Hemicraniectomy for malignant middle cerebral artery infarction

Long-Term Functionality Prediction for First Time Ischemic Middle Cerebral Artery Stroke Patients Receiving Conventional Medical Treatment

BACKGROUND

Middle cerebral artery (MCA) ischemic stroke poses a major threat to human beings and prompts intravenous thrombolytic and/or thrombectomy management remains the gold standard treatment. However, not all MCA stroke patients fit in the inclusion and exclusion criteria that many patients only receive conventional medical therapy. We attempt to seek the baseline parameters that can effectively predict patients' long-term functionality, as well as hypothesizing that the carotid duplex derived resistance/pulsatility index might be capable of fulfilling this purpose.

METHODS

The 741 MCA ischemic stroke patients have been retrospectively recruited for the project. Under the initial screening, matching the inclusion and exclusion criteria, there are 471 participants to be enrolled in the study. The patients' basic information, along with outcome assessments, pre-admission Barthel index and NIHSS score, and pre- and post-treatment mRS are recorded. All statistical analyses were performed using R for Windows (version 3.6.3). The significance level was set at P < 0.05 for all analyses.

RESULTS

Of the 471 patients, 239 participants show a net mRS improvement, whereas the other 232 show deterioration. Hyperlipidaemia, chronic kidney disease, and dementia are related to long-term functionality improvement. The multivariate logistic regression analysis shows that right common carotid artery (CCA) resistance index (RI) and ischemic heart disease play a significant role in favourable outcome functionality. The ROC and Youden Index models are formulated, and it shows that Barthel Index and the NIHSS are most significant in the outcome measurement group (AUC: 0.675, 0.653; cut-off point: 57.5, 3.5, respectively). The right-side CCA RI is the solely important outcome predictor for the baseline carotid duplex study (AUC: 0.5; cut-off point: 0.785).

CONCLUSION

The favourable long-term functionality of MCA ischemic stroke patients receiving conventional medical treatment seems to correlate fairly with pre-admission NIHSS and Barthel index scores. Underlying hyperlipidaemia, chronic kidney disease, and dementia are conversely associated with favourable long-term capability. Moreover, the value of CCA RI appears to significantly alter the long-term outcomes in this group of patients.

Malignant middle cerebral artery (MCA) infarction in people over 85 years old - Diagnosis, management and risk factors

INTRODUCTION

Malignant ischemic stroke of the middle cerebral artery (MCA) territory causes neurological deterioration due to the effects of space occupying cerebral edema. The prognosis is poor, and death usually occurs as a result of brainstem compression. There is no information on ischemic stroke, especially the malignant ones, in patients over 85 years old.

AIM

The aim of this retrospective study was to evaluate the disease course, risk factors, survival rate and treatment of MCA malignant infarction in people over 85 years old.

METHOD

The medical history of 66 patients with malignant MCA stroke was analyzed. The frequency of the occurrence of the risk factors like hypertension, hyperlipidemia, atrial fibrillation, heart failure, diabetes was evaluated. Disability was measured with the use of the National Institutes of Health Stroke Scale (NIHSS). Safety and effectiveness of the anticoagulants used in the group of patients with atrial fibrillation were analyzed. Chi-quadrat test and Mann-Whitney U test were used for statistical analysis of data. We also described 85 year-old patient with malignant brain stroke who was treated neurosurgically with a positive effect.

RESULTS

Atrial fibrillation was diagnosed in 65% of patients of the investigated group. There were no statistically significant changes in the survival rate between the group of patients treated with the use of mannitol and patients without this treatment.

CONCLUSION

The key risk factor in this group is the atrial fibrillation. The elderly patients require an intensive monitoring of the health condition by reference to brain stroke risk factors, especially atrial fibrillation.

Functional Outcome After Decompressive Craniectomy in Patients with Dominant or Non-Dominant Malignant Middle Cerebral Infarcts

BACKGROUND

 The use of decompressive craniectomy (DC) has been studied in the setting of different conditions, including traumatic brain injury, subarachnoid hemorrhage, and malignant middle cerebral artery (MCA) infarction. The rationale of this study is to determine the functional outcome after DC in patients with malignant MCA infarcts.

METHODS

 A longitudinal cohort study was performed based on patients diagnosed with malignant MCA territory infarction admitted to the Neurosurgery Department of a tertiary care hospital in Islamabad, Pakistan between July 2015 and November 2016. All patients had a clinical diagnosis of stroke according to the World Health Organization (WHO) stroke criteria.

RESULTS

 A total of 34 patients participated in this study, out of which 20/31 (64.5%) were males while 11/31 (35.5%) were females with a mean age of 51.61 ± 13.96 years. The mean time from diagnosis to surgery was 60.61 ± 49.83 hours. Out of 31 patients, 18 (58.1%) had a right middle cerebral artery infarct (RMCAI) and 13 (41.9%) had a left middle cerebral artery infarct (LCAI). Logistic regression was applied to assess the association between the type of MCA infarct with the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), modified Barthel Index (mBI) scores, and upper and lower limb motor power. However, the logistic regression model was not statistically significant χ² (4) = 3.896, p = 0.866. There was a statistically significant mild improvement of neurological scores and upper and lower motor power over a course of six months, but the overall functional outcome was poor with mBI < 60 and mRS > 4 (p < 0.001) with total mortality of 8.7%.

CONCLUSION

 Decompressive craniectomy is a life-saving surgery that appears to benefit patients with malignant MCA infarcts of either the dominant or non-dominant cerebral hemisphere. Decompressive craniectomy results in mild improvements in neurological scores but still poor functional outcome after six months.

A Cohort Study of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction: A Real-World Experience in Clinical Practice

Decompressive hemicraniectomy with malignant middle cerebral artery (MCA) infarction is effective but remains underutilized. The aim of this study was to observe the utilization of this intervention in mainland China.We included patients with malignant MCA infarction who admitted in West China Hospital between December 2007 to March 2011. The outcomes were death and favorable outcome (mRS < 4) at 1 month and 1 year. The multivariate logistic regression model was used to identify the independent predictors for outcomes.Ten percent (219/2174) of patients with acute ischemic stroke had malignant MCA infarction and 31.1% (68/219) patients meet the criteria that ≤60 years of age and the timing to hospital <48 hours after stroke onset. Of them, 18 patients (26.5%) underwent to decompressive hemicraniectomy. In total, 31 patients (14.2%) underwent the decompressive surgery. The average age was 53 ± 12 years; median NIHSS score was 21. The case fatality rate of patients in surgery group was significantly lower than those of in nonsurgery group at 1 month and 1 year follow-ups (32.3% and 38.7% vs. 51.1% and 61.2%, respectively, P < 0.05). Patients in surgery group had a higher proportion of good outcome at 1 year follow-up (32.2% vs. 13.3%, P = 0.006). After adjusting for confounders including age, sex, NIHSS score, and GCS score on admission, decompressive hemicraniectomy was an independent predictor of good outcome for 1 year (OR = 3.44, 95% CI, 1.27-9.31).This study shows better outcomes in the surgical group, which are consistent with findings in previous prospective randomized trials. However, this beneficial intervention remains underutilized in clinical settings.

Measurement of brain edema by noninvasive cerebral electrical impedance in patients with massive hemispheric cerebral infarction

BACKGROUND

Malignant cerebral infarction often occurs in patients with massive cerebral infarction. Monitoring brain edema is therefore helpful to make correct clinical decisions. Our previous studies have confirmed that cerebral electrical impedance (CEI) can sensitively reflect the brain edema after stroke.

METHODS

The CEI was measured consecutively by a noninvasive brain edema monitor in 69 patients with massive hemispheric cerebral infarction (MHCI). The results of the CEI were converted into the perturbation index (PI). The characteristics of dynamic changes of the CEI after MHCI were analyzed. Receiver-operating characteristics analysis was used to calculate predictive values for PI and other known parameters including NIHSS score and infarct volume.

RESULTS

(1) The overall rate of positive CEI was 88.4% (61/69) in all patients with MHCI. (2) The PI on the infarct side increased significantly within 24 h after stroke onset and reached a peak level 3-5 days after stroke onset (p < 0.01). (3) Age, NIHSS score at admission, infarct volume, and the PI at 24 h after stroke onset were significantly different between the malignant and nonmalignant groups. The best predictor of a malignant MHCI was the PI at 24 h after stroke onset with a cut-off value of 10.02 (90.9% sensitivity, 87.2% specificity, 76.9% positive predictive value, 95.3% negative predictive value).

CONCLUSIONS

The noninvasive CEI can sensitively reflect the brain edema in patients with MHCI. Monitoring the CEI may help to predict malignant MHCI and guide treatment decisions.

Will molecular optical imaging have clinically important roles in stroke management, and how?

Molecular imaging is a novel technology to visualize biological processes at the cellular and molecular levels, which is reshaping both biomedical research and clinical practice. By providing molecular information to supplement and augment conventional anatomy-based imaging, molecular imaging is expected to allow 1) the earlier detection of diseases, 2) precise evaluation of disease stages, and 3) both diagnostic and therapeutic monitoring of disease progression in a quantitative manner. In this brief review, we present our view on the prospects of molecular optical imaging in the field of stroke practice, focusing on the imaging vulnerability of atherosclerotic plaques, thrombolytic resistance, real-time cerebral perfusion, and penumbra.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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