Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial

A CT-based machine learning model for using clinical-radiomics to predict malignant cerebral edema after stroke: a two-center study

Purpose

This research aimed to create a machine learning model for clinical-radiomics that utilizes unenhanced computed tomography images to assess the likelihood of malignant cerebral edema (MCE) in individuals suffering from acute ischemic stroke (AIS).

Methods

The research included 179 consecutive patients with AIS from two different hospitals. These patients were randomly assigned to training (n = 143) and validation (n = 36) sets with an 8:2 ratio. Using 3DSlicer software, the radiomics features of regions impacted by infarction were derived from unenhanced CT scans. The radiomics features linked to MCE were pinpointed through a consistency test, Student's t test and the least absolute shrinkage and selection operator (LASSO) method for selecting features. Clinical parameters associated with MCE were also identified. Subsequently, machine learning models were constructed based on clinical, radiomics, and clinical-radiomics. Ultimately, the efficacy of these models was evaluated by measuring the operating characteristics of the subjects through their area under the curve (AUCs).

Results

Logistic regression (LR) was found to be the most effective machine learning algorithm, for forecasting the MCE. In the training and validation cohorts, the AUCs of clinical model were 0.836 and 0.773, respectively, for differentiating MCE patients; the AUCs of radiomics model were 0.849 and 0.818, respectively; the AUCs of clinical and radiomics model were 0.912 and 0.916, respectively.

Conclusion

This model can assist in predicting MCE after acute ischemic stroke and can provide guidance for clinical treatment and prognostic assessment.

No difference in 6-month functional outcome between early and late decompressive craniectomies following acute ischaemic stroke in a national neurosurgical centre: a single-centre retrospective case-cohort study

BACKGROUND

Decompressive craniectomies (DCs) are recommended for the treatment of raised intracranial pressure after acute ischaemic stroke. Some studies have demonstrated improved outcomes with early decompressive craniectomy (< 48 h from onset) in patients with malignant cerebral oedema following middle cerebral artery infarction. Limited data is available on suboccipital decompressive craniectomy after cerebellar infarction.

AIMS

Our primary objective was to determine whether the timing of DCs influenced functional outcomes at 6 months. Our secondary objectives were to analyse whether age, gender, the territory of stroke, or preceding thrombectomy impacts functional outcome post-DC.

METHODS

We conducted a retrospective study of patients admitted between January 2014 and December 2020 who had DCs post-acute ischaemic stroke. Data was collected from ICU electronic records, individual patient charts, and the stroke database.

RESULTS

Twenty-six patients had early DC (19 anterior/7 posterior) and 21 patients had late DC (17 anterior/4 posterior). There was no difference in the modified Rankin Scale (mRS) score of the two groups at 90 (p = 0.318) and 180 (p = 0.333) days post early vs late DC. Overall outcomes were poor, with 5 out of 46 patients (10.9%) having a mRS score ≤ 3 at 6 months. There was no difference in mRS scores between the patients who had hemicraniectomies for anterior circulation stroke (n = 35) and suboccipital DC for posterior circulation stroke (n = 11) (p = 0.594).

CONCLUSION

In this single-centre retrospective study, we found no significant difference in functional outcomes between patients who had early or late DC after ischaemic stroke.

Swiss trial of decompressive craniectomy versus best medical treatment of spontaneous supratentorial intracerebral haemorrhage (SWITCH): an international, multicentre, randomised-controlled, two-arm, assessor-blinded trial

RATIONALE

Decompressive craniectomy (DC) is beneficial in people with malignant middle cerebral artery infarction. Whether DC improves outcome in spontaneous intracerebral haemorrhage (ICH) is unknown.

AIM

To determine whether DC without haematoma evacuation plus best medical treatment (BMT) in people with ICH decreases the risk of death or dependence at 6 months compared to BMT alone.

METHODS AND DESIGN

SWITCH is an international, multicentre, randomised (1:1), two-arm, open-label, assessor-blinded trial. Key inclusion criteria are age ⩽75 years, stroke due to basal ganglia or thalamic ICH that may extend into cerebral lobes, ventricles or subarachnoid space, Glasgow coma scale of 8-13, NIHSS score of 10-30 and ICH volume of 30-100 mL. Randomisation must be performed <66 h after onset and DC <6 h after randomisation. Both groups will receive BMT. Participants randomised to the treatment group will receive DC of at least 12 cm in diameter according to institutional standards.

SAMPLE SIZE

A sample of 300 participants randomised 1:1 to DC plus BMT versus BMT alone provides over 85% power at a two-sided alpha-level of 0.05 to detect a relative risk reduction of 33% using a chi-squared test.

OUTCOMES

The primary outcome is the composite of death or dependence, defined as modified Rankin scale score 5-6 at 6 months. Secondary outcomes include death, functional status, quality of life and complications at 180 days and 12 months.

DISCUSSION

SWITCH will inform physicians about the outcomes of DC plus BMT in people with spontaneous deep ICH, compared to BMT alone.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02258919.

Decompressive Craniectomy in Patients with Malignant Stroke with Additional Vascular Territory

BACKGROUND

Decompressive craniectomy substantially reduces mortality and disability rates following a malignant stroke. This procedure remains a life-saving option, especially in contexts with little access to mechanical thrombectomy despite downward trends in the performance of decompressive craniectomy due to discussions on the acceptance of living with severe disabilities. However, the outcomes of the surgery in cases involving concomitant occlusion of anterior or posterior cerebral arteries have not been extensively studied.

METHODS

In this retrospective cohort study, spanning January 2010 to December 2022 and including patients who underwent decompressive craniectomy, we compared outcomes between patients with and without additional vascular territory involvement. Independent variables included age, sex, comorbidities, admission National Institutes of Health Stroke Scale and Glasgow Coma Scale scores, time elapsed between stroke and surgery, laterality of the stroke, midline shift, and postoperative infarction volume. Outcomes included mortality and modified Rankin Score at the 3-month follow-up.

RESULTS

Of the 86 patients analyzed, 61 (70.9%) and 25 (29.1%) demonstrated no territory and additional territory involvement, respectively. Patients with involvement of additional territories exhibited lower admission Glasgow Coma Scale scores, higher National Institutes of Health Stroke Scale scores, and larger postoperative infarction volumes. However, these variables were not associated with poor outcomes. Univariate analyses revealed no differences in mortality or severe disability. Even after adjustment, the differences remained insignificant for mortality and severe disability. Age emerged as the sole variable linked to increased mortality.

CONCLUSIONS

Our data suggest that, for patients with malignant stroke undergoing decompressive craniectomy, the outcomes for patients with and without involvement of additional vascular territory are similar.

Decompressive Surgery in the Treatment of Acute Ischemic Stroke during the First Four Waves of the COVID-19 Pandemic in Germany: A Nationwide Observational Cohort Study

BACKGROUND

 The COVID-19 pandemic has significantly affected acute ischemic stroke (AIS) care. In this study, we examined the effects of the pandemic on neurosurgical AIS care by means of decompressive surgery (DS).

METHODS

 In this retrospective observational study, we compared the characteristics, in-hospital processes, and in-hospital mortality rates among patients hospitalized for AIS during the first four waves of the pandemic (between January 1, 2020 and October 26, 2021) versus the corresponding periods in 2019 (prepandemic). We used administrative data from a nationwide hospital network in Germany.

RESULTS

 Of the 177 included AIS cases with DS, 60 were from 2019 and 117 from the first four pandemic waves. Compared with the prepandemic levels, there were no changes in weekly admissions for DS during the pandemic. The same was true for patient age (range: 51.7-60.4 years), the number of female patients (range: 33.3-57.1%), and the prevalence of comorbidity, as measured by the Elixhauser Comorbidity Index (range: 13.2-20.0 points). Also, no alterations were observed in transfer to the intensive care unit (range: 87.0-100%), duration of in-hospital stay (range: 14.6-22.7 days), and in-hospital mortality rates (range: 11.8-55.6%).

CONCLUSION

 In Germany, compared with the prepandemic levels, AIS patients undergoing DS during the first four waves of the pandemic showed no changes in demographics, rates of comorbidity, and in-hospital mortality rates. This is in contrast to previous evidence on patients with less critical types of AIS not requiring DS and underlines the uniqueness of the subgroup of AIS patients requiring DS. Our findings suggests that these patients, in contrast to AIS patients in general, were unable to forgo hospitalization during the COVID-19 pandemic. Maintaining the delivery of DS is an essential aspect of AIS care during a pandemic.

Primary decompressive craniectomy in patients with large intracerebral hematomas due to aneurysmal subarachnoid hemorrhage

BACKGROUND

Decompressive craniectomy (DC) can alleviate increased intracranial pressure in aneurysmal subarachnoid hemorrhage patients with concomitant space-occupying intracerebral hemorrhage, but also carries a high risk for complications. We studied outcomes and complications of DC at time of ruptured aneurysm repair.

METHODS

Of 47 patients treated between 2010 and 2020, 30 underwent DC during aneurysm repair and hematoma evacuation and 17 did not. We calculated odds ratios (OR) for delayed cerebral ischemia (DCI), angiographic vasospasm, DCI-related infarction, and unfavorable functional outcome (extended Glasgow Outcome Scale 1-5) at three months. Complication rates after DC and cranioplasty in the aneurysmal subarachnoid hemorrhage patients were compared to those of all 107 patients undergoing DC for malignant cerebral infarction during the same period.

RESULTS

In DC versus no DC patients, proportions were for clinical DCI 37% versus 53% (OR = 0.5;95%CI:0.2-1.8), angiographic vasospasm 37% versus 47% (OR = 0.7;95%CI:0.2-2.2), DCI-related infarctions 17% versus 47% (OR = 0.2;95%CI:0.1-0.7) and unfavorable outcome 80% versus 88% (OR = 0.5;95%CI:0.1-3.0). ORs were similar after adjustment for baseline predictors for outcome. Complications related to DC and cranioplasty occurred in 18 (51%) of subarachnoid hemorrhage patients and 41 (38%) of cerebral infarction patients (OR = 1.7;95%CI:0.8-3.7).

CONCLUSIONS

In patients with aneurysmal subarachnoid hemorrhage and concomitant space-occupying intracerebral hemorrhage, early DC was not associated with improved functional outcomes, but with a reduced rate of DCI-related infarctions. This potential benefit has to be weighed against high complication rates of DC in subarachnoid hemorrhage patients.

Clot removAl with or without decompRessive craniectomy under ICP monitoring for supratentorial IntraCerebral Hemorrhage (CARICH): a randomized controlled trial

BACKGROUND

Decompressive craniectomy (DC), a surgery to remove part of the skull and open the dura mater, maybe an effective treatment for controlling intracranial hypertension. It remains great interest to elucidate whether DC is beneficial to intracerebral hemorrhage (ICH) patients who warrant clot removal (CR) to prevent intracranial hypertension.

METHODS

The trial was a prospective, pragmatic, controlled trial involving adult patients with ICH who were undergoing removal of hematoma. ICH patients were randomly assigned at a 1:1 ratioto undergo CR with or without DC under the monitoring of intracranial pressure. The primary outcome was the proportion of unfavorable functional outcome (modified Rankin Scale 3-6) at 3 months. Secondary outcomes included the mortality at 3 months and the occurrence of reoperation.

RESULTS

A total of 102 patients were assigned to the CR with DC group and 102 to the CR group. Median hematoma volume was 54.0 ml (range 30-80 ml) and median preoperative Glasgow Coma Scale was 10 (range 5-15). At 3 months, 94 patients (92.2%) in CR with DC group and 83 patients (81.4%) in the CR group had unfavorable functional outcome ( P =0.023). Fourteen patients (13.7%) in the CR with DC group died versus five patients (4.9%) in the CR group ( P =0.030). The number of patients with reoperation was similar between the CR with DC group and CR group (5.9 vs. 3.9%; P =0.517). Postoperative intracranial pressure values were not significantly different between two groups and the mean values were less than 20 mmHg.

CONCLUSIONS

CR without DC decreased the rate of modified Rankin Scale score of 3-6 and mortality in patients with ICH, compared with CR with DC.

Perfusion tomography in early follow-up of acute traumatic subdural hematoma: a case series

Perfusion Computed Tomography (PCT) is an alternative tool to assess cerebral hemodynamics during trauma. As acute traumatic subdural hematomas (ASH) is a severe primary injury associated with poor outcomes, the aim of this study was to evaluate the cerebral hemodynamics in this context. Five adult patients with moderate and severe traumatic brain injury (TBI) and ASH were included. All individuals were indicated for surgical evacuation. Before and after surgery, PCT was performed and cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were evaluated. These parameters were associated with the outcome at 6 months post-trauma with the extended Glasgow Outcome Scale (GOSE). Mean age of population was 46 years (SD: 8.1). Mean post-resuscitation Glasgow coma scale (GCS) was 10 (SD: 3.4). Mean preoperative midline brain shift was 10.1 mm (SD: 1.8). Preoperative CBF and MTT were 23.9 ml/100 g/min (SD: 6.1) and 7.3 s (1.3) respectively. After surgery, CBF increase to 30.7 ml/100 g/min (SD: 5.1), and MTT decrease to 5.8s (SD:1.0), however, both changes don't achieve statistically significance (p = 0.06). Additionally, CBV increase after surgery, from 2.34 (SD: 0.67) to 2.63 ml/100 g (SD: 1.10), (p = 0.31). Spearman correlation test of postoperative and preoperative CBF ratio with outcome at 6 months was 0.94 (p = 0.054). One patient died with the highest preoperative MTT (9.97 s) and CBV (4.51 ml/100 g). CBF seems to increase after surgery, especially when evaluated together with the MTT values. It is suggested that the improvement in postoperative brain hemodynamics correlates to favorable outcome.

Decompressive craniectomy: A primer for acute care practitioners

Decompressive craniectomy (DC) involves surgical removal of the skull that overlies swollen, imperiled, brain. This is done to combat intracranial hypertension and mitigate a vicious cycle of secondary brain injury. If, instead, this pathophysiology goes uninterrupted, it can mean brain herniation and brain stem death. As such, DC can save lives when all else fails. Regardless, it is no panacea and can also "ruin deaths," and leave patients profoundly disabled. DC is not a new procedure; however, this therapy is increasingly noteworthy due to advances in neurocritical care, alongside ethical concerns. We cover the physiological rationale, the surgical basics, the trial data, and focus on secondary decompression (for refractory intracranial pressure (ICP)) rather than primary decompression (i.e. during evacuation of an intracranial mass). Given that DC should not be undertaken indiscriminately, we conclude by introducing ways in which to discuss DC with families and colleagues. Our goal is to provide a primer and common resource for the multidisciplinary team. We aim to increase not only knowledge but wisdom, prudence, collegiality, and family-focused care.

Neurological functional outcome of early versus delayed cranioplasty following decompressive craniectomy at a tertiary care centre

Cranioplasty performed after a decompressive craniectomy (DC) for traumatic brain injury (TBI), stroke, or aneurysmal bleed has a role of restoring cerebral protection and craniofacial cosmesis as well as improving neuromotor function. There has been no consensus with regards to the ideal timing of cranioplasty (CP) after DC. A retrospective cohort study was carried out at a tertiary care hospital on patients who had undergone early (less than or equal to 12 weeks) and late (greater than 12 weeks) cranioplasty using autologous cranial bone after DC. Functional independence measure (FIM) tools were used to compare neuromotor and cognitive function outcome between the two groups. Appropriate statistical tools were used to compare neuromotor and cognitive function improvement as well as complication rates between early and late cranioplasty. A total of 31 adult patients of cranioplasty (21 male and 10 female) were evaluated. Sixteen had undergone early and 15 late cranioplasty. Comparison for neuromotor and cognitive function using FIM tools revealed statistically significant neuromotor and cognitive advantages in the early cranioplasty group. Overall complication rates between the two groups varied but were statistically insignificant. Performing an early cranioplasty provides advantages of improvement of neuromotor and cognitive function through early restoration of cerebrospinal fluid and intracerebral haemo-dynamics. It further avoids the potential problems of developing the 'Syndrome of the Trephined' (otherwise known as sinking skin flap syndrome) and resorption of the autologous bone.

Single-centre real-life observational study on mortality and outcomes: decompressive craniectomy and brain death in traumatic brain injury, haemorrhage, and other cerebral diseases

BACKGROUND

Decompressive hemicraniectomy (DHC) is used after severe brain damages with elevated, refractory intracranial pressure (ICP). In a non age-restricted population, mortality rates and long-term outcomes following DHC are still unclear. This study's objectives were to examine both, as well as to identify predictors of unfavourable outcomes.

METHODS

We undertook a retrospective observational analysis of patients aged 18 years and older who underwent DHC at the University Hospital of Bonn between 2018 and 2020, due to traumatic brain injury (TBI), haemorrhage, tumours or infections. Patient outcomes were assessed by conducting telephone interviews, utilising questionnaires for modified Rankin Scale (mRS) and extended Glasgow Outcome scale (GOSE). We evaluated the health-related quality of life using the EuroQol (EQ-5D-5L) scale.

RESULTS

A total of 144 patients with a median age of 58.5 years (range: 18 to 85 years) were evaluated. The mortality rate was 67%, with patients passing away at a median of 6.0 days (IQR [1.9-37.6]) after DHC. Favourable outcomes, as assessed by the mRS and GOSE were observed in 10.4% and 6.3% of patients, respectively. Cox regression analysis revealed a 2.0% increase in the mortality risk for every year of age (HR = 1.017; 95% CI [1.01-1.03]; p = 0.004). Uni- and bilateral fixed pupils were associated with a 1.72 (95% CI [1.03-2.87]; p = 0.037) and 3.97 (95% CI [2.44-6.46]; p < 0.001) times higher mortality risk, respectively. ROC-analysis demonstrated that age and pupillary reactivity predicted 6-month mortality with an AUC of 0.77 (95% CI [0.69-0.84]). The only parameter significantly associated with a better quality of life was younger age.

CONCLUSIONS

Following DHC, mortality remains substantial, and favourable outcomes occur rarely. Particularly in elderly patients and in the presence of clinical signs of herniation, mortality rates are notably elevated. Hence, the indication for DHC should be set critically.

Association of Dynamic Trajectories of Time-Series Data and Life-Threatening Mass Effect in Large Middle Cerebral Artery Stroke

BACKGROUND

Life-threatening, space-occupying mass effect due to cerebral edema and/or hemorrhagic transformation is an early complication of patients with middle cerebral artery stroke. Little is known about longitudinal trajectories of laboratory and vital signs leading up to radiographic and clinical deterioration related to this mass effect.

METHODS

We curated a retrospective data set of 635 patients with large middle cerebral artery stroke totaling 95,463 data points for 10 longitudinal covariates and 40 time-independent covariates. We assessed trajectories of the 10 longitudinal variables during the 72 h preceding three outcomes representative of life-threatening mass effect: midline shift ≥ 5 mm, pineal gland shift (PGS) > 4 mm, and decompressive hemicraniectomy (DHC). We used a "backward-looking" trajectory approach. Patients were aligned based on outcome occurrence time and the trajectory of each variable was assessed before that outcome by accounting for cases and noncases, adjusting for confounders. We evaluated longitudinal trajectories with Cox proportional time-dependent regression.

RESULTS

Of 635 patients, 49.0% were female, and the mean age was 69 years. Thirty five percent of patients had midline shift ≥ 5 mm, 24.3% of patients had PGS > 4 mm, and 10.7% of patients underwent DHC. Backward-looking trajectories showed mild increases in white blood cell count (10-11 K/UL within 72 h), temperature (up to half a degree within 24 h), and sodium levels (1-3 mEq/L within 24 h) before the three outcomes of interest. We also observed a decrease in heart rate (75-65 beats per minute) 24 h before DHC. We found a significant association between increased white blood cell count with PGS > 4 mm (hazard ratio 1.05, p value 0.007).

CONCLUSIONS

Longitudinal profiling adjusted for confounders demonstrated that white blood cell count, temperature, and sodium levels appear to increase before radiographic and clinical indicators of space-occupying mass effect. These findings will inform the development of multivariable dynamic risk models to aid prediction of life-threatening, space-occupying mass effect.

Radiologic and Blood Markers Predicting Long-Term Neurologic Outcome Following Decompressive Craniectomy for Malignant Ischemic Stroke: A Preliminary Single-Center Study

BACKGROUND

 Malignant ischemic stroke (MIS) is defined by progressive cerebral edema leading to increased intracranial pressure (ICP), compression of neural structures, and, eventually, death. Decompressive craniectomy (DC) has been advocated as a lifesaving procedure in the management of patients with MIS. This study aims to identify pre- and postoperative predictive variables of neurologic outcomes in patients undergoing DC for MIS.

METHODS

 We conducted a retrospective study of patients undergoing DC in a single center from April 2016 to April 2020. Preoperative workup included baseline clinical status, laboratory data, and brain computed tomography (CT). The primary outcome was the 6-month modified Rankin score (mRS). The secondary outcome was the 30-day mortality.

RESULTS

 During data capture, a total of 58 patients fulfilled the criteria for MIS, of which 22 underwent DC for medically refractory increased ICP and were included in the present analysis. The overall median age was 58.5 years. An immediate (24 hour) postoperative extended Glasgow Outcome Scale (GOSE) score ≥5 was associated with a good 6-month mRS (1-3; p = 0.004). Similarly, low postoperative neutrophils (p = 0.002), low lymphocytes (p = 0.004), decreased neutrophil-to-lymphocyte ratio (NLR; p = 0.02), and decreased platelet-to-lymphocytes ratio (PLR; p = 0.03) were associated with good neurologic outcomes. Preoperative variables independently associated with worsened 6-month mRS were the following: increased age (odds ratio [OR]: 1.10; 95% confidence interval [CI]: 1.01-1.20; p = 0.02), increased National Institutes of Health Stroke Scale (NIHSS) score (OR: 7.8; 95% CI: 2.5-12.5; p = 0.035), Glasgow Coma Scale (GCS) score less than 8 at the time of neurosurgical referral (OR: 21.63; 95% CI: 1.42-328; p = 0.02), and increased partial thromboplastin time (PTT) before surgery (OR: 2.11; 95% CI: 1.11-4; p = 0.02). Decreased postoperative lymphocytes confirmed a protective role against worsened functional outcomes (OR: 0.01; 95% CI: 0.01-0.4; p = 0.02). Decreased postoperative lymphocyte count was associated with a protective role against increased mRS (OR: 0.01; 95% CI: 0.01-0.4; p = 0.02). The occurrence of hydrocephalus at the postoperative CT scan was associated with 30-day mortality (p = 0.005), while the persistence of postoperative compression of the ambient and crural cistern showed a trend towards higher mortality (p = 0.07).

CONCLUSIONS

 This study reports that patients undergoing DC for MIS showing decreased postoperative blood inflammatory markers achieved better 6-month neurologic outcomes than patients with increased inflammatory markers. Similarly, poor NIHSS score, poor GCS score, increased age, and larger PTT values at the time of surgery were independent predictors of poor outcomes. Moreover, the persistence of postoperative compression of basal cisterns and the occurrence of hydrocephalus are associated with 30-day mortality.

Computed tomography perfusion as an early predictor of malignant cerebral infarction

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.

Trends and predictors of decompressive craniectomy in acute ischemic stroke, 2011-2020

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.

Neurocritical Care for Patients With Ischemic Stroke

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.

Updates in Management of Large Hemispheric Infarct

This review delves into updates in management of large hemispheric infarction (LHI), a condition affecting up to 10% of patients with supratentorial strokes. While traditional management paradigms have endured, recent strides in research have revolutionized the approach to acute therapies, monitoring, and treatment. Notably, advancements in triage methodologies and the application of both pharmacological and mechanical abortive procedures have reshaped the acute care trajectory for patients with LHI. Moreover, ongoing endeavors have sought to refine strategies for the optimal surveillance and mitigation of complications, notably space-occupying mass effect, which can ensue in the aftermath of LHI. By amalgamating contemporary guidelines with cutting-edge clinical trial findings, this review offers a comprehensive exploration of the current landscape of acute and ongoing patient care for LHI, illuminating the evolving strategies that underpin effective management in this critical clinical domain.

Association of large core middle cerebral artery stroke and hemorrhagic transformation with hospitalization outcomes

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.

Later Midline Shift Is Associated with Better Outcomes after Large Middle Cerebral Artery Stroke

Background/Objective

Space occupying cerebral edema is the most feared early complication after large ischemic stroke, occurring in up to 30% of patients with middle cerebral artery (MCA) occlusion, and is reported to peak 2-4 days after injury. Little is known about the factors and outcomes associated with peak edema timing, especially when it occurs after 96 hours. We aimed to characterize differences between patients who experienced maximum midline shift (MLS) or decompressive hemicraniectomy (DHC) in the acute (<48 hours), average (48-96 hours), and subacute (>96 hours) groups and determine whether patients with subacute peak edema timing have improved discharge dispositions.

Methods

We performed a two-center, retrospective study of patients with ≥1/2 MCA territory infarct and MLS. We constructed a multivariable model to test the association of subacute peak edema and favorable discharge disposition, adjusting for age, admission Alberta Stroke Program Early CT Score (ASPECTS), National Institute of Health Stroke Scale (NIHSS), acute thrombolytic intervention, cerebral atrophy, maximum MLS, parenchymal hemorrhagic transformation, DHC, and osmotic therapy receipt.

Results

Of 321 eligible patients with MLS, 32%, 36%, and 32% experienced acute, average, and subacute peak edema. Subacute peak edema was significantly associated with higher odds of favorable discharge than non-subacute swelling, adjusting for confounders (aOR, 1.85; 95% CI, 1.05-3.31).

Conclusions

Subacute peak edema after large MCA stroke is associated with better discharge disposition compared to earlier peak edema courses. Understanding how the timing of cerebral edema affects risk of unfavorable discharge has important implications for treatment decisions and prognostication.

Decompressive craniectomy for patients with malignant infarction of the middle cerebral artery: A pooled analysis of two randomized controlled trials

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.

An Explainable Artificial Intelligence Model to Predict Malignant Cerebral Edema after Acute Anterior Circulating Large-Hemisphere Infarction

INTRODUCTION

Malignant cerebral edema (MCE) is a serious complication and the main cause of poor prognosis in patients with large-hemisphere infarction (LHI). Therefore, the rapid and accurate identification of potential patients with MCE is essential for timely therapy. This study utilized an artificial intelligence-based machine learning approach to establish an interpretable model for predicting MCE in patients with LHI.

METHODS

This study included 314 patients with LHI not undergoing recanalization therapy. The patients were divided into MCE and non-MCE groups, and the eXtreme Gradient Boosting (XGBoost) model was developed. A confusion matrix was used to measure the prediction performance of the XGBoost model. We also utilized the SHapley Additive exPlanations (SHAP) method to explain the XGBoost model. Decision curve and receiver operating characteristic curve analyses were performed to evaluate the net benefits of the model.

RESULTS

MCE was observed in 121 (38.5%) of the 314 patients with LHI. The model showed excellent predictive performance, with an area under the curve of 0.916. The SHAP method revealed the top 10 predictive variables of the MCE such as ASPECTS score, NIHSS score, CS score, APACHE II score, HbA1c, AF, NLR, PLT, GCS, and age based on their importance ranking.

CONCLUSION

An interpretable predictive model can increase transparency and help doctors accurately predict the occurrence of MCE in LHI patients not undergoing recanalization therapy within 48 h of onset, providing patients with better treatment strategies and enabling optimal resource allocation.

The role of decompressive craniectomy following microsurgical repair of a ruptured aneurysm: Analysis of a South Australian cerebrovascular registry

OBJECTIVE

Decompressive craniectomy (DC) remains a controversial intervention for intracranial hypertension among patients with aneurysmal subarachnoid haemorrhage (aSAH).

METHODS

We identified aSAH patients who underwent DC following microsurgical aneurysm repair from a prospectively maintained registry and compared their outcomes with a propensity-matched cohort who did not. Logistic regression was used to identify predictors of undergoing decompressive surgery and post-operative outcome. Outcomes of interest were inpatient mortality, unfavourable outcome, NIS-Subarachnoid Hemorrhage Outcome Measure and modified Rankin Score (mRS).

RESULTS

A total of 246 patients with aSAH underwent clipping of the culprit aneurysm between 01/09/2011 and 20/07/2020. Of these, 46 underwent DC and were included in the final analysis. Unsurprisingly, DC patients had a greater chance of unfavourable outcome (p < 0.001) and higher median mRS (p < 0.001) at final follow-up. Despite this, almost two-thirds (64.1 %) of DC patients had a favourable outcome at this time-point. When compared with a propensity-matched cohort who did not, patients treated with DC fared worse at all endpoints. Multivariable logistic regression revealed that the presence of intracerebral haemorrhage and increased pre-operative mid-line shift were predictive of undergoing DC, and WFNS grade ≥ 4 and a delayed ischaemic neurological deficit requiring endovascular angioplasty were associated with an unfavourable outcome.

CONCLUSIONS

Our data suggest that DC can be performed with acceptable rates of morbidity and mortality. Further research is required to determine the superiority, or otherwise, of DC compared with structured medical management of intracranial hypertension in this context, and to identify predictors of requiring decompressive surgery and patient outcome.

Proper Indication of Decompressive Craniectomy for the Patients with Massive Brain Edema after Intra-arterial Thrombectomy

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.

Functional Outcomes in Conservatively vs Surgically Treated Cerebellar Infarcts

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.

Scalp incision technique for decompressive hemicraniectomy: comparative systematic review and meta-analysis of the reverse question mark versus alternative retroauricular and Kempe incision techniques

Decompressive hemicraniectomy (DHC) is a critical procedure used to alleviate elevated intracranial pressure (ICP) in emergent situations. It is typically performed to create space for the swelling brain and to prevent dangerous and potentially fatal increases in ICP. DHC is indicated for pathologies ranging from MCA stroke to traumatic subarachnoid hemorrhage-essentially any cause of refractory brain swelling and elevated ICPs. Scalp incisions for opening and closing the soft tissues during DHC are crucial to achieve optimal outcomes by promoting proper wound healing and minimizing surgical site infections (SSIs). Though the reverse question mark (RQM) scalp incision has gained significant traction within neurosurgical practice, alternatives-including the retroauricular (RA) and Kempe incisions-have been proposed. As choice of technique can impact postoperative outcomes and complications, we sought to compare outcomes associated with different scalp incision techniques used during DHC. We queried three databases according to PRISMA guidelines in order to identify studies comparing outcomes between the RQM versus "alternative" scalp incision techniques for DHC. Our primary outcome of interest in the present study was postoperative wound infection rates according to scalp incision type. Secondary outcomes included estimated blood loss (EBL) and operative duration. We identified seven studies eligible for inclusion in the formal meta-analysis. The traditional RQM technique shortened operative times by 36.56 min, on average. Additionally, mean EBL was significantly lower when the RQM scalp incision was used. Postoperatively, there was no significant association between DHC incision type and mean intensive care unit (ICU) length of stay (LOS), nor was there a significant difference in predisposition to developing wound complications or infections between the RQM and retroauricular/Kempe incision cohorts. Superficial temporal artery (STA) preservation and reoperation rates were collected but could not be analyzed due to insufficient number of studies reporting these outcomes. Our meta-analysis suggests that there is no significant difference between scalp incision techniques as they relate to surgical site infection and wound complications. At present, it appears that outcomes following DHC can be improved by ensuring that the bone flap is large enough to enable sufficient cerebral expansion and decompression of the temporal lobe, the latter of which is of particular importance. Although previous studies have suggested that there are several advantages to performing alternative scalp incision techniques during DHC, the present study (which is to our knowledge the first to meta-analyze the literature on outcomes in DHC by scalp incision type) does not support these findings. As such, further investigations in the form of prospective trials with high statistical power are merited.

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

The application of decompressive craniectomy (DC) is thoroughly documented in the management of brain edema, particularly following traumatic brain injury. However, an increasing amount of concern is developing among the universal medical community as regards the application of DC in the treatment of other causes of brain edema, such as subarachnoid hemorrhage, cerebral hemorrhage, sinus thrombosis and encephalitis. Managing stroke continues to remain challenging, and demands the aggressive and intensive consulting of a number of medical specialties. Middle cerebral artery (MCA) infarcts, which consist of 1-10% of all supratentorial infarcts, are often associated with mass effects, and high mortality and morbidity rates. Over the past three decades, a number of neurosurgical medical centers have reported their experience with the application of DC in the treatment of malignant MCA infarction with varying results. In addition, over the past decade, major efforts have been dedicated to multicenter randomized clinical trials. The present study reviews the pertinent literature to outline the use of DC in the management of malignant MCA infarction. The PubMed database was systematically searched for the following terms: 'Malignant cerebral infarction', 'surgery for stroke', 'DC for cerebral infarction', and all their combinations. Case reports were excluded from the review. The articles were categorized into a number of groups; the majority of these were human clinical studies, with a few animal experimental clinical studies. The surgical technique involved was DC, or hemicraniectomy. Other aspects that were included in the selection of articles were methodological characteristics and the number of patients. The multicenter randomized trials were promising. The mortality rate has unanimously decreased. As for the functional outcome, different scales were employed; the Glasgow Outcome Scale Extended was not sufficient; the Modified Rankin Scale and Bathel index, as well as other scales, were applied. Other aspects considered were demographics, statistics and the very interesting radiological ones. There is no doubt that DC decreases mortality rates, as shown in all clinical trials. Functional outcome appears to be the goal standard in modern-era neurosurgery, and quality of life should be further discussed among the medical community and with patient consent.

Functional Outcome and Mortality Predictors in Patients with Cerebral Ischemic Infarction After Decompressive Craniectomy: Cross-Sectional Study

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.

Novel advanced imaging techniques for cerebral oedema

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.

Development and validation of a prognostic computed tomography scoring model for functional outcomes in patients with large hemispheric infarction following decompressive craniectomy

Background

There is no established prognostic scoring system developed for patients with large hemispheric infarction (LHI) following decompressive craniectomy (DC) based on imaging characteristics. The present study aimed to develop and validate a new computed tomography scoring model to assess the 6-month risk of poor functional outcomes (modified-Rankin scale [mRS] score of 4-6) in patients with LHI receiving DC.

Methods

This retrospective cohort study included patients at two tertiary stroke centers. A prediction model was developed based on a multivariable logistic regression. The final risk factors included the ASPECTS (Alberta Stroke Program Early Computed Tomography Score), longitudinal fissure cistern, Sylvian fissure cistern, and additional vascular territory involvement. 1,000 bootstrap resamples and temporal validation were implemented as validations for the scoring system.

Results

Of the 100 individuals included in the development cohort, 71 had poor functional outcomes. The scoring model presented excellent discrimination and calibration with C-index = 0.87 for the development cohort, and C-index = 0.83 for the temporal validation cohort with non-significant Hosmer-Lemeshow goodness-of-fit test. The scoring model also showed an improved AUC compared to the ASPECTS. For each point in the score model, the adjusted risk of poor functional outcomes increase by 47.8% (OR = 1.48, p < 0.001). The scores were inversely correlated with MAP (mean arterial pressure, paired t-test, p = 0.0015) and CPP (cerebral perfusion pressure, rho = -0.17, p = 0.04).

Conclusion

In patients with LHI following DC, the score system is an excellent predictor of poor functional outcomes and is associated with CPP and MAP, which might be worth considering in clinical settings after further external validation.

Perioperative stroke

Ischaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1-0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1-5% range in patients undergoing cardiac surgery and in the 1-10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.

Prognostic variables predict clinical outcome after decompressive craniectomy: A single institute experience; A retrospective study

Decompressive craniectomy (DC) is a well-established neurosurgical intervention in patients with high intracranial pressure who fail to respond to medical treatment. Data on predictive factors for functional outcomes in patients with DC who have malignant middle cerebral artery (MCA) infarction as opposed to intracranial hemorrhage (ICH) are scarce. Eighty-four patients who underwent DC treatment for ICH and malignant MCA infarction were examined. All patients underwent surgery in the Bahrain Salmaniya Medical Complex Neurosurgery Unit between January 2017 and June 2021. To determine whether any of these demonstrated a link to the functional outcome, radiographic factors were compared with clinical data. The postsurgical midline shift (MLS) (ICH group) showed the strongest correlation (ρ = 0.434; P = .006), as in the MCA infarction group as well (ρ = 0.46; P = .005). Further analyses using binary logistic regression with postsurgical basal cistern status and ∆ MLS, and it was observed to be statistically significant (odds ratios: 0.067, 95% CI: 0.007, 0.67; P = .021). The initial Glasgow coma scale, postsurgical MLS, basal cistern status, and ∆ are Measurable variables that can be used to predict outcomes in the groups with ICH and MCA infarction.

Canadian Stroke Best Practice Recommendations: Acute Stroke Management, 7th Edition Practice Guidelines Update, 2022

The 2022 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for Acute Stroke Management, 7th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by an interdisciplinary team of healthcare providers and system planners caring for persons with an acute stroke or transient ischemic attack. These recommendations are a timely opportunity to reassess current processes to ensure efficient access to acute stroke diagnostics, treatments, and management strategies, proven to reduce mortality and morbidity. The topics covered include prehospital care, emergency department care, intravenous thrombolysis and endovascular thrombectomy (EVT), prevention and management of inhospital complications, vascular risk factor reduction, early rehabilitation, and end-of-life care. These recommendations pertain primarily to an acute ischemic vascular event. Notable changes in the 7th edition include recommendations pertaining the use of tenecteplase, thrombolysis as a bridging therapy prior to mechanical thrombectomy, dual antiplatelet therapy for stroke prevention, the management of symptomatic intracerebral hemorrhage following thrombolysis, acute stroke imaging, care of patients undergoing EVT, medical assistance in dying, and virtual stroke care. An explicit effort was made to address sex and gender differences wherever possible. The theme of the 7th edition of the CSBPR is building connections to optimize individual outcomes, recognizing that many people who present with acute stroke often also have multiple comorbid conditions, are medically more complex, and require a coordinated interdisciplinary approach for optimal recovery. Additional materials to support timely implementation and quality monitoring of these recommendations are available at www.strokebestpractices.ca.

New insight in massive cerebral infarction predictions after anterior circulation occlusion

To predict massive cerebral infarction (MCI) occurrence after anterior circulation occlusion (ACO) by cASPECTS-CTA-CS (combined ASPECTS and CTA-CS). Of 185 cerebral infarction patients with the ACO, their collateral circulation scores from CT angiography (CTA) images in two groups (MCI and non-MCI) were evaluated using Alberta Stroke Program Early CT Score (ASPECTS) and CT angiography collateral score (CTA-CS) approaches. The cASPECTS-CTA-CS was validated internally using the bootstrap sampling method with 1000 bootstrap repetitions and compared to CTA-CS. Receiver-operating characteristic curve (ROC), clinical impact curve (CIC), and decision curve analysis (DCA) strategies were used to assess the clinical practicality and predictability of both approaches (cASPECTS-CTA-CS and CTA-CS). Using net reclassification improvement (NRI) and integrated discrimination improvement (IDI) analyses, discrimination levels of the cASPECTS-CTA-CS were compared with CTA-CS. Classification and regression tree (CART) analyses was conducted to identify the best predictive values and identify subgroup of MCI. The discrimination ability of collateral circulation evaluation score using the cASPECTS-CTA-CS [AUC: 0.918, 95% confidence interval (CI): 0.869-0.967, P < 0.01; NRI: 0.200, 95% CI: -0.104 to 0.505, P = 0.197; and IDI: 0.107, 95% CI: 0.035-0.178, P = 0.004] was better than CTA-CS alone (AUC: 0.885, 95% CI: 0.833-0.937, P < 0.01). DCA indicated the net benefits of the cASPECTS-CTA-CS approach was higher than CTA-CS alone when the threshold probability range over 20%. CIC analyses showed that the number of high risks and true positives were in agreement when the threshold probability > 80%. Less than 23 of cASPECTS-CTA-CS by CART was important factor in determining MCI occurrence, and ASPECTS < 7 was followed factor. The cASPECTS-CTA-CS approach cumulatively predicted MCI after ACO.

Definition, prediction, prevention and management of patients with severe ischemic stroke and large infarction

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.

Risk Factors for Stroke Development After Thoracic Aortic Surgery

OBJECTIVES

Stroke after thoracic aortic surgery is a complication that is associated with poor outcomes. The aim is to characterize the intraoperative risk factors for stroke development.

DESIGN

A retrospective analysis.

SETTING

Tertiary, high-volume cardiac surgery center.

PARTICIPANTS

Patients who had surgical repair of thoracic aortic diseases from January 1, 2017, through December 31, 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 704 patients were included, of whom 533 had ascending aortic aneurysms, and 171 had type A aortic dissection. The incidence of postoperative stroke was 4.5% (95% CI 2.9%-6.6%) for ascending aortic aneurysms compared with 12.3% (95% CI 7.8%-18.16%) in type-A aortic dissections. Patients who developed postoperative strokes had significantly lower intraoperative hemoglobin median (7.5 gm/dL [IQR 6.8-8.6] v 8.55 gm/dL [IQR 7.3-10.0]; p < 0.001). The median cardiopulmonary bypass time was 185 minutes (IQR 136-328) in the stroke group versus 156 minutes (IQR 113-206) in the nonstroke group (p = 0.014). Circulatory arrest was used in 57.8% versus 38.5% of the nonstroke patients (p = 0.017). The initial temperature after leaving the operating room was lower, with a median of 35.0°C (IQR 34-35.92) in the stroke group versus 35.5°C (IQR 35-36) in the nonstroke cohort (p = 0.021).

CONCLUSIONS

This single-center study highlighted the potential importance of intra-operative factors in preventing stroke. Lower hemoglobin, longer duration of cardiopulmonary bypass, deep hypothermic circulatory arrest, and postoperative hypothermia are potential risk factors for postoperative stroke. Further studies are needed to prevent this significant complication in patients with thoracic aortic diseases.

Skull bone marrow channels as immune gateways to the central nervous system

Decades of research have characterized diverse immune cells surveilling the CNS. More recently, the discovery of osseous channels (so-called 'skull channels') connecting the meninges with the skull and vertebral bone marrow has revealed a new layer of complexity in our understanding of neuroimmune interactions. Here we discuss our current understanding of skull and vertebral bone marrow anatomy, its contribution of leukocytes to the meninges, and its surveillance of the CNS. We explore the role of this hematopoietic output on CNS health, focusing on the supply of immune cells during health and disease.

Surgical timing and indications for decompressive craniectomy in malignant stroke: results from a single-center retrospective analysis

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.

Incidence of hydrocephalus following decompressive craniectomy for ischaemic stroke: A systematic review and meta-analysis

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.

Current and Emerging Endovascular and Neurocritical Care Management Strategies in Large-Core Ischemic Stroke

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.

Use of biomarkers for predicting a malignant course in acute ischemic stroke: an observational case-control study

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.

Outcome and management of decompressive hemicraniectomy in malignant hemispheric stroke following cardiothoracic surgery

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.

Long-term quality of life after decompressive craniectomy

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.

Mechanical thrombectomy in M1 and M2 segments of middle cerebral arteries: A meta-analysis of prospective cohort studies

BACKGROUND

Recent studies indicate that endovascular therapy is superior to intravenous thrombolysis in treating M1 segment MCA occlusions, however, the effectiveness of mechanical thrombectomy in MI vs. M2 segment occlusions is unclear.

METHODS

The meta-analysis was conducted by searching databases from January 2016 to January 2023, without language constraints. The quality of the studies was assessed using the Newcastle-Ottawa Scale. Pooled data analysis of outcomes, pre-existing medical comorbidities, and baseline scores were performed.

RESULTS

Six prospective cohort studies with 6356 patients were included (4405 vs. 1638). Patients with M2 occlusion had a significantly lower mean baseline NIHSS at admission (MD: -2.14; 95 %CI: -3.48 to -0.81; p = 0.002). Conversely, patients with M1 occlusion had a lower ASPECTS at admission score (MD: 0.29; 95 %CI: 0.00-0.59; p = 0.05). No significant difference was found between segments in terms of pre-existing medical comorbidities (OR: 0.96; 95 %CI: 0.87-1.05; p = 0.36), mortality rate at 90 days (OR: 0.88; 95 %CI: 0.76-1.02; p = 0.10), and hemorrhage occurrence within 24-hours (OR: 1.06; 95 %CI: 0.89-1.25; p = 0.53). Patients with M2 occlusion were more likely to have good outcomes after therapy (OR: 1.18; 95 %CI: 1.05-1.32; p = 0.006). Successful recanalization rates were comparatively higher among patients with an M1 occlusion (OR: 0.79; 95 %CI: 0.68-0.92; p = 0.003). Functional outcomes at 90 days are better in M2 occlusion patients, while successful recanalization rates are higher in M1 occlusion patients. No significant differences were found in mortality rates or hemorrhage incidence.

CONCLUSIONS

These results suggest that mechanical thrombectomy is a safe and effective treatment for MCA occlusions in both M1 and M2 segments.

Surgery for Malignant Acute Ischemic Stroke: A Narrative Review of the Knowns and Unknowns

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..

Recent Updates on Controversies in Decompressive Craniectomy and Cranioplasty: Physiological Effect, Indication, Complication, and Management

Decompressive craniectomy (DCE) and cranioplasty (CP) are surgical procedures used to manage elevated intracranial pressure (ICP) in various clinical scenarios, including ischemic stroke, hemorrhagic stroke, and traumatic brain injury. The physiological changes following DCE, such as cerebral blood flow, perfusion, brain tissue oxygenation, and autoregulation, are essential for understanding the benefits and limitations of these procedures. A comprehensive literature search was conducted to systematically review the recent updates in DCE and CP, focusing on the fundamentals of DCE for ICP reduction, indications for DCE, optimal sizes and timing for DCE and CP, the syndrome of trephined, and the debate on suboccipital CP. The review highlights the need for further research on hemodynamic and metabolic indicators following DCE, particularly in relation to the pressure reactivity index. It provides recommendations for early CP within three months of controlling increased ICP to facilitate neurological recovery. Additionally, the review emphasizes the importance of considering suboccipital CP in patients with persistent headaches, cerebrospinal fluid leakage, or cerebellar sag after suboccipital craniectomy. A better understanding of the physiological effects, indications, complications, and management strategies for DCE and CP to control elevated ICP will help optimize patient outcomes and improve the overall effectiveness of these procedures.

Large diameter hemicraniectomy does not improve long-term outcome in malignant infarction

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).

Predicting the emergence of malignant brain oedema in acute ischaemic stroke: a prospective multicentre study with development and validation of predictive modelling

Background

We aimed to develop and validate a prognostic model for predicting malignant brain oedema in patients with acute ischaemic stroke in a real-world setting of practice.

Methods

A prospective multicentre study enrolled adult patients with acute ischaemic stroke with brain CT < 24 h of onset of symptoms admitted to nine tertiary-level hospitals in China between September 2017 and December 2019. Malignant brain oedema was defined as any patient who had decompressive craniectomy, discharge in coma, or in-hospital death attributed to symptomatic brain swelling. The derivation cohort was a consecutive cohort of patients from one centre and the validation cohort was non-consecutive patients from the other centres. Multivariable logistic regression was used to define independent predictors from baseline clinical characteristics, imaging features, complications, and management. A web-based nomogram and a risk score were developed based on the final model. Model performance was assessed for discrimination and calibration in both derivation and validation cohorts. The study is registered, NCT03222024.

Findings

Based on the derivation cohort (n = 1627), the model was developed with seven variables including large infarct (adjusted odds ratio [OR] 40.90, 95% CI 20.20-82.80), National Institutes of Health Stroke Scale (NIHSS) score (OR 1.09, 1.06-1.12), thrombolysis (OR 2.11, 1.18-3.78), endovascular treatment (OR 2.87, 1.47-5.59), pneumonia (OR 2.47, 1.53-3.97), brain atrophy (OR 0.57, 0.37-0.86), and recanalisation (OR 0.36, 0.17-0.75). The classification threshold of a predicted probability ≥0.14 showed good discrimination and calibration in both derivation cohort (area under the receiver-operating curve [AUC] 0.90, 0.87-0.92; sensitivity 0.95, 0.92-0.98) and validation cohort (n = 556, AUC 0.88, 0.82-0.95; sensitivity 0.84, 0.73-0.95). The risk score based on this model had a total point that ranged from -1 to 20, with an optimal score of ≥10 showing good discrimination and calibration in both derivation (AUC 0.89, 0.87-0.92; sensitivity 0.95, 0.92-0.98) and validation (AUC 0.88, 0.82-0.95; sensitivity 0.84, 0.73-0.95) cohorts.

Interpretation

The INTEP-AR model (i.e. large Infarct, NIHSS score, Thrombolysis, Endovascular treatment, Pneumonia, brain Atrophy, and Recanalisation) incorporating multiple clinical and radiological characteristics has shown good prognostic value for predicting malignant brain oedema after acute ischaemic stroke.

Funding

National Natural Science Foundation of China; Science and Technology Department of Sichuan Province; West China Hospital.

A Novel Nomogram for Predicting Malignant Cerebral Edema After Endovascular Thrombectomy in Acute Ischemic Stroke: A Retrospective Cohort Study

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.