
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea; Department of Emergency Medicine, Chungnam National University Hospital, Daejoen, Republic of Korea
| | - Yeonho You
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea; Department of Emergency Medicine, Chungnam National University Hospital, Daejoen, Republic of Korea
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea; Department of Emergency Medicine, Chungnam National University Sejong Hospital, Daejoen, Republic of Korea
| | - Dongyoung Lee
- Department of Emergency Medicine, Chungnam National University Hospital, Daejoen, Republic of Korea
| | - In Ho Lee
- Department of Radiology, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Hye Seon Jeong
- Department of Neurology, Chungnam National University Hospital, 266, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Chonnam National Univesity Hospital, Gwangju, Republic of Korea
| | - Jae Kwang Lee
- Department of Emergency Medicine, Konyang University Hospital, College of Medicine, Republic of Korea
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15
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Findlay M, Bauer SZ, Gautam D, Holdaway M, Kim RB, Salah WK, Twitchell S, Menacho ST, Gandhoke GS, Grandhi R. Cost differences between autologous and nonautologous cranioplasty implants: A propensity score-matched value driven outcomes analysis. World Neurosurg X 2024; 22:100358. [PMID: 38440375 PMCID: PMC10909750 DOI: 10.1016/j.wnsx.2024.100358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 02/21/2024] [Indexed: 03/06/2024] Open
Affiliation(s)
- Matthew Findlay
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Sawyer Z. Bauer
- Reno School of Medicine, University of Nevada, Reno, NV, USA
| | - Diwas Gautam
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | | | - Robert B. Kim
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Walid K. Salah
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Spencer Twitchell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Sarah T. Menacho
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Gurpreet S. Gandhoke
- Department of Surgery, University of Missouri Kansas City, Marion Bloch Neuroscience Institute, Saint Luke's Hospital of Kansas City, Kansas, MO, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
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16
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Hernandez-Duran S, Walter J, Behmanesh B, Bernstock JD, Czabanka M, Dinc N, Dubinski D, Freiman TM, Günther A, Hellmuth K, Herrmann E, Konczalla J, Maier I, Melkonian R, Mielke D, Müller SJ, Naser P, Rohde V, Schaefer JH, Senft C, Storch A, Unterberg A, Walter U, Wittstock M, Gessler F, Won SY. Necrosectomy Versus Stand-Alone Suboccipital Decompressive Craniectomy for the Management of Space-Occupying Cerebellar Infarctions-A Retrospective Multicenter Study. Neurosurgery 2024; 94:559-566. [PMID: 37800900 DOI: 10.1227/neu.0000000000002707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/08/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Space-occupying cerebellar stroke (SOCS) when coupled with neurological deterioration represents a neurosurgical emergency. Although current evidence supports surgical intervention in such patients with SOCS and rapid neurological deterioration, the optimal surgical methods/techniques to be applied remain a matter of debate. METHODS We conducted a retrospective, multicenter study of patients undergoing surgery for SOCS. Patients were stratified according to the type of surgery as (1) suboccipital decompressive craniectomy (SDC) or (2) suboccipital craniotomy with concurrent necrosectomy. The primary end point examined was functional outcome using the modified Rankin Scale (mRS) at discharge and at 3 months (mRS 0-3 defined as favorable and mRS 4-6 as unfavorable outcome). Secondary end points included the analysis of in-house postoperative complications, mortality, and length of hospitalization. RESULTS Ninety-two patients were included in the final analysis: 49 underwent necrosectomy and 43 underwent SDC. Those with necrosectomy displayed significantly higher rate of favorable outcome at discharge as compared with those who underwent SDC alone: 65.3% vs 27.9%, respectively ( P < .001, odds ratios 4.9, 95% CI 2.0-11.8). This difference was also observed at 3 months: 65.3% vs 41.7% ( P = .030, odds ratios 2.7, 95% CI 1.1-6.7). No significant differences were observed in mortality and/or postoperative complications, such as hemorrhagic transformation, infection, and/or the development of cerebrospinal fluid leaks/fistulas. CONCLUSION In the setting of SOCS, patients treated with necrosectomy displayed better functional outcomes than those patients who underwent SDC alone. Ultimately, prospective, randomized studies will be needed to confirm this finding.
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Affiliation(s)
| | - Johannes Walter
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg , Germany
| | - Bedjan Behmanesh
- Department of Neurosurgery, University Medicine Rostock, Rostock , Germany
| | - Joshua D Bernstock
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston , Massachusetts , USA
| | - Marcus Czabanka
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main , Germany
| | - Nazife Dinc
- Department of Neurosurgery, Jena University Hospital, Jena , Germany
| | - Daniel Dubinski
- Department of Neurosurgery, University Medicine Rostock, Rostock , Germany
| | - Thomas M Freiman
- Department of Neurosurgery, University Medicine Rostock, Rostock , Germany
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena , Germany
| | - Kara Hellmuth
- Department of Neurosurgery, University Medicine Rostock, Rostock , Germany
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modelling, Goethe University, Frankfurt am Main , Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main , Germany
| | - Ilko Maier
- Department of Neurology, Göttingen University Hospital, Göttingen , Germany
| | | | - Dorothee Mielke
- Department of Neurosurgery, Göttingen University Hospital, Göttingen , Germany
| | - Sebastian Johannes Müller
- Department of Neuroradiology, Göttingen University Hospital, Göttingen , Germany
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart , Germany
| | - Paul Naser
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg , Germany
| | - Veit Rohde
- Department of Neurosurgery, Göttingen University Hospital, Göttingen , Germany
| | - Jan Hendrik Schaefer
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main , Germany
| | - Christian Senft
- Department of Neurosurgery, Jena University Hospital, Jena , Germany
| | - Alexander Storch
- Department of Neurology, University Medicine Rostock, Rostock , Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg , Germany
| | - Uwe Walter
- Department of Neurology, University Medicine Rostock, Rostock , Germany
| | | | - Florian Gessler
- Department of Neurosurgery, University Medicine Rostock, Rostock , Germany
| | - Sae-Yeon Won
- Department of Neurosurgery, University Medicine Rostock, Rostock , Germany
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17
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Adwane G, Lapergue B, Piotin M, Gory B, Blanc R, Consoli A, Rodesch G, Mazighi M, Kyheng M, Labreuche J, Pico F. Frequency and predictors of decompressive craniectomy in ischemic stroke patients treated by mechanical thrombectomy in the ETIS registry. Rev Neurol (Paris) 2024; 180:177-181. [PMID: 37863718 DOI: 10.1016/j.neurol.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 08/09/2023] [Accepted: 08/30/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND AND AIMS Mechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS) is usually performed in a comprehensive stroke center with on-site neurosurgical expertise. The question of whether MT can be performed in a primary stroke center without a neurosurgical facility is debated. In this context, there is a need to determine the frequency, delay and predictors of neurosurgical procedures in patients treated by MT. This study aims to determine these factors. METHODS In total, 432 patients under 60years old, diagnosed with an acute ischemic stroke with a large vessel occlusion and treated by MT between January 2018 and December 2019 in six French stroke centers, were selected from the French clinical registry ETIS. Univariate and multivariate logistic regression models were used to identify predictive factors for decompressive craniectomy. RESULTS Among the 432 included patients, 43 (9.9%) patients with an anterior circulation infarct underwent decompressive craniectomy. Higher admission NIHSS (OR: 1.08 [95% CI: 1.02-1.16]), lower ASPECT (OR per 1 point of decrease 1.53 [1.31-1.79] P<0.001) and preadmission antiplatelet use (OR: 3.03 [1.31-7.01]) were independent risk factors for decompressive craniectomy. The risk of decompressive craniectomy increases to more than 30% with an ASPECT score<4, an NIHSS>16, and current antiplatelet use. CONCLUSION In this multicenter registry, 9% of acute ischemic stroke patients (<60years old) treated with MT, required decompressive craniectomy. Higher NIHSS score, lower ASPECT score, and preadmission antiplatelet use increase the risk of subsequent requirement for decompressive craniectomy.
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Affiliation(s)
- G Adwane
- Department of Neurology and Stroke Center, Centre Hospitalier de Versailles, Versailles, France; Departement of Neurology and Stroke Center, Rothschild Foundation, Paris ,Fance.
| | - B Lapergue
- Neurology Department and Stroke Center, Foch Hospital, Suresnes, France
| | - M Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - B Gory
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France
| | - R Blanc
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - A Consoli
- Department of Diagnostic and Interventional Neuroradiology, Hopital Foch, Suresnes, France
| | - G Rodesch
- Department of Diagnostic and Interventional Neuroradiology, Hopital Foch, Suresnes, France
| | - M Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France; Paris Denis-Diderot University, Paris, France
| | - M Kyheng
- Lille University, CHU de Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, 59000 Lille, France
| | - J Labreuche
- Lille University, CHU de Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, 59000 Lille, France
| | - F Pico
- Department of Neurology and Stroke Center, Centre Hospitalier de Versailles, Versailles, France; Versailles Saint-Quentin-en-Yvelines and Paris Saclay University, Versailles, France; INSERM, Laboratory for Vascular Translational Science (LVTS)-1148, Paris, France
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18
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Im SH, Yoo DS, Park HK. Proper Indication of Decompressive Craniectomy for the Patients with Massive Brain Edema after Intra-arterial Thrombectomy. J Korean Neurosurg Soc 2024; 67:227-236. [PMID: 38173228 PMCID: PMC10924906 DOI: 10.3340/jkns.2023.0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 08/21/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE Numerous studies have indicated that early decompressive craniectomy (DC) for patients with major infarction can be life-saving and enhance neurological outcomes. However, most of these studies were conducted by neurologists before the advent of intra-arterial thrombectomy (IA-Tx). This study aims to determine whether neurological status significantly impacts the final clinical outcome of patients who underwent DC following IA-Tx in major infarction. METHODS This analysis included 67 patients with major anterior circulation major infarction who underwent DC after IA-Tx, with or without intravenous tissue plasminogen activator. We retrospectively reviewed the medical records, radiological findings, and compared the neurological outcomes based on the "surgical time window" and neurological status at the time of surgery. RESULTS For patients treated with DC following IA-Tx, a Glasgow coma scale (GCS) score of 7 was the lowest score correlated with a favorable outcome (p=0.013). Favorable outcomes were significantly associated with successful recanalization after IA-Tx (p=0.001) and perfusion/diffusion (P/D)-mismatch evident on magnetic resonance imaging performed immediately prior to IA-Tx (p=0.007). However, the surgical time window (within 36 hours, p=0.389; within 48 hours, p=0.283) did not correlate with neurological outcomes. CONCLUSION To date, early DC surgery after major infarction is crucial for patient outcomes. However, this study suggests that the indication for DC following IA-Tx should include neurological status (GCS ≤7), as some patients treated with early DC without considering the neurological status may undergo unnecessary surgery. Recanalization of the occluded vessel and P/D-mismatch are important for long-term neurological outcomes.
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Affiliation(s)
- Sang-Hyuk Im
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do-Sung Yoo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hae-Kwan Park
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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19
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Won SY, Hernández-Durán S, Behmanesh B, Bernstock JD, Czabanka M, Dinc N, Dubinski D, Freiman TM, Günther A, Hellmuth K, Herrmann E, Konczalla J, Maier I, Melkonian R, Mielke D, Naser P, Rohde V, Senft C, Storch A, Unterberg A, Walter J, Walter U, Wittstock M, Schaefer JH, Gessler F. Functional Outcomes in Conservatively vs Surgically Treated Cerebellar Infarcts. JAMA Neurol 2024:2815568. [PMID: 38407889 PMCID: PMC10897822 DOI: 10.1001/jamaneurol.2023.5773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 12/21/2023] [Indexed: 02/27/2024]
Abstract
Importance According to the current American Heart Association/American Stroke Association guidelines, decompressive surgery is indicated in patients with cerebellar infarcts that demonstrate severe cerebellar swelling. However, there is no universal definition of swelling and/or infarct volume(s) available to support a decision for surgery. Objective To evaluate functional outcomes in surgically compared with conservatively managed patients with cerebellar infarcts. Design, Setting, and Participants In this retrospective multicenter cohort study, patients with cerebellar infarcts treated at 5 tertiary referral hospitals or stroke centers within Germany between 2008 and 2021 were included. Data were analyzed from November 2020 to November 2023. Exposures Surgical treatment (ie, posterior fossa decompression plus standard of care) vs conservative management (ie, medical standard of care). Main Outcomes and Measures The primary outcome examined was functional status evaluated by the modified Rankin Scale (mRS) at discharge and 1-year follow-up. Secondary outcomes included the predicted probabilities for favorable outcome (mRS score of 0 to 3) stratified by infarct volumes or Glasgow Coma Scale score at admission and treatment modality. Analyses included propensity score matching, with adjustments for age, sex, Glasgow Coma Scale score at admission, brainstem involvement, and infarct volume. Results Of 531 included patients with cerebellar infarcts, 301 (57%) were male, and the mean (SD) age was 68 (14.4) years. After propensity score matching, a total of 71 patients received surgical treatment and 71 patients conservative treatment. There was no significant difference in favorable outcomes (ie, mRS score of 0 to 3) at discharge for those treated surgically vs conservatively (47 [66%] vs 45 [65%]; odds ratio, 1.1; 95% CI, 0.5-2.2; P > .99) or at follow-up (35 [73%] vs 33 [61%]; odds ratio, 1.8; 95% CI, 0.7-4.2; P > .99). In patients with cerebellar infarct volumes of 35 mL or greater, surgical treatment was associated with a significant improvement in favorable outcomes at 1-year follow-up (38 [61%] vs 3 [25%]; odds ratio, 4.8; 95% CI, 1.2-19.3; P = .03), while conservative treatment was associated with favorable outcomes at 1-year follow-up in patients with infarct volumes of less than 25 mL (2 [34%] vs 218 [74%]; odds ratio, 0.2; 95% CI, 0-1.0; P = .047). Conclusions and Relevance Overall, surgery was not associated with improved outcomes compared with conservative management in patients with cerebellar infarcts. However, when stratifying based on infarct volume, surgical treatment appeared to be beneficial in patients with larger infarct volumes, while conservative management appeared favorable in patients with smaller infarct volumes.
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Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | | | - Bedjan Behmanesh
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | - Joshua D. Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marcus Czabanka
- Department of Neurosurgery, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Nazife Dinc
- Department of Neurosurgery, Jena University Hospital, Jena, Germany
| | - Daniel Dubinski
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | - Thomas M. Freiman
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Kara Hellmuth
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Ilko Maier
- Department of Neurology, Göttingen University Hospital, Göttingen, Germany
| | | | - Dorothee Mielke
- Department of Neurosurgery, Göttingen University Hospital, Göttingen, Germany
| | - Paul Naser
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Veit Rohde
- Department of Neurosurgery, Göttingen University Hospital, Göttingen, Germany
| | - Christian Senft
- Department of Neurosurgery, Jena University Hospital, Jena, Germany
| | - Alexander Storch
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Johannes Walter
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Uwe Walter
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Matthias Wittstock
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Jan Hendrik Schaefer
- Department of Neurology, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Florian Gessler
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
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20
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Pelz JO, Engelmann S, Scherlach C, Bungert-Kahl P, Dabbagh A, Lindner D, Michalski D. No Harmful Effect of Endovascular Treatment before Decompressive Surgery-Implications for Handling Patients with Space-Occupying Brain Infarction. J Clin Med 2024; 13:918. [PMID: 38337612 PMCID: PMC10856747 DOI: 10.3390/jcm13030918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/28/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
This study explored short- and mid-term functional outcomes in patients undergoing decompressive hemicraniectomy (DHC) due to space-occupying cerebral infarction and asked whether there is a potentially harmful effect of a priorly performed endovascular treatment (EVT). Medical records were screened for patients requiring DHC due to space-occupying cerebral infarction between January 2016 and July 2021. Functional outcomes at hospital discharge and at 3 months were assessed by the modified Rankin Scale (mRS). Out of 65 patients with DHC, 39 underwent EVT before DHC. Both groups, i.e., EVT + DHC and DHC alone, had similar volumes (280 ± 90 mL vs. 269 ± 73 mL, t-test, p = 0.633) and proportions of edema and infarction (22.1 ± 6.5% vs. 22.1 ± 6.1%, t-test, p = 0.989) before the surgical intervention. Patients undergoing EVT + DHC tended to have a better functional outcome at hospital discharge compared to DHC alone (mRS 4.8 ± 0.8 vs. 5.2 ± 0.7, Mann-Whitney-U, p = 0.061), while the functional outcome after 3 months was similar (mRS 4.6 ± 1.1 vs. 4.8 ± 0.9, Mann-Whitney-U, p = 0.352). In patients initially presenting with a relevant infarct demarcation (Alberta Stroke Program Early CT Score ≤ 5), the outcome was similar at hospital discharge and after 3 months between patients with EVT + DHC and DHC alone. This study provided no evidence for a harmful effect of EVT before DHC in patients with space-occupying brain infarction.
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Affiliation(s)
- Johann Otto Pelz
- Department of Neurology, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Simone Engelmann
- Institute of Neuroradiology, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Cordula Scherlach
- Institute of Neuroradiology, University Hospital Leipzig, 04103 Leipzig, Germany
| | | | - Alhuda Dabbagh
- Department of Neurology, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Dirk Lindner
- Department of Neurosurgery, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Dominik Michalski
- Department of Neurology, University Hospital Leipzig, 04103 Leipzig, Germany
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21
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Chen W, Wang X, Liu J, Wang M, Yang S, Yang L, Gong Z, Hu W. Association Between Hypoperfusion Intensity Ratio and Postthrombectomy Malignant Brain Edema for Acute Ischemic Stroke. Neurocrit Care 2024; 40:196-204. [PMID: 38148437 DOI: 10.1007/s12028-023-01900-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 11/22/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Malignant brain edema (MBE) is a life-threatening complication that can occur after mechanical thrombectomy (MT) for acute ischemic stroke. The hypoperfusion intensity ratio (HIR) reflects the tissue-level perfusion status within the ischemic territory. This study investigated the association between HIR and MBE occurrence after MT in patients with anterior circulation large artery occlusion. METHODS We conducted a retrospective cohort study of patients who received MT at a comprehensive stroke center from February 2020 to June 2022. Using computed tomography perfusion, the HIR was derived from the ratio of tissue volume with a time to maximum (Tmax) > 10 s to that with a Tmax > 6 s. We dichotomized patients based on the occurrence of MBE following MT. The primary outcome, assessed using a multivariable logistic regression model, was the MBE occurrence post MT. The secondary outcome focused on favorable outcomes, defined as achieving a modified Rankin Scale score of 0-2 at 90 days. RESULTS Of the 603 included patients, 90 (14.9%) developed MBE after MT. The median HIR exhibited a significantly higher value in the MBE group compared with the non-MBE group (0.5 vs. 0.3; P < 0.001). Multivariable logistic regression analysis indicated that a higher HIR (adjusted odds ratio [aOR] 8.98; 95% confidence interval [CI] 2.85-28.25; P < 0.001), baseline large infarction (Alberta Stroke Program Early Computed Tomography Score < 6; aOR 1.77; 95% CI 1.04-3.01; P = 0.035), internal carotid artery occlusion (aOR 1.80; 95% CI 1.07-3.01; P = 0.028), and unsuccessful recanalization (aOR 8.45; 95% CI 4.75-15.03; P < 0.001) were independently associated with MBE post MT. Among those with successful recanalization, a higher HIR (P = 0.017) and baseline large infarction (P = 0.032) remained as predictors of MBE occurrence. Furthermore, a higher HIR (P = 0.001) and the occurrence of MBE (P < 0.001) both correlated with reduced odds of achieving favorable outcomes. CONCLUSIONS The presence of a higher HIR on pretreatment perfusion imaging serves as a robust predictor for MBE occurrence after MT, irrespective of successful recanalization.
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Affiliation(s)
- Wang Chen
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang, Beijing, 100020, China
| | - Xianjun Wang
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Ji Liu
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Mengen Wang
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Shuna Yang
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang, Beijing, 100020, China
| | - Lei Yang
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang, Beijing, 100020, China
| | - Zixiang Gong
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Wenli Hu
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang, Beijing, 100020, China.
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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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23
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Rostami A, Elyassirad D, Vatanparast M, Abouei Mehrizi MA, Hasanpour M, Rezaee H, Haghir A, Keykhosravi E. Functional Outcome and Mortality Predictors in Patients with Cerebral Ischemic Infarction After Decompressive Craniectomy: Cross-Sectional Study. World Neurosurg 2024; 182:e847-e853. [PMID: 38101538 DOI: 10.1016/j.wneu.2023.12.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 12/09/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE Surgeons commonly perform Decompressive craniectomy (DC) to manage patients with cerebral ischemic infarction. However, there are conflicting data on the long-term functional outcomes following DC. Therefore, this study aims to determine the functional outcome of patients with cerebral ischemic infarction after DC. METHODS This prospective and retrospective cross-sectional study included 148 patients with cerebral ischemic infarction who underwent DC at Ghaem Hospital, Mashhad, Iran, from March 2011 to March 2021. The Modified Rankin Scale (mRS) assesses disability in these patients and determines the recovery and degree of long-term functional outcomes. Demographic and clinical data were extracted and recorded in a researcher-made questionnaire. RESULTS In summary, the follow-up revealed a survival rate of 39.2% among patients with ischemic stroke. The comparison of the mean infarct volume in patients with various mRS scores showed that the mean infarct volume was significantly higher in patients with unfavorable functional outcomes, based on mRS scores at discharge (P = 0.05), 3 months mRS (P < 0.01), and mRS score at final follow-up (P = 0.01). Final mortality was higher in patients with higher mRS scores at discharge, after 3 months, and final follow-up (P < 0.01). Older age and infarction volume can predict mRS and mortality in patients with ischemic stroke (P < 0.01). CONCLUSIONS The present study showed that mortality and mRS scores at various times are associated with infarction volume and older age in patients with ischemic stroke.
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Affiliation(s)
- Amin Rostami
- Department of Neurosurgery, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Daniel Elyassirad
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahsa Vatanparast
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Mohammad Hasanpour
- Department of Neurosurgery, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Rezaee
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amirhosein Haghir
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ehsan Keykhosravi
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran.
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24
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Pham J, Ng FC. Novel advanced imaging techniques for cerebral oedema. Front Neurol 2024; 15:1321424. [PMID: 38356883 PMCID: PMC10865379 DOI: 10.3389/fneur.2024.1321424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 01/09/2024] [Indexed: 02/16/2024] Open
Abstract
Cerebral oedema following acute ischemic infarction has been correlated with poor functional outcomes and is the driving mechanism of malignant infarction. Measurements of midline shift and qualitative assessment for herniation are currently the main CT indicators for cerebral oedema but have limited sensitivity for small cortical infarcts and are typically a delayed sign. In contrast, diffusion-weighted (DWI) or T2-weighted magnetic resonance imaging (MRI) are highly sensitive but are significantly less accessible. Due to the need for early quantification of cerebral oedema, several novel imaging biomarkers have been proposed. Based on neuroanatomical shift secondary to space-occupying oedema, measures such as relative hemispheric volume and cerebrospinal fluid displacement are correlated with poor outcomes. In contrast, other imaging biometrics, such as net water uptake, T2 relaxometry and blood brain barrier permeability, reflect intrinsic tissue changes from the influx of fluid into the ischemic region. This review aims to discuss quantification of cerebral oedema using current and developing advanced imaging techniques, and their role in predicting clinical outcomes.
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Affiliation(s)
- Jenny Pham
- Department of Radiology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Felix C. Ng
- Department of Neurology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
- Department of Medicine at Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Parkville, VIC, Australia
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25
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Dangare MS, Saklecha A, Harjpal P. A Case Report Emphasizing an Early Approach in a Patient With Diffuse Axonal Injury. Cureus 2024; 16:e52750. [PMID: 38389626 PMCID: PMC10882254 DOI: 10.7759/cureus.52750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
Diffuse axonal injury (DAI) is a severe and frequently life-altering form of traumatic brain injury that is brought on by forces of rapid acceleration as well as deceleration impacting the brain. DAI primarily stems from mechanical forces that lead to the widespread disruption of axons throughout the brain. Unlike focal injuries that affect a specific brain region, DAI manifests as multifocal axonal damage, often impairing vital neural connections. This injury occurs due to shear and tensile forces during traumatic events, such as car accidents, falls, and sports-related incidents. This current case report includes a 19-year-old male who had a fall from his bike and was hospitalised with brain trauma. A Magnetic resonance imaging (MRI) scan was done, which revealed a case of DAI, and a computed tomography (CT) scan of the brain revealed the extra-calvarial soft tissue swelling in the left parietal region. Small haemorrhagic contusions involved the right ganglio-capsular region. Several integrative techniques, including joint approximation, proprioceptive neuromuscular facilitation (PNF) rhythmic initiation, D1 flexion-extension, and patient education, were used to manage the patient. The patient's development was evaluated using outcome measures, such as the functional independence measure (FIM) and the Glasgow coma scale (GCS). Thus, we conclude that completing physiotherapy exercises consistently helps patients achieve their highest level of functional independence and also enhances their quality of life.
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Affiliation(s)
- Mansee S Dangare
- Department of Neuro-Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Akshaya Saklecha
- Department of Neuro-Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Pallavi Harjpal
- Department of Neuro-Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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26
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Hua X, Liu M, Wu S. Definition, prediction, prevention and management of patients with severe ischemic stroke and large infarction. Chin Med J (Engl) 2023; 136:2912-2922. [PMID: 38030579 PMCID: PMC10752492 DOI: 10.1097/cm9.0000000000002885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Indexed: 12/01/2023] Open
Abstract
ABSTRACT Severe ischemic stroke carries a high rate of disability and death. The severity of stroke is often assessed by the degree of neurological deficits or the extent of brain infarct, defined as severe stroke and large infarction, respectively. Critically severe stroke is a life-threatening condition that requires neurocritical care or neurosurgical intervention, which includes stroke with malignant brain edema, a leading cause of death during the acute phase, and stroke with severe complications of other vital systems. Early prediction of high-risk patients with critically severe stroke would inform early prevention and treatment to interrupt the malignant course to fatal status. Selected patients with severe stroke could benefit from intravenous thrombolysis and endovascular treatment in improving functional outcome. There is insufficient evidence to inform dual antiplatelet therapy and the timing of anticoagulation initiation after severe stroke. Decompressive hemicraniectomy (DHC) <48 h improves survival in patients aged <60 years with large hemispheric infarction. Studies are ongoing to provide evidence to inform more precise prediction of malignant brain edema, optimal indications for acute reperfusion therapies and neurosurgery, and the individualized management of complications and secondary prevention. We present an evidence-based review for severe ischemic stroke, with the aims of proposing operational definitions, emphasizing the importance of early prediction and prevention of the evolution to critically severe status, summarizing specialized treatment for severe stroke, and proposing directions for future research.
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Affiliation(s)
- Xing Hua
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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27
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Matur AV, Candelario-Jalil E, Paul S, Karamyan VT, Lee JD, Pennypacker K, Fraser JF. Translating Animal Models of Ischemic Stroke to the Human Condition. Transl Stroke Res 2023; 14:842-853. [PMID: 36125734 DOI: 10.1007/s12975-022-01082-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/30/2022] [Accepted: 09/12/2022] [Indexed: 11/30/2022]
Abstract
Ischemic stroke is a leading cause of death and disability. However, very few neuroprotective agents have shown promise for treatment of ischemic stroke in clinical trials, despite showing efficacy in many successful preclinical studies. This may be attributed, at least in part, to the incongruency between experimental animal stroke models used in preclinical studies and the manifestation of ischemic stroke in humans. Most often the human population selected for clinical trials are more diverse than the experimental model used in a preclinical study. For successful translation, it is critical to develop clinical trial designs that match the experimental animal model used in the preclinical study. This review aims to provide a comprehensive summary of commonly used animal models with clear correlates between rodent models used to study ischemic stroke and the clinical stroke pathologies with which they most closely align. By improving the correlation between preclinical studies and clinical trials, new neuroprotective agents and stroke therapies may be more accurately and efficiently identified.
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Affiliation(s)
- Abhijith V Matur
- Department of Radiology, University of Kentucky, Lexington, KY, USA.
| | - Eduardo Candelario-Jalil
- Department of Neuroscience, McKnight Brain Institute, University of Florida, Gainesville, FL, USA
| | - Surojit Paul
- Department of Neurology and Department of Neurosciences, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Vardan T Karamyan
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Jessica D Lee
- Department of Neurology, University of Kentucky, Lexington, KY, USA
| | - Keith Pennypacker
- Department of Neurology, University of Kentucky, Lexington, KY, USA
- Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, USA
| | - Justin F Fraser
- Department of Radiology, University of Kentucky, Lexington, KY, USA
- Department of Neurology, University of Kentucky, Lexington, KY, USA
- Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, USA
- Department of Neuroscience, University of Kentucky, Lexington, KY, USA
- Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA
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28
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Panigrahi B, Thakur Hameer S, Bhatia R, Haldar P, Sharma A, Srivastava MVP. Effect of endovascular therapy in large anterior circulation ischaemic strokes: A systematic review and meta-analysis of randomised controlled trials. Eur Stroke J 2023; 8:932-941. [PMID: 37641885 PMCID: PMC10683735 DOI: 10.1177/23969873231196381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 07/25/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION The benefit of endovascular treatment in large anterior circulation ischaemic strokes with low ASPECTS score (<6) is uncertain. Recent randomised studies have demonstrated the benefit of endovascular treatment (EVT) in large ischaemic strokes. The present meta-analysis aims to assess the combined effect of these studies on efficacy and safety of endovascular treatment in this group of patients. MATERIALS AND METHODS We conducted a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases MEDLINE, PubMed, EMBASE, SCOPUS, Google Scholar, Tripdatabase were searched for randomised controlled trials with at least 50 participants from inception until February 16, 2023. The primary efficacy outcome analysed was the relative risk of functional independence defined as mRS - 0-2 at 90 days. Secondary efficacy outcomes included early neurological improvement, death due to any cause at 90 days and proportion of patients requiring decompressive hemicraniectomy. The primary safety outcome was the risk of developing symptomatic intracerebral haemorrhage (sICH). RESULTS A total of three studies (RESCUE Japan-LIMIT, SELECT 2 and ANGEL ASPECTS) involving 1011 patients; 510 in the EVT arm and 501 in the medical management (MM) arm met the defined criteria (ASPECTS-3-5). The combined RR for the primary outcome of mRS 0-2 was 2.53 [1.84-3.47] (p = <0.0001) favouring EVT over MM. The primary safety outcome of sICH was not significant in the EVT arm with a combined RR of 1.84 [0.94-3.60] (p = 0.5157). Mortality rates were similar in both arms (26.67% in EVT arm vs 27.94% in MM arm) with a combined RR of 0.95 [0.78; 1.16] (p = 1.000). CONCLUSION In patients with Large vessel occlusion (LVO) and low ASPECTS (3-5), EVT was associated with higher likelihood of achieving functional independence and early neurologic improvement but did not provide any mortality benefit.
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Affiliation(s)
- Baikuntha Panigrahi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Partha Haldar
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Agrata Sharma
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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Thorén M, Escudero-Martínez I, Andersson T, Chen SY, Tsao N, Khurana D, Beretta S, Peeters A, Tsivgoulis G, Roffe C, Ahmed N. Reperfusion by endovascular thrombectomy and early cerebral edema in anterior circulation stroke: Results from the SITS-International Stroke Thrombectomy Registry. Int J Stroke 2023; 18:1193-1201. [PMID: 37226337 PMCID: PMC10676032 DOI: 10.1177/17474930231180451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/08/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND A large infarct and expanding cerebral edema (CED) due to a middle cerebral artery occlusion confers a 70% mortality unless treated surgically. There is still conflicting evidence whether reperfusion is associated with a lower risk for CED in acute ischemic stroke. AIM To investigate the association of reperfusion with development of early CED after stroke thrombectomy. METHODS From the SITS-International Stroke Thrombectomy Registry, we selected patients with occlusion of the intracranial internal carotid or middle cerebral artery (M1 or M2). Successful reperfusion was defined as mTICI ⩾ 2b. Primary outcome was moderate or severe CED, defined as focal brain swelling ⩾1/3 of the hemisphere on imaging scans at 24 h. We used regression methods while adjusting for baseline variables. Effect modification by severe early neurological deficits, as indicators of large infarct at baseline and at 24 h, were explored. RESULTS In total, 4640 patients, median age 70 years and median National Institutes of Health Stroke Score (NIHSS) 16, were included. Of these, 86% had successful reperfusion. Moderate or severe CED was less frequent among patients who had reperfusion compared to patients without reperfusion: 12.5% versus 29.6%, p < 0.05, crude risk ratio (RR) 0.42 (95% confidence interval (CI): 0.37-0.49), and adjusted RR 0.50 (95% CI: 0.44-0.57). Analysis of effect modification indicated that severe neurological deficits weakened the association between reperfusion and lower risk of CED. The RR reduction was less favorable in patients with severe neurological deficits, defined as NIHSS score 15 or more at baseline and at 24 h, used as an indicator for larger infarction. CONCLUSION In patients with large artery anterior circulation occlusion stroke who underwent thrombectomy, successful reperfusion was associated with approximately 50% lower risk for early CED. Severe neurological deficit at baseline seems to be a predictor for moderate or severe CED also in patients with successful reperfusion by thrombectomy.
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Affiliation(s)
- Magnus Thorén
- Stroke Research Unit, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Danderyd Hospital, Stockholm, Sweden
| | - Irene Escudero-Martínez
- Department of Neurology, Hospital Universitari i Politécnic La Fe, Valencia, Spain
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
| | - Tomas Andersson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | - Nicole Tsao
- Global Medical Affairs, Biogen, Cambridge, MA, USA
| | - Dheeraj Khurana
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Simone Beretta
- Department of Neurology and Stroke Unit, San Gerardo Hospital, Monza, Italy
| | - Andre Peeters
- Department of Neurology and Stroke Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, Athens, Greece
| | | | - Niaz Ahmed
- Stroke Research Unit, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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30
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Hernández-Durán S, Hautmann X, Rohde V, von der Brelie C, Mielke D. Surgical timing and indications for decompressive craniectomy in malignant stroke: results from a single-center retrospective analysis. Acta Neurochir (Wien) 2023; 165:3815-3820. [PMID: 37749288 PMCID: PMC10739510 DOI: 10.1007/s00701-023-05817-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/15/2023] [Indexed: 09/27/2023]
Abstract
PURPOSE Acute ischemic stroke induces rapid neuronal death and time is a key factor in its treatment. Despite timely recanalization, malignant cerebral infarction can ensue, requiring decompressive surgery (DC). The ideal timing of surgery is still a matter of debate; in this study, we attempt to establish the ideal time to perform surgery in this population. METHODS We conducted a retrospective study of patients undergoing DC for stroke at our department. The indication for DC was based on drop in level of consciousness and standard imaging parameters. Patients were stratified according to the timing of DC in four groups: (a) "ultra-early" ≤12 h, (b) "early" >12≤24 h, (c) "timely" >24≤48 h, and (d) "late" >48 h. The primary endpoint of this study was in-house mortality, as a dependent variable from surgical timing. Secondary endpoint was modified Rankin scale at discharge. RESULTS In a cohort of 110 patients, the timing of surgery did not influence mortality or functional outcome (p=0.060). Patients undergoing late DC were however significantly older (p=0.008), and those undergoing ultra-early DC showed a trend towards a lower GCS at admission. CONCLUSIONS Our results add to the evidence supporting an extension of the time window for DC in stroke beyond 48 h. Further criteria beyond clinical and imaging signs of herniation should be considered when selecting patients for DC after stroke to identify patients who would benefit from the procedure.
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Affiliation(s)
- Silvia Hernández-Durán
- Department of Neurosurgery, Georg August University Göttingen, Robert Koch Strasse 40, 37075, Göttingen, Germany.
| | - Xenia Hautmann
- Department of Neurosurgery, Georg August University Göttingen, Robert Koch Strasse 40, 37075, Göttingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, Georg August University Göttingen, Robert Koch Strasse 40, 37075, Göttingen, Germany
| | | | - Dorothee Mielke
- Department of Neurosurgery, Georg August University Göttingen, Robert Koch Strasse 40, 37075, Göttingen, Germany
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31
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Chung MG, Pabst L. Acute management of childhood stroke. Curr Opin Pediatr 2023; 35:648-655. [PMID: 37800414 DOI: 10.1097/mop.0000000000001295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
PURPOSE OF REVIEW The purpose of this paper is to review recent updates in the acute management of childhood arterial ischemic stroke, including reperfusion therapies and neuroprotective measures. RECENT FINDINGS With the emergence of pediatric stroke centers in recent years, processes facilitating rapid diagnosis and treatment have resulted in improved implementation of early targeted neuroprotective measures as well as the increased use of reperfusion therapies in childhood arterial ischemic stroke. Retrospective data has demonstrated that alteplase is safe in carefully selected children with arterial ischemic stroke in the first 4.5 h from symptom onset, though data regarding its efficacy in children are still lacking. There is also increasing data that suggests that thrombectomy in children with large vessel occlusion improves functional outcomes. Recent adult studies, including the use of Tenecteplase as an alteplase alternative and expansion of late thrombectomy to include patients with large ischemic cores, also are reviewed along with limitations to application of the adult data to pediatric care. SUMMARY There have been significant advances in the hyperacute care of children with ischemic stroke and early diagnosis and targeted management are of the upmost importance in improving long-term outcomes.
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Affiliation(s)
- Melissa G Chung
- Nationwide Children's Hospital, Department of Pediatrics, Divisions of Critical Care Medicine and Pediatric Neurology
| | - Lisa Pabst
- Department of Pediatrics, Division of Neurology, University of Utah, Salt Lake City, Utah, USA
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Ovenden CD, Barot DD, Gupta A, Aujayeb N, Nathin K, Hewitt J, Kovoor J, Stretton B, Bacchi S, Edwards S, Kaukas L, Wells AJ. Incidence of hydrocephalus following decompressive craniectomy for ischaemic stroke: A systematic review and meta-analysis. Clin Neurol Neurosurg 2023; 234:107989. [PMID: 37826959 DOI: 10.1016/j.clineuro.2023.107989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/22/2023] [Accepted: 09/23/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE Decompressive craniectomy (DC) following malignant ischaemic stroke is a potentially life-saving procedure. Event rates of ventriculomegaly following DC performed in this setting remain poorly defined. Accordingly, we performed a systematic review to determine the incidence of hydrocephalus and the need for cerebrospinal fluid (CSF) diversion following DC for malignant stroke. METHODS MEDLINE, EMBASE and Cochrane libraries were searched from database inception to 17 July 2021. Our search strategy consisted of "Decompressive Craniectomy", AND "Ischaemic stroke", AND "Hydrocephalus", along with synonyms. Through screening abstracts and then full texts, studies reporting on rates of ventriculomegaly following DC to treat ischaemic stroke were included for analysis. Event rates were calculated for both of these outcomes. A risk of bias assessment was performed to determine the quality of the included studies. RESULTS From an initial 1117 articles, 12 were included following full-text screening. All were of retrospective design. The 12 included studies reported on 677 patients, with the proportion experiencing hydrocephalus/ventriculomegaly being 0.38 (95% CI: 0.24, 0.53). Ten studies incorporating 523 patients provided data on the need for permanent CSF diversion, with 0.10 (95% CI: 0.07, 0.13) requiring a shunt. The included studies were overall of high methodological quality and rigour. CONCLUSION Though hydrocephalus is relatively common following DC in this clinical setting, only a minority of patients are deemed to require permanent CSF diversion. Clinicians should be aware of the incidence of this complication and counsel patients and families appropriately.
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Affiliation(s)
- Christopher Dillon Ovenden
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Australia; Discipline of Surgery, University of Adelaide, Adelaide, Australia
| | | | - Aashray Gupta
- Discipline of Surgery, University of Adelaide, Adelaide, Australia; Gold Coast University Hospital, Southport, Australia
| | - Nidhi Aujayeb
- Discipline of Surgery, University of Adelaide, Adelaide, Australia
| | - Kayla Nathin
- Discipline of Surgery, University of Adelaide, Adelaide, Australia
| | - Joseph Hewitt
- Discipline of Surgery, University of Adelaide, Adelaide, Australia
| | - Joshua Kovoor
- Discipline of Surgery, University of Adelaide, Adelaide, Australia
| | - Brandon Stretton
- Discipline of Surgery, University of Adelaide, Adelaide, Australia
| | - Stephen Bacchi
- Discipline of Surgery, University of Adelaide, Adelaide, Australia
| | - Suzanne Edwards
- Discipline of Surgery, University of Adelaide, Adelaide, Australia
| | - Lola Kaukas
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Adam J Wells
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Australia; Discipline of Surgery, University of Adelaide, Adelaide, Australia
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Migdady I, Johnson-Black PH, Leslie-Mazwi T, Malhotra R. Current and Emerging Endovascular and Neurocritical Care Management Strategies in Large-Core Ischemic Stroke. J Clin Med 2023; 12:6641. [PMID: 37892779 PMCID: PMC10607145 DOI: 10.3390/jcm12206641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
The volume of infarcted tissue in patients with ischemic stroke is consistently associated with increased morbidity and mortality. Initial studies of endovascular thrombectomy for large-vessel occlusion excluded patients with established large-core infarcts, even when large volumes of salvageable brain tissue were present, due to the high risk of hemorrhagic transformation and reperfusion injury. However, recent retrospective and prospective studies have shown improved outcomes with endovascular thrombectomy, and several clinical trials were recently published to evaluate the efficacy of endovascular management of patients presenting with large-core infarcts. With or without thrombectomy, patients with large-core infarcts remain at high risk of in-hospital complications such as hemorrhagic transformation, malignant cerebral edema, seizures, and others. Expert neurocritical care management is necessary to optimize blood pressure control, mitigate secondary brain injury, manage cerebral edema and elevated intracranial pressure, and implement various neuroprotective measures. Herein, we present an overview of the current and emerging evidence pertaining to endovascular treatment for large-core infarcts, recent advances in neurocritical care strategies, and their impact on optimizing patient outcomes.
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Affiliation(s)
- Ibrahim Migdady
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Phoebe H. Johnson-Black
- Department of Neurosurgery, Division of Neurocritical Care, UCLA David Geffen School of Medicine, Ronald Reagan Medical Center, Los Angeles, CA 90095, USA;
| | | | - Rishi Malhotra
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
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Hawash AMA, Zaytoun TM, Helmy TA, El Reweny EM, Abdel Galeel AMA, Taleb RSZ. S100B and brain ultrasound: Novel predictors for functional outcome in acute ischemic stroke patients. Clin Neurol Neurosurg 2023; 233:107907. [PMID: 37541157 DOI: 10.1016/j.clineuro.2023.107907] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/16/2023] [Accepted: 07/17/2023] [Indexed: 08/06/2023]
Abstract
OBJECTIVE Stroke is a leading cause of mortality and disability worldwide. This study aimed to assess the prognostic value of serum S100B protein, transcranial color-coded duplex sonography (TCCD), and optic nerve sheath diameter (ONSD) in predicting functional outcomes in critically ill patients with acute ischemic stroke (AIS). METHODS In this prospective observational study, 80 adult AIS patients were evaluated. Serum S100B protein levels, ONSD, and middle cerebral artery pulsatility index (MCA PI) were measured on days 1 and 3. Functional outcomes at 90 days were assessed using the modified Rankin Scale (mRS) and categorized into favourable (mRS 0-2) or unfavourable (mRS 3-6) groups. The association of demographic, clinical, laboratory, and imaging parameters with mRS outcomes was analyzed. RESULTS Poor mRS outcomes occurred in 82.5 % of patients. Factors significantly associated with poor outcomes were female sex, higher National Institutes of Health Stroke Scale (NIHSS) scores on days 1, 3, and 7, and larger stroke size. Receiver Operating Characteristic (ROC) curve analysis revealed that ONSD at days 1 and 3, serum S100B levels at day 1, and right MCA PI at day 1 had significant predictive value for poor mRS outcome. Multivariate analysis identified female sex, S100B on day 1, and NIHSS on days 1, 3, and 7 as independent predictors of poor mRS outcomes. CONCLUSIONS The combination of S100B, ONSD, and MCA PI improved the prediction of functional outcomes in critically ill AIS patients. Early S100B measurement and brain ultrasound evaluation may serve as valuable prognostic tools for guiding therapeutic decision-making. This study provides novel insights into the role of S100B and brain ultrasound in stroke outcome prediction, particularly in critically ill AIS patients.
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Affiliation(s)
| | - Tayseer Mohamed Zaytoun
- Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Tamer AbdAllah Helmy
- Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ehab Mahmoud El Reweny
- Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Raghda Saad Zaghloul Taleb
- Clinical and Chemical Pathology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Guimarães de Almeida Barros A, Roquim E Silva L, Pessoa A, Eiras Falcão A, Viana Magno LA, Valadão Freitas Rosa D, Aurelio Romano Silva M, Marques de Miranda D, Nicolato R. Use of biomarkers for predicting a malignant course in acute ischemic stroke: an observational case-control study. Sci Rep 2023; 13:16097. [PMID: 37752283 PMCID: PMC10522689 DOI: 10.1038/s41598-023-43408-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/23/2023] [Indexed: 09/28/2023] Open
Abstract
Acute ischemic stroke is a sudden neurological event caused by brain ischemia. Patients with large vessel occlusion are at high risk of developing significant cerebral edema, which can lead to rapid neurological decline. The optimal timing for decompressive hemicraniectomy to prevent further brain damage is still uncertain. This study aimed to identify potential predictors of severe brain edema. The data indicate that specific cytokines may help identify patients with a higher risk of developing life-threatening brain swelling in the early phase post-stroke. The association between a positive biomarker and the outcome was calculated, and three biomarkers-S100B protein, MMP-9, and IL-10-were found to be significantly associated with malignant edema. A model was derived for early predicting malignant cerebral edema, including S100B protein and IL-1 beta. These findings suggest that molecular biomarkers related to the ischemic cascade may be a helpful way of predicting the development of malignant cerebral edema in ischemic stroke patients, potentially widening the time window for intervention and assisting in decision-making. In conclusion, this study provides insights into the molecular mechanisms of severe brain edema and highlights the potential use of biomarkers in predicting the course of ischemic stroke.
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Affiliation(s)
| | - Lucas Roquim E Silva
- Medical School of Universidade Federal de Minas Gerais, Prof. Alfredo Balena Avenue, 190, Belo Horizonte, 30130-100, Brazil
| | - Alberlúcio Pessoa
- Medical School of Universidade Federal de Minas Gerais, Prof. Alfredo Balena Avenue, 190, Belo Horizonte, 30130-100, Brazil
| | - Antonio Eiras Falcão
- Medical School of Universidade Estadual de Campinas, R. Vital Brasil, 251, Cidade Universitária, Campinas, 13083-888, Brazil
| | - Luiz Alexandre Viana Magno
- Medical School of Universidade Federal de Minas Gerais, Prof. Alfredo Balena Avenue, 190, Belo Horizonte, 30130-100, Brazil
| | - Daniela Valadão Freitas Rosa
- Medical School of Universidade Federal de Minas Gerais, Prof. Alfredo Balena Avenue, 190, Belo Horizonte, 30130-100, Brazil
| | - Marco Aurelio Romano Silva
- Medical School of Universidade Federal de Minas Gerais, Prof. Alfredo Balena Avenue, 190, Belo Horizonte, 30130-100, Brazil
| | - Debora Marques de Miranda
- Medical School of Universidade Federal de Minas Gerais, Prof. Alfredo Balena Avenue, 190, Belo Horizonte, 30130-100, Brazil
| | - Rodrigo Nicolato
- Medical School of Universidade Federal de Minas Gerais, Prof. Alfredo Balena Avenue, 190, Belo Horizonte, 30130-100, Brazil
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McCullough-Hicks M, Topiwala K, Christensen S, Ruiz-Betancourt D, Mlynash M, Albers GW. Anatomical predictors of need for decompressive craniectomy after stroke using voxel-based lesion symptom mapping. J Neuroimaging 2023; 33:737-741. [PMID: 37400939 DOI: 10.1111/jon.13144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/20/2023] [Accepted: 06/25/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND AND PURPOSE Malignant cerebral edema (MCE) secondary to ischemic stroke is a highly morbid condition. Decompressive craniectomy (DC) is the only treatment for MCE that has been shown to reduce mortality. We examined whether early infarction and/or hypoperfusion in specific topographic regions was predictive of the need for later DC. METHODS A retrospective database of patients evaluated for large vessel occlusion (LVO) stroke at Stanford between 2010 and 2019 was used. Thirty patients with LVO and baseline perfusion MRI who underwent DC were evaluated. Propensity matching based on age, lesion size, and recanalization status was performed on the remaining cohort. Baseline masks of apparent diffusion coefficient (ADC) + Tmax >6 seconds lesions were generated using automated perfusion software. Voxel-based lesion symptom maping was used to perform logistic regression at each voxel to generate statistical maps of lesion location associated with DC. Hemispheres were combined to increase statistical power. RESULTS Sixty patients were analyzed. After adjusting for age, lesion size, and recanalization status as covariates, scattered cortical regions, predominately within the temporal and frontal lobe, were mildly to moderately predictive of the need for DC (z-scores: 2.4-6.74, p < .01). CONCLUSIONS Scattered temporal and frontal lobe regions on baseline diffusion and perfusion MRI were found to be mildly to moderately predictive of the need for subsequent DC in patients with LVO stroke.
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Affiliation(s)
| | - Karan Topiwala
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Soren Christensen
- Department of Neurology, Stanford University, Palo Alto, California, USA
| | | | - Michael Mlynash
- Department of Neurology, Stanford University, Palo Alto, California, USA
| | - Gregory W Albers
- Department of Neurology, Stanford University, Palo Alto, California, USA
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Lu P, Cui L, Zhao X. Prominent veins sign is associated with malignant cerebral edema after acute ischemic stroke. Heliyon 2023; 9:e19758. [PMID: 37809708 PMCID: PMC10559062 DOI: 10.1016/j.heliyon.2023.e19758] [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: 05/16/2023] [Revised: 07/21/2023] [Accepted: 08/31/2023] [Indexed: 10/10/2023] Open
Abstract
Malignant cerebral edema (MCE) is often associated with severe physical disability and a high mortality rate. The current prediction of MCE is focused on infarct volume, and tools are relatively lacking. The prominent veins sign (PVS-SWI) is considered a marker of severely impaired tissue perfusion. This study aimed to determine whether PVS-SWI is associated with early-onset MCE. Patients with acute ischemic stroke (AIS) due to severe large arterial stenosis or occlusion (SLASO) from June 2018 to June 2020 were included. The ASPECTS score assessed the extent of PVS-SWI, and 4-10 was defined as a positive group. The primary outcome was MCE, defined as the deterioration of neurological function and midline structural excursions of >5 mm during hospitalization. The secondary outcomes included worsening of the NIHSS by ≥ 2 points, in-hospital death, and death within 1 year after stroke. Logistic regression was used to assess the correlation between PVS-SWI and outcomes. The study included 157 patients, 40 (25.5%) of whom developed MCE. PVS-SWI was more prevalent in patients who developed MCE (75.0% vs 45.3%; P = 0.001). In multivariate regression analysis, PVS-SWI was an independent predictor of MCE development in patients with larger infarct sizes (OR: 4.00, 95%CI: 1.54-10.35,p = 0.004). In patients with small infarct sizes, PVS-SWI was an independent predictor of a worsening NIHSS of ≥2(OR: 11.13, 95%CI: 2.26-54.89, p = 0.003). However, PVS-SWI was not associated with death. The main finding of our study was that in patients with larger infarct sizes, a positive PVS-SWI increased the risk of developing MCE. In these patients, more interventions may be needed.
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Affiliation(s)
- Ping Lu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Lingyun Cui
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
- China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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Carlhan-Ledermann A, Bartoli A, Gebistorf F, Beghetti M, Sologashvili T, Rebollo Polo M, Fluss J. Decompressive hemicraniectomy in pediatric malignant arterial ischemic stroke: a case-based review. Childs Nerv Syst 2023; 39:2377-2389. [PMID: 37493722 PMCID: PMC10432330 DOI: 10.1007/s00381-023-06086-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/15/2023] [Indexed: 07/27/2023]
Abstract
PURPOSE Malignant stroke is a life-threatening emergency, with a high mortality rate (1-3). Despite strong evidence showing decreased morbidity and mortality in the adult population, decompressive hemicraniectomy (DCH) has been scarcely reported in the pediatric stroke population, and its indication remains controversial, while it could be a potential lifesaving option. METHODS AND RESULTS We performed an extensive literature review on pediatric malignant arterial ischemic stroke (pmAIS) and selected 26 articles reporting 97 cases. Gathering the data together, a 67% mortality rate is observed without decompressive therapy, contrasting with a 95.4% survival rate with it. The median modified Rankin score (mRS) is 2.1 after surgery with a mean follow-up of 31.8 months. For the 33% of children who survived without surgery, the mRS is 3 at a mean follow-up of 19 months. As an illustrative case, we report on a 2-year-old girl who presented a cardioembolic right middle cerebral artery stroke with subsequent malignant edema and ongoing cerebral transtentorial herniation in the course of a severe myocarditis requiring ECMO support. A DCH was done 32 h after symptom onset. At the age of 5 years, she exhibits an mRS of 3. CONCLUSION Pediatric stroke with malignant edema is a severe condition with high mortality rate if left untreated and often long-lasting consequences. DCH might minimize the vicious circle of cerebral swelling, increasing intracranial pressure and brain ischemia. Our literature review underscores DCH as an efficient therapeutic measure management of pmAIS even when performed after a significant delay; however, long-lasting morbidities remain high.
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Affiliation(s)
- Audrey Carlhan-Ledermann
- Neonatology and Pediatric Intensive Care Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Andrea Bartoli
- Neurosurgery Unit, Department of Clinical Neuroscience, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Fabienne Gebistorf
- Neonatology and Pediatric Intensive Care Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Maurice Beghetti
- Pediatric Cardiology Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Tornike Sologashvili
- Cardiovascular Surgery Unit, Department of Surgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Monica Rebollo Polo
- Pediatric Radiology Unit, Department of Radiology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Joel Fluss
- Pediatric Neurology Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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Truckenmueller P, Fritzsching J, Schulze D, Früh A, Jacobs S, Ahlborn R, Vajkoczy P, Prinz V, Hecht N. Outcome and management of decompressive hemicraniectomy in malignant hemispheric stroke following cardiothoracic surgery. Sci Rep 2023; 13:12994. [PMID: 37563196 PMCID: PMC10415332 DOI: 10.1038/s41598-023-40202-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 08/07/2023] [Indexed: 08/12/2023] Open
Abstract
Management of malignant hemispheric stroke (MHS) after cardiothoracic surgery (CTS) remains difficult as decision-making needs to consider severe cardiovascular comorbidities and complex coagulation management. The results of previous randomized controlled trials on decompressive surgery for MHS cannot be generally translated to this patient population and the expected outcome might be substantially worse. Here, we analyzed mortality and functional outcome in patients undergoing decompressive hemicraniectomy (DC) for MHS following CTS and assessed the impact of perioperative coagulation management on postoperative hemorrhagic and cardiovascular complications. All patients that underwent DC for MHS resulting as a complication of CTS between June 2012 and November 2021 were included in this observational cohort study. Outcome was determined according to the modified Rankin Scale (mRS) score at 1 and 3-6 months. Clinical and demographic data, anticoagulation management and postoperative hemorrhagic and thromboembolic complications were assessed. In order to evaluate a predictive association between clinical and radiological parameters and the outcome, we used a multivariate logistic regression analysis. Twenty-nine patients undergoing DC for MHS after CTS with a female-to-male ratio of 1:1.9 and a median age of 60 (IQR 49-64) years were identified out of 123 patients undergoing DC for MHS. Twenty-four patients (83%) received pre- or intraoperative substitution. At 30 days, the in-hospital mortality rate and neurological outcome corresponded to 31% and a median mRS of 5 (5-6), which remained stable at 3-6 months [Mortality: 42%, median mRS: 5 (4-6)]. Postoperatively, 15/29 patients (52%) experienced new hemorrhagic lesions and Bayesian logistic regression predicting mortality (mRS = 6) after imputing missing data demonstrated a significantly increased risk for mortality with longer aPPT (OR = 13.94, p = .038) and new or progressive hemorrhagic lesions after DC (OR = 3.03, p = .19). Notably, all but one hemorrhagic lesion occurred before discontinued anticoagulation and/or platelet inhibition was re-initiated. Despite perioperative discontinuation of anticoagulation and/or platelet inhibition, no coagulation-associated cardiovascular complications were noted. In conclusion, Cardiothoracic surgery patients suffering MHS will likely experience severe neurological disability after DC, which should remain a central aspect during counselling and decision-making. The complex coagulation situation after CTS, however, should not per se rule out the option of performing life-saving surgical decompression.
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Affiliation(s)
- Peter Truckenmueller
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Jonas Fritzsching
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Daniel Schulze
- Institute of Medical Biometrics and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anton Früh
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Stephan Jacobs
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Robert Ahlborn
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Vincent Prinz
- Department of Neurosurgery, Goethe Universität Frankfurt, Frankfurt am Main, Germany
| | - Nils Hecht
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
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Kollmar R, De Georgia M. Milestones in the history of neurocritical care. Neurol Res Pract 2023; 5:43. [PMID: 37559106 PMCID: PMC10413505 DOI: 10.1186/s42466-023-00271-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023] Open
Abstract
Over the last century, significant milestones have been achieved in managing critical illness and diagnosing and treating neurological diseases. Building upon these milestones, the field of neurocritical care emerged in the 1980 and 1990 s at the convergence of critical care medicine and acute neurological treatment. This comprehensive review presents a historical account of key developments in neurocritical care in both the United States and Europe, with a special emphasis on German contributions. The scope of the review encompasses: the foundations of neurocritical care, including post-operative units in the 1920s and 30s, respiratory support during the poliomyelitis epidemics in the 40 and 50 s, cardiac and hemodynamic care in the 60 and 70 s, and stroke units in the 80 and 90 s; key innovations including cerebral angiography, computed tomography, and intracranial pressure and multi-modal monitoring; and advances in stroke, traumatic brain injury, cardiac arrest, neuromuscular disorders, meningitis and encephalitis. These advances have revolutionized the management of neurological emergencies, emphasizing interdisciplinary teamwork, evidence-based protocols, and personalized approaches to care.
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Affiliation(s)
- Rainer Kollmar
- Department of Neurology and Neurointensive Care, Darmstadt Academic Hospital, Darmstadt, Germany.
| | - Michael De Georgia
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Buffagni D, Zamarron A, Melgosa I, Gutierrez-Gonzalez R. Long-term quality of life after decompressive craniectomy. Front Neurol 2023; 14:1222080. [PMID: 37564730 PMCID: PMC10410286 DOI: 10.3389/fneur.2023.1222080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/03/2023] [Indexed: 08/12/2023] Open
Abstract
Introduction This study aims to assess the quality of life (QoL) in patients who have undergone decompressive craniectomy (DC) for any pathology that has caused life-threatening intracranial hypertension. Similarly, it aims to evaluate QoL perceived by caregivers or external informants. In addition to that, the last purpose is to determine which clinical or therapeutic factors could correlate with a better QoL. Methods A single-center cross-sectional study was designed. All patients over 18 years old who underwent a supratentorial DC at our department due to intracranial hypertension of any etiology, from January 2015 to December 2021, were retrospectively selected. Patients with incomplete follow-up (under 1 year from the event or those who died) or who declined to participate in the study were excluded. QoL was assessed with SF-36 and CAVIDACE scales. The correlation between clinical and therapeutic variables and SF-36 subscales was studied with Spearman's correlation and the Mann-Whitney U-test. Results A total of 55 consecutive patients were recruited: 22 patients had died, three were missed for follow-up, and 15 declined to participate, thus 15 subjects were finally included. The mean follow-up was 47 months (IQR 21.5-67.5). A significant reduction in the "role physical" and "role emotional" subscales of SF-36 was observed compared with the general population. According to caregivers, a significant reduction was assigned to the "physical wellbeing" and "rights" domains. The "physical functioning" score was poorer in women, older patients, those with dominant hemisphere disease, those who required tracheostomy, and those with poor outcomes in the modified Rankin scale. A strong correlation was found between the QoL index at the CAVIDACE scale and the SF-36 subscales "physical functioning" and "role physical". Conclusion Most patients and caregivers reported acceptable QoL after DC due to a life-threatening disease. A significant reduction in SF- 36 subscales scores "role limitation due to physical problems" and "role limitation due to emotional problems" was referred by patients. According to caregivers' QoL perception, only 25% of the survey's participants showed low scores in the QoL index of the CAVIDACE scale. Only 26.7% of the patients showed mood disorders.
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Affiliation(s)
- Daniel Buffagni
- Department of Surgery, Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Alvaro Zamarron
- Department of Neurosurgery, Puerta de Hierro University Hospital, IDIPHISA, Madrid, Spain
| | - Isabel Melgosa
- Department of Anesthesiology, Marques de Valdecilla University Hospital, Santander, Spain
| | - Raquel Gutierrez-Gonzalez
- Department of Surgery, Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
- Department of Neurosurgery, Puerta de Hierro University Hospital, IDIPHISA, Madrid, Spain
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Siddiqi MM, Khawar WI, Donnelly BM, Lim J, Kuo CC, Monteiro A, Baig AA, Waqas M, Soliman MAR, Davies JM, Snyder KV, Levy EI, Siddiqui AH, Vakharia K. Pretreatment and Posttreatment Factors Associated with Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 175:e925-e939. [PMID: 37075897 DOI: 10.1016/j.wneu.2023.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Hydrocephalus is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to evaluate novel preoperative and postoperative risk factors for shunt-dependent hydrocephalus (SDHC) after aSAH via a systematic review and meta-analysis. METHODS A systematic search was conducted using PubMed and Embase databases for studies pertaining to aSAH and SDHC. Articles were assessed by meta-analysis if the number of risk factors for SDHC was reported by >4 studies and could be extracted separately for patients who did or did not develop SDHC. RESULTS Thirty-seven studies were included, comprising 12,667 patients with aSAH (SDHC 2214 vs. non-SDHC 10,453). In a primary analysis of 15 novel potential risk factors, 8 were identified to be significantly associated with increased prevalence of SDHC after aSAH, including high World Federation of Neurological Surgeons grades (odds ratio [OR], 2.43), hypertension (OR, 1.33), anterior cerebral artery (OR, 1.36), middle cerebral artery (OR, 0.65), and vertebrobasilar artery (2.21) involvement, decompressive craniectomy (OR, 3.27), delayed cerebral ischemia (OR, 1.65), and intracerebral hematoma (OR, 3.91). CONCLUSIONS Several new factors associated with increased odds of developing SDHC after aSAH were found to be significant. By providing evidence-based risk factors for shunt dependency, we describe an identifiable list of preoperative and postoperative prognosticators that may influence how surgeons recognize, treat, and manage patients with aSAH at high risk for developing SDHC.
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Affiliation(s)
- Manhal M Siddiqi
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.
| | - Wasiq I Khawar
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Brianna M Donnelly
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Mohammed A R Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Neurosurgery Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
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Yang Y, Long X, Li A, Liang X, Qin X, Ma W, Han Y. Clinical Analysis of Microvascular Reconstruction Combined With Decompressive Craniectomy in Patients With Malignant Middle Cerebral Artery Infarctions. World Neurosurg 2023; 175:e790-e795. [PMID: 37061033 DOI: 10.1016/j.wneu.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 04/06/2023] [Indexed: 04/17/2023]
Abstract
PURPOSE This study aimed to evaluate the safety and efficacy of microvascular reconstruction combined with decompressive craniectomy (DHC) in patients with malignant middle cerebral artery infarctions (MMCA). METHODS We searched for patients with MMCA and aged<60 years old, postoperative survival of more than 3 months, consistent with decompression of bone flap removal. Patients were divided into experimental group and control group according to whether they underwent emergency vascular revascularization within 5 days after onset of ischemic stroke. RESULTS A total of sixpatients were included in the treatment group and 12 patients in the control group. The National Institutes of Health Stroke Scale (NIHSS) score of the treatment group was lower than that of the control group seven days after operation, but the difference was not statistically significant; 3 months after surgery, modified ranking scale (mRs) score in the treatment group was lower than that in the control group, the difference was statistically significant (P = 0.002); mRs scores of the treatment group 3 months after surgery were significantly different from those before surgery (P < 0.05), but no such difference was found in the control group. CONCLUSION Compared with decompressive craniectomy, open surgical revascularization can improve early cerebral perfusion in MMCA patients, and neurological recovery is better at 3 months after operation. By ensuring that surgeons are properly trained and hospitals are equipped, open surgical revascularization can be a treatment option for patients with MMCA.
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Affiliation(s)
- Yumin Yang
- Department of Neurosurgery, People's Hospital of Deyang City, Deyang, China
| | - Xiaodong Long
- Department of Neurosurgery, People's Hospital of Deyang City, Deyang, China
| | - Aiguo Li
- Department of Neurosurgery, People's Hospital of Deyang City, Deyang, China
| | - Xiaolong Liang
- Department of Neurosurgery, People's Hospital of Deyang City, Deyang, China
| | - Xinghu Qin
- Department of Neurosurgery, People's Hospital of Deyang City, Deyang, China
| | - Wenchao Ma
- Department of Neurosurgery, People's Hospital of Deyang City, Deyang, China
| | - Yangyun Han
- Center for Neurological Diseases, People's Hospital of Deyang City, Deyang, China.
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Krishnan K, Hollingworth M, Nguyen TN, Kumaria A, Kirkman MA, Basu S, Tolias C, Bath PM, Sprigg N. Surgery for Malignant Acute Ischemic Stroke: A Narrative Review of the Knowns and Unknowns. Semin Neurol 2023; 43:370-387. [PMID: 37595604 DOI: 10.1055/s-0043-1771208] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
Malignant acute ischemic stroke (AIS) is characterized by acute neurological deterioration caused by progressive space-occupying brain edema, often occurring in the first hours to days after symptom onset. Without any treatment, the result is often fatal. Despite advances in treatment for AIS, up to 80% of patients with a large hemispheric stroke or cerebellar stroke are at risk of poor outcome. Decompressive surgery can be life-saving in a subgroup of patients with malignant AIS, but uncertainties exist on patient selection, predictors of malignant infarction, perioperative management, and timing of intervention. Although survivors are left disabled, most agree with the original decision to undergo surgery and would make the same decision again. In this narrative review, we focus on the clinical and radiological predictors of malignant infarction in AIS and outline the technical aspects of decompressive surgery as well as duraplasty and cranioplasty. We discuss the current evidence and recommendations for surgery in AIS, highlighting gaps in knowledge, and suggest directions for future studies. KEY POINTS: · Acute ischemic stroke from occlusion of a proximal intracranial artery can progress quickly to malignant edema, which can be fatal in 80% of patients despite medical management.. · Decompression surgery is life-saving within 48 hours of stroke onset, but the benefits beyond this time and in the elderly are unknown.. · Decompressive surgery is associated with high morbidity, particularly in the elderly. The decision to operate must be made after considering the individual's preference and expectations of quality of life in the context of the clinical condition.. · Further studies are needed to refine surgical technique including value of duraplasty and understand the role monitoring intracranial pressure during and after decompressive surgery.. · More studies are needed on the pathophysiology of malignant cerebral edema, prediction models including imaging and biomarkers to identify which subgroup of patients will benefit from decompressive surgery.. · More research is needed on factors associated with morbidity and mortality after cranioplasty, safety and efficacy of implants, and comparisons between them.. · Further studies are needed to assess the long-term effects of physical disability and quality of life of survivors after surgery, particularly those with severe neurological deficits..
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Affiliation(s)
- Kailash Krishnan
- Stroke Unit, Department of Acute Medicine Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Milo Hollingworth
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Thanh N Nguyen
- Department of Neurology, Neurosurgery and Radiology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Ashwin Kumaria
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Matthew A Kirkman
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Surajit Basu
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Christos Tolias
- Department of Neurosurgery, King's College Hospitals NHS Foundation Trust, London, United Kingdom
| | - Philip M Bath
- Stroke Unit, Department of Acute Medicine Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Nikola Sprigg
- Stroke Unit, Department of Acute Medicine Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
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Mee H, Castano Leon A, Anwar F, Grieve K, Owen N, Turner C, Whiting G, Viaroli E, Timofeev I, Helmy A, Kolias A, Hutchinson P. Towards a core outcome set for cranioplasty following traumatic brain injury and stroke 'A systematic review of reported outcomes'. BRAIN & SPINE 2023; 3:101735. [PMID: 37383457 PMCID: PMC10293280 DOI: 10.1016/j.bas.2023.101735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 03/23/2023] [Accepted: 04/03/2023] [Indexed: 06/30/2023]
Abstract
Background There is wide-ranging published literature around cranioplasty following traumatic brain injury (TBI) and stroke, but the heterogeneity of outcomes limits the ability for meta-analysis. Consensus on appropriate outcome measures has not been reached, and given the clinical and research interest, a core outcome set (COS) would be beneficial. Objectives To collate outcomes currently reported across the cranioplasty literature which will subsequently be used in developing a cranioplasty COS. Methods This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. All full-text English studies with more than ten patients (prospective) or more than 20 patients (retrospective) published after 1990 examining outcomes in CP were eligible for inclusion. Results The review included 205 studies from which 202 verbatim outcomes were extracted, grouped into 52 domains, and categorised into one or more of the OMERACT 2.0 framework core area(s). The total numbers of studies that reported outcomes in the core areas are 192 (94%) pathophysiological manifestations/ 114 (56%) resource use/economic impact/ 94 (46%) life impact/mortality 20 (10%). In addition, there are 61 outcome measures used in the 205 studies across all domains. Conclusion This study shows considerable heterogeneity in the types of outcomes used across the cranioplasty literature, demonstrating the importance and necessity of developing a COS to help standardise reporting across the literature.
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Affiliation(s)
- H. Mee
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Department of Rehabilitation, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - A. Castano Leon
- Neurosurgery Department, Research Institute i+12-CIBERESP, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Spain
| | - F. Anwar
- Department of Rehabilitation, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - K. Grieve
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
| | - N. Owen
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
| | - C. Turner
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
| | - G. Whiting
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
| | - E. Viaroli
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
| | - I. Timofeev
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
| | - A. Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
| | - A. Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - P. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
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Lehrieder D, Müller HP, Kassubek J, Hecht N, Thomalla G, Michalski D, Gattringer T, Wartenberg KE, Schultze-Amberger J, Huttner H, Kuramatsu JB, Wunderlich S, Steiner HH, Weissenborn K, Heck S, Günther A, Schneider H, Poli S, Dohmen C, Woitzik J, Jüttler E, Neugebauer H. Large diameter hemicraniectomy does not improve long-term outcome in malignant infarction. J Neurol 2023:10.1007/s00415-023-11766-3. [PMID: 37162579 DOI: 10.1007/s00415-023-11766-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/11/2023]
Abstract
INTRODUCTION In malignant cerebral infarction decompressive hemicraniectomy has demonstrated beneficial effects, but the optimum size of hemicraniectomy is still a matter of debate. Some surgeons prefer a large-sized hemicraniectomy with a diameter of more than 14 cm (HC > 14). We investigated whether this approach is associated with reduced mortality and an improved long-term functional outcome compared to a standard hemicraniectomy with a diameter of less than 14 cm (HC ≤ 14). METHODS Patients from the DESTINY (DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY) registry who received hemicraniectomy were dichotomized according to the hemicraniectomy diameter (HC ≤ 14 cm vs. HC > 14 cm). The primary outcome was modified Rankin scale (mRS) score ≤ 4 after 12 months. Secondary outcomes were in-hospital mortality, mRS ≤ 3 and mortality after 12 months, and the rate of hemicraniectomy-related complications. The diameter of the hemicraniectomy was examined as an independent predictor of functional outcome in multivariable analyses. RESULTS Among 130 patients (32.3% female, mean (SD) age 55 (11) years), the mean hemicraniectomy diameter was 13.6 cm. 42 patients (32.3%) had HC > 14. There were no significant differences in the primary outcome and mortality by size of hemicraniectomy. Rate of complications did not differ (HC ≤ 14 27.6% vs. HC > 14 36.6%, p = 0.302). Age and infarct volume but not hemicraniectomy diameter were associated with outcome in multivariable analyses. CONCLUSION In this post-hoc analysis, large hemicraniectomy was not associated with an improved outcome or lower mortality in unselected patients with malignant middle cerebral artery infarction. Randomized trials should further examine whether individual patients could benefit from a large-sized hemicraniectomy. CLINICAL TRIAL REGISTRATION INFORMATION German Clinical Trials Register (URL: https://www.drks.de ; Unique Identifier: DRKS00000624).
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Affiliation(s)
- Dominik Lehrieder
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany.
| | | | - Jan Kassubek
- Department of Neurology, University Hospital Ulm, Ulm, Germany
| | - Nils Hecht
- Department of Neurosurgery and Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dominik Michalski
- Department of Neurology, University Hospital Leipzig, Leipzig, Germany
| | | | - Katja E Wartenberg
- Department of Neurology, University Hospital Leipzig, Leipzig, Germany
- Department of Neurology, University of Halle-Wittenberg, Halle/Saale, Germany
| | | | - Hagen Huttner
- Department of Neurology, University Hospital Giessen, Giessen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Silke Wunderlich
- Department of Neurology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | | | - Suzette Heck
- Department of Neurology, University of Munich, Ludwig Maximilian University, Munich, Germany
| | - Albrecht Günther
- Department of Neurology, University Hospital Jena, Jena, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital Dresden, Dresden, Germany
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Sven Poli
- Department of Neurology and Stroke, Eberhard-Karls University Tuebingen, Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Christian Dohmen
- Department of Neurology, University Hospital Cologne, Cologne, Germany
- Department for Neurology and Neurological Intensive Care, LVR Clinic Bonn, Bonn, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, University Hospital Oldenburg, Oldenburg, Germany
| | - Eric Jüttler
- Department of Neurology, Ostalb-Klinikum Aalen, Aalen, Germany
| | - Hermann Neugebauer
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
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He Y, Zuo M, Huang J, Jiang Y, Zhou L, Li G, Chen L, Liu Q, Liang D, Wang Y, Wang L, Zhou Z. A Novel Nomogram for Predicting Malignant Cerebral Edema After Endovascular Thrombectomy in Acute Ischemic Stroke: A Retrospective Cohort Study. World Neurosurg 2023; 173:e548-e558. [PMID: 36842531 DOI: 10.1016/j.wneu.2023.02.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/20/2023] [Indexed: 02/28/2023]
Abstract
BACKGROUND Malignant cerebral edema (MCE) is a common and feared complication after endovascular thrombectomy (EVT) in acute ischemic stroke (AIS). This study aimed to establish a nomogram to predict MCE in anterior circulation large vessel occlusion stroke (LVOS) patients receiving EVT in order to guide the postoperative medical care in the acute phase. METHODS In this retrospective cohort study, 381 patients with anterior circulation LVOS receiving EVT were screened from 636 hospitalized patients with LVOS at 2 stroke medical centers. Clinical baseline data and imaging data were collected within 2-5 days of admission to the hospital. The patients were divided into 2 groups based on whether MCE occurred after EVT. Multivariate logistic regression analysis was used to evaluate the independent risk factors for MCE and to establish a nomogram. RESULTS Sixty-six patients out of 381 (17.32%) developed MCE. The independent risk factors for MCE included admission National Institutes of Health Stroke Scale (NIHSS) ≥16 (odds ratio [OR] 1.851; 95% CI 1.029-3.329; P = 0.038), ASPECT score (OR 0.621; 95% CI 0.519-0.744; P < 0.001), right hemisphere (OR 1.636; 95% CI 0.941-2.843; P = 0.079), collateral circulation (OR 0.155; 95% CI 0.074-0.324; P < 0.001), recanalization (OR 0.223; 95% CI 0.109-0.457; P < 0.001), hematocrit (OR, 0.937; 95% CI: 0.892-0.985; P =0.010), and glucose (OR 1.118; 95% CI 1.023-1.223; P = 0.036), which were adopted as parameters of the nomogram. The receiver operating characteristic curve analysis showed that the area under the curve of the nomogram in predicting MCE was 0.901(95% CI 0.848-0.940; P < 0.001). The Hosmer-Lemeshow test results were not significant (P = 0.685), demonstrating a good calibration of the nomogram. CONCLUSIONS The novel nomogram composed of admission NIHSS, ASPECT scores, right hemisphere, collateral circulation, recanalization, hematocrit, and serum glucose provide a potential predictor for MCE in patients with AIS after EVT.
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Affiliation(s)
- Yuxuan He
- Department of Neurology, School of Medicine, Chongqing University, Chongqing, China; Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Meng Zuo
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jialu Huang
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Ying Jiang
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Linke Zhou
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Guangjian Li
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Lin Chen
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Qu Liu
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Dingwen Liang
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yu Wang
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Li Wang
- Department of Neurology, Zigong Third People's Hospital, Zigong, Sichuang, China
| | - Zhenhua Zhou
- Department of Neurology, School of Medicine, Chongqing University, Chongqing, China; Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.
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Lim NA, Lin HY, Tan CH, Ho AFW, Yeo TT, Nga VDW, Tan BYQ, Lim MJR, Yeo LLL. Functional and Mortality Outcomes with Medical and Surgical Therapy in Malignant Posterior Circulation Infarcts: A Systematic Review. J Clin Med 2023; 12:jcm12093185. [PMID: 37176624 PMCID: PMC10179120 DOI: 10.3390/jcm12093185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND There remains uncertainty regarding optimal definitive management for malignant posterior circulation infarcts (MPCI). While guidelines recommend neurosurgery for malignant cerebellar infarcts that are refractory to medical therapy, concerns exist about the functional outcome and quality of life after decompressive surgery. OBJECTIVE This study aims to evaluate the outcomes of surgical intervention compared to medical therapy in MPCI. METHODS In this systematic review, MEDLINE, Embase and Cochrane databases were searched from inception until 2 April 2021. Studies were included if they involved posterior circulation strokes treated with neurosurgical intervention and reported mortality and functional outcome data. Data were collected according to PRISMA guidelines. RESULTS The search yielded 6677 studies, of which 31 studies (comprising 723 patients) were included for analysis. From the included studies, we found that surgical therapy led to significant differences in mortality and functional outcomes in patients with severe disease. Neurological decline and radiological criteria were often used to decide the timing for surgical intervention, as there is currently limited evidence for preventative neurosurgery. There is also limited evidence for the superiority of one surgical modality over another. CONCLUSION For patients with MPCI who are clinically stable at the time of presentation, in terms of mortality and functional outcome, surgical therapy appears to be equivocal to medical therapy. Reliable evidence is lacking, and further prospective studies are rendered.
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Affiliation(s)
- Nicole-Ann Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Hong-Yi Lin
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Choon Han Tan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 636921, Singapore
| | - Andrew F W Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore
- Pre-Hospital & Emergency Care Research Centre, Duke-NUS Medical School, Singapore 169547, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore 119074, Singapore
| | - Vincent Diong Weng Nga
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore 119074, Singapore
| | - Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119074, Singapore
| | - Mervyn J R Lim
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore 119074, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119074, Singapore
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Pu M, Chen J, Chen Z, Li Z, Li Z, Tang Y, Li Q. Predictors and outcome of malignant cerebral edema after successful reperfusion in anterior circulation stroke. J Stroke Cerebrovasc Dis 2023; 32:107139. [PMID: 37105014 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 04/08/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Risk factors and predictors of malignant cerebral edema (MCE) after successful endovascular thrombectomy (EVT) were not fully explored. This study aimed to evaluate the incidence and risk factors of MCE after successful reperfusion. METHODS We retrospectively analyzed consecutive ischemic stroke patients who underwent EVT in our institution from November 2015 to April 2022. Patients who failed to achieve successful reperfusion (modified thrombolysis in cerebral infarction [mTICI]<2b) were excluded. Based on multivariate logistic models, the best-fit monogram was established. The discriminative performance was assessed by the receiver operating characteristics curve (ROC). RESULTS A total of 307 patients were included and 48 (15.6%) were diagnosed with MCE after successful reperfusion. Patients with MCE after successful reperfusion had a lower 3-month favorable outcome (15.2% versus 59.6%; p<0.001), a lower 3-month good outcome (17.4% versus 68.4%; p<0.001), and a higher rate of mortality at 3-month (54.3% versus 8.8%; p<0.001) compared with patients without MCE. Predictors of MCE after successful reperfusion included admission glucose level, baseline National Institutes of Health Stroke Scale (NIHSS) score, stroke etiology, occlusion site and puncture-to-reperfusion (PTR) time>120 min. The area under the curve (AUC) of the nomogram was 0.805 (95% CI, 0.756-0.847). CONCLUSIONS MCE after successful reperfusion is associated with poor outcome and mortality. A nomogram containing admission glucose level, baseline NIHSS score, stroke etiology, occlusion site and PTR time>120 min may predict the risk of MCE after successful reperfusion in patients with acute ischemic stroke and treated successfully with EVT.
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Affiliation(s)
- Mingjun Pu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang 621000, China
| | - Jun Chen
- Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang 621000, China
| | - Zhonglun Chen
- Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang 621000, China
| | - Zhaokun Li
- Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang 621000, China
| | - Zuoqiao Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yufeng Tang
- Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang 621000, China.
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
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50
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Macha K, Schwab S. It is all about timing: decompressive hemicraniectomy for malignant middle-cerebral-artery infarction. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:327-328. [PMID: 37160135 PMCID: PMC10169221 DOI: 10.1055/s-0043-1768674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 05/11/2023]
Affiliation(s)
- Kosmas Macha
- Friedrich-Alexander-University of Erlangen-Nuremberg, University Hospital Erlangen, Department of Neurology, Erlangen, Germany.
| | - Stefan Schwab
- Friedrich-Alexander-University of Erlangen-Nuremberg, University Hospital Erlangen, Department of Neurology, Erlangen, Germany.
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