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Zhang L, Ma J, Wang M, Zhang L, Sun W, Ji H, Yue C, Huang J, Zi W, Li F, Guo C, Wang P. The Association Between National Institutes of Health Stroke Scale Score and Clinical Outcome in Patients with Large Core Infarctions Undergoing Endovascular Treatment. Neurol Ther 2024; 13:563-581. [PMID: 38427274 PMCID: PMC11136902 DOI: 10.1007/s40120-024-00588-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/07/2024] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION This study aimed to analyze the association between baseline National Institutes of Health Stroke Scale (NIHSS) scores and clinical outcomes in patients with large core infarctions undergoing endovascular treatment (EVT), a relationship that remains unclear. METHODS Data were obtained from the MAGIC study, a prospective multicenter cohort study focusing on patients with acute large core ischemic stroke. This analysis evaluated the impact of NIHSS scores on EVT outcomes in patients with large core infarctions. Primary outcome metrics included favorable outcomes (modified Rankin Scale [mRS] of 0-3 at 90 days), while secondary outcomes encompassed shifts in mRS scores, functional independence (mRS score of 0-2), mRS score of 0-4, and successful recanalization rates. Adverse events considered were symptomatic intracranial hemorrhage (sICH) and mortality. RESULTS A total of 490 patients were enrolled in this study. Higher baseline NIHSS scores were inversely correlated with favorable outcomes (adjusted odds ratio [OR] in model 3, 0.848 [0.797-0.903], P < 0.001), particularly in patients with NIHSS scores above 20 (adjusted OR in model 3, 0.518 [0.306-0.878] vs. 0.290 [0.161-0.523]). Regarding adverse events, higher baseline NIHSS scores significantly correlated with increased 90-day mortality rates (adjusted OR in model 3, 1.129 [1.072-1.189], P < 0.001). This correlation became insignificant when baseline NIHSS scores exceeded 22. Additionally, baseline NIHSS scores partially mediated the association between age (indirect effect = - 0.0005, 19.39% mediated) and sex (indirect effect = 0.0457, 25.08% mediated) with the primary outcome. CONCLUSIONS The findings indicate that higher baseline NIHSS scores correlate with poorer outcomes and increased mortality, particularly when scores exceed 20. Moreover, age and sex indirectly influence favorable outcomes through their association with baseline NIHSS scores.
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Affiliation(s)
- Lingyu Zhang
- School of Clinical Medicine, Shandong Second Medical University, Weifang, 261000, Shandong, China
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No. 70, Heping Road, Huancui District, Weihai City, Shandong Province, China
| | - Jinfu Ma
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Mengmeng Wang
- School of Clinical Medicine, Shandong Second Medical University, Weifang, 261000, Shandong, China
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No. 70, Heping Road, Huancui District, Weihai City, Shandong Province, China
| | - Lin Zhang
- Department of Cardiology, Yantai Penglai Hospital of Traditional Chinese Medicine, Yantai, China
| | - Wenzhe Sun
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Honghong Ji
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No. 70, Heping Road, Huancui District, Weihai City, Shandong Province, China
- The Second School of Clinical Medicine of Binzhou Medical University, Yantai, Shandong, China
| | - Chengsong Yue
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Changwei Guo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China.
| | - Pengfei Wang
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No. 70, Heping Road, Huancui District, Weihai City, Shandong Province, China.
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Cui J, Yang J, Wang Y, Ma M, Zhang N, Wang R, Zhou B, Meng C, Yang P, Yang J, Xu L, Tan G, Liu L, Zhen J, Guo L, Liu X. Automatic segmentation of hemispheric CSF on MRI using deep learning: Quantifying cerebral edema following large hemispheric infarction. Heliyon 2024; 10:e26673. [PMID: 38463867 PMCID: PMC10920171 DOI: 10.1016/j.heliyon.2024.e26673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 01/27/2024] [Accepted: 02/16/2024] [Indexed: 03/12/2024] Open
Abstract
Background and objective Cerebral edema (CED) is a serious complication of acute ischemic stroke (AIS), especially in patients with large hemispheric infarction (LHI). Herein, a deep learning-based approach is implemented to extract CSF from T2-Weighted Imaging (T2WI) and evaluate the relationship between quantified cerebrospinal fluid and outcomes. Methods Patients with acute LHI who underwent magnetic resonance imaging (MRI) were included. We used a deep learning algorithm to segment the CSF from T2WI. The hemispheric CSF ratio was calculated to evaluate its relationship with the degree of brain edema and prognosis in patients with LHI. Results For the 93 included patients, the left and right cerebrospinal fluid regions were automatically extracted with a mean Dice similarity coefficient of 0.830. Receiver operating characteristic analysis indicated that hemispheric CSF ratio was an accurate marker for qualitative severe cerebral edema (area under receiver-operating-characteristic curve 0.867 [95% CI, 0.781-0.929]). Multivariate logistic regression analysis of functional prognosis showed that previous stroke (OR = 5.229, 95% CI 1.013-26.984), ASPECT≤6 (OR = 13.208, 95% CI 1.136-153.540) and low hemispheric CSF ratio (OR = 0.966, 95% CI 0.937-0.997) were significantly associated with higher chances for unfavorable functional outcome in patients with LHI. Conclusions Automated assessment of CSF volume provides an objective biomarker of cerebral edema that can be leveraged to quantify the degree of cerebral edema and confirm its predictive effect on outcomes after LHI.
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Affiliation(s)
- Junzhao Cui
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jingyi Yang
- Department of Data Center, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ye Wang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Meixin Ma
- University of California, Berkeley College of Letters and Science, US
| | - Ning Zhang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Rui Wang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Biyi Zhou
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chaoyue Meng
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Peng Yang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jianing Yang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lei Xu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Guojun Tan
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lidou Liu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Junli Zhen
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Li Guo
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaoyun Liu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
- Department of Neurology, The First Hospital of Hebei Medical University, Shijiazhuang, China
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Kossel CS, Kobus F, Borutta MC, Kärtner M, Kuramatsu JB, Engelhorn T, Schwab S, Koehn J. Pupillometry in the follow-up of patients undergoing EVT - prediction of space-occupying hemispheric infarction. J Neurol 2023; 270:4507-4517. [PMID: 37300717 PMCID: PMC10421763 DOI: 10.1007/s00415-023-11797-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/26/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Despite benefits of endovascular treatment (EVT) for large vessel occlusion (LVO) ischemic stroke, space-occupying brain edema (BE) represents a detrimental complication. In critical-care settings, CT-imaging is needed for monitoring these patients. Yet, bed-side techniques with the potential to predict whether patients develop BE or not would facilitate a time- and cost-efficient patient care. We assessed clinical significance of automated pupillometry in the follow-up of patients undergoing EVT. METHODS From 10/2018 to 10/2021, neurocritical-care-unit patients were retrospectively enrolled after EVT of anterior circulation LVO. We monitored parameters of pupillary reactivity [light-reflex-latency (Lat), constriction- and redilation-velocities (CV, DV), percentage-change-of-apertures (per-change); NeurOptics-pupilometer®] up to every hour on day 1-3 of ICU stay. BE was defined as midline shift ≥ 5 mm on follow-up imaging 3-5 days after EVT. We calculated mean values of intra-individual differences between successive pairs of parameters (mean-deltas), determined best discriminative cut-off values for BE development (ROC-analyses), and evaluated prognostic performance of pupillometry for BE development (sensitivity/specificity/positive-/negative-predictive-values). RESULTS 3241 pupillary assessments of 122 patients [67 women, 73 years (61.0-85.0)] were included. 13/122 patients developed BE. Patients with BE had significantly lower CVs, DVs, and smaller per-changes than patients without BE. On day 1 after EVT mean-deltas of CV, DV, and per-changes were significantly lower in patients with than without BE. Positive-predictive-values of calculated thresholds to discriminate both groups were considerably low, yet, we found high negative-predictive-values for CV, DV, per-changes, and mean-deltas (max.: 98.4%). CONCLUSION Our data suggest associations between noninvasively detected changes in pupillary reactivity and BE early after LVO-EVT. Pupillometry may identify patients who are unlikely to develop BE and may not need repetitive follow-up-imaging or rescue-therapy.
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Affiliation(s)
- Clara-Sophie Kossel
- Department of Neurology, Friedrich-Alexander-University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Franca Kobus
- Department of Neurology, Friedrich-Alexander-University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Matthias C Borutta
- Department of Neurology, Friedrich-Alexander-University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Maximilian Kärtner
- Department of Neurology, Friedrich-Alexander-University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, Friedrich-Alexander-University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, Friedrich-Alexander-University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Julia Koehn
- Department of Neurology, Friedrich-Alexander-University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany.
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Escudero-Martínez I, Thorén M, Ringleb P, Nunes AP, Cappellari M, Rand VM, Sobolewski P, Egido J, Toni D, Chen SY, Tsao N, Ahmed N. Cerebral Edema in Patients with severe Hemispheric Syndrome: Incidence, Risk Factors, and Outcomes-Data from SITS-ISTR. J Stroke 2023; 25:101-110. [PMID: 36470246 PMCID: PMC9911855 DOI: 10.5853/jos.2022.01956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/11/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Cerebral edema (CED) in ischemic stroke can worsen prognosis and about 70% of patients who develop severe CED die if treated conservatively. We aimed to describe incidence, risk factors and outcomes of CED in patients with extensive ischemia. METHODS Oservational study based on Safe Implementation of Treatments in Stroke-International Stroke Treatment Registry (2003-2019). Severe hemispheric syndrome (SHS) at baseline and persistent SHS (pSHS) at 24 hours were defined as National Institutes of Health Stroke Score (NIHSS) >15. Outcomes were moderate/severe CED detected by neuroimaging, functional independence (modified Rankin Scale 0-2) and death at 90 days. RESULTS Patients (n=8,560) presented with SHS and developed pSHS at 24 hours; 82.2% received intravenous thrombolysis (IVT), 10.5% IVT+thrombectomy, and 7.3% thrombectomy alone. Median age was 77 and NIHSS 21. Of 7,949 patients with CED data, 3,780 (47.6%) had any CED and 2,297 (28.9%) moderate/severe CED. In the multivariable analysis, age <50 years (relative risk [RR], 1.56), signs of acute infarct (RR, 1.29), hyperdense artery sign (RR, 1.39), blood glucose >128.5 mg/dL (RR, 1.21), and decreased level of consciousness (RR, 1.14) were associated with moderate/severe CED (for all P<0.05). Patients with moderate/severe CED had lower odds to achieve functional Independence (adjusted odds ratio [aOR], 0.35; 95% confidence interval [CI], 0.23 to 0.55) and higher odds of death at 90 days (aOR, 2.54; 95% CI, 2.14 to 3.02). CONCLUSIONS In patients with extensive ischemia, the most important predictors for moderate/ severe CED were age <50, high blood glucose, signs of acute infarct, hyperdense artery on baseline scans, and decreased level of consciousness. CED was associated with worse functional outcome and a higher risk of death at 3 months.
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Affiliation(s)
- Irene Escudero-Martínez
- Department of Neurology, University Hospital La FE, Valencia, Spain,Neurovascular Research Laboratory, Biomedicine Institute IBiS, Sevilla, Spain,Correspondence: IreneEscudero-Martínez Stroke Unit, Department of Neurology, University Hospital La Fe, Av. Fernando Abril 106, 46026, Valencia, Spain Tel: +34-96-124-4000 Fax: +34-96-124-6241 E-mail:
| | - Magnus Thorén
- Department of Neurology, Danderyd Hospital, Stockholm, Sweden,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Peter Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ana Paiva Nunes
- Department of Neurology, Sao Jose Hospital, University Hospital Lisboa, Lisboa, Portugal
| | - Manuel Cappellari
- Department of Neuroscience, Integrate University Hospital, Verona, Italy
| | - Viiu-Marika Rand
- Department of Neurology, North Estonia Medical Centre Foundation, Tallinn, Estonia
| | - Piotr Sobolewski
- Department of Neurology and Stroke Unit in Sandomierz, Collegium Medicum, Jan Kochanowski University in Kielce, Kielce, Poland
| | - Jose Egido
- Stroke Unit, Department of Neurology, San Carlos Clinic Hospital, Madrid, Spain
| | - Danilo Toni
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | | | | | - Niaz Ahmed
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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Lee SJ, Do T, Lee TK. Postinterventional contrast accumulation early predicts malignant stroke in successfully recanalized patients with emergent large vessel occlusion. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Decompressive hemicraniectomy versus medical treatment for malignant middle cerebral artery infarction: Eleven years experience in a Tunisian center. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Alonso-Alonso ML, Sampedro-Viana A, Rodríguez-Yáñez M, López-Dequidt I, Pumar JM, Mosqueira AJ, Ouro A, Ávila-Gómez P, Sobrino T, Campos F, Castillo J, Hervella P, Iglesias-Rey R. Antihyperthermic Treatment in the Management of Malignant Infarction of the Middle Cerebral Artery. J Clin Med 2022; 11:jcm11102874. [PMID: 35629002 PMCID: PMC9146428 DOI: 10.3390/jcm11102874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 11/16/2022] Open
Abstract
Malignant infarction of the middle cerebral artery (m-MCA) is a complication of ischemic stroke. Since hyperthermia is a predictor of poor outcome, and antihyperthermic treatment is well tolerated, our main aim was to analyze whether the systemic temperature decrease within the first 24 h was associated with a better outcome. Furthermore, we studied potential biochemical and neuroimaging biomarkers. This is a retrospective observational analysis that included 119 patients. The temperature variations within the first 24 h were recorded. Biochemical laboratory parameters and neuroimaging variables were also analyzed. The temperature increase at the first 24 h (OR: 158.97; CI 95%: 7.29−3465.61; p < 0.001) was independently associated with a higher mortality. Moreover, antihyperthermic treatment (OR: 0.08; CI 95%: 0.02−0.38; p = 0.002) was significantly associated with a good outcome at 3 months. Importantly, antihyperthermic treatment was associated with higher survival at 3 months (78% vs. 50%, p = 0.003). Significant independently associations between the development of m-MCA and both microalbuminuria (OR: 1.01; CI 95%: 1.00−1.02; p = 0.005) and leukoaraiosis (OR: 3.07; CI 1.84−5.13−1.02; p < 0.0001) were observed. Thus, antihyperthermic treatment within the first 24 h was associated with both a better outcome and higher survival. An increased risk of developing m-MCA was associated with leukoaraiosis and an elevated level of microalbuminuria.
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Affiliation(s)
- Maria Luz Alonso-Alonso
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (A.S.-V.); (J.M.P.); (A.J.M.); (J.C.)
- Correspondence: (M.L.A.-A.); (P.H.); (R.I.-R.)
| | - Ana Sampedro-Viana
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (A.S.-V.); (J.M.P.); (A.J.M.); (J.C.)
| | - Manuel Rodríguez-Yáñez
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain; (M.R.-Y.); (I.L.-D.)
| | - Iria López-Dequidt
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain; (M.R.-Y.); (I.L.-D.)
| | - José M. Pumar
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (A.S.-V.); (J.M.P.); (A.J.M.); (J.C.)
- Department of Neuroradiology, Health Research Institute of Santiago de Compostela (IDIS), Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain
| | - Antonio J. Mosqueira
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (A.S.-V.); (J.M.P.); (A.J.M.); (J.C.)
- Department of Neuroradiology, Health Research Institute of Santiago de Compostela (IDIS), Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain
| | - Alberto Ouro
- NeuroAging Group (NEURAL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (A.O.); (T.S.)
| | - Paulo Ávila-Gómez
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (P.Á.-G.); (F.C.)
| | - Tomás Sobrino
- NeuroAging Group (NEURAL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (A.O.); (T.S.)
| | - Francisco Campos
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (P.Á.-G.); (F.C.)
| | - José Castillo
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (A.S.-V.); (J.M.P.); (A.J.M.); (J.C.)
| | - Pablo Hervella
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (A.S.-V.); (J.M.P.); (A.J.M.); (J.C.)
- Correspondence: (M.L.A.-A.); (P.H.); (R.I.-R.)
| | - Ramón Iglesias-Rey
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (A.S.-V.); (J.M.P.); (A.J.M.); (J.C.)
- Correspondence: (M.L.A.-A.); (P.H.); (R.I.-R.)
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Lu W, Jia D, Qin Y. Decompressive craniectomy combined with temporal pole resection in the treatment of massive cerebral infarction. BMC Neurol 2022; 22:167. [PMID: 35501820 PMCID: PMC9063210 DOI: 10.1186/s12883-022-02688-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/25/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy and prognosis of decompressive craniectomy combined with temporal pole resection in the treatment of massive cerebral infarction, in order to provide basis for treatment selection. METHODS The clinical data of the patient with massive cerebral infarction treated in our hospital from January 2015 to December 2018 were analyzed retrospectively. According to the surgical methods, the patients were divided into control group (decompressive craniectomy) and study group (decompressive craniectomy + temporal pole resection). Intracranial pressure monitoring devices were placed in both groups. The NIHSS scores of the two groups before and 14 days after operation, the changes of intracranial pressure, length of hospital stay, length of NICU, mortality and modified Rankin scale before and after treatment were compared between the two groups. RESULTS The NIHSS score of the two groups after operation was lower than that before operation, and the NIHSS score of the study group was significantly lower than that of the control group (P < 0.05); The intracranial pressure in the study group was significantly lower than that in the control group (P < 0.05); One month after operation, the mortality of the study group (13.0%) was lower than that of the control group (27.8%). After one year of follow-up, the mortality of the study group (21.7%) was significantly lower than that of the control group (38.8%) (P < 0.05); The scores of mRS in the two groups were significantly improved compared with those before treatment (P < 0.05), and the scores of mRS in the study group were better than those in the control group (P < 0.05). CONCLUSION Decompressive craniectomy combined with temporal pole resection has a better effect in the treatment of patients with massive cerebral infarction. It has good decompression effect, the postoperative intracranial pressure is well controlled, and significantly reduced the mortality. So it has better clinical application value.
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Affiliation(s)
- Wenchao Lu
- Department of Neurosurgery, the Xi'an Daxing Hospital, No. 353 Laodong North Road, Xi'an, 710000, Shaanxi Province, China
| | - Dong Jia
- Department of Neurosurgery, the Xi'an Daxing Hospital, No. 353 Laodong North Road, Xi'an, 710000, Shaanxi Province, China
| | - Yanchang Qin
- Department of Neurosurgery, the Xi'an Daxing Hospital, No. 353 Laodong North Road, Xi'an, 710000, Shaanxi Province, China.
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Wang Z, Chen M, Wang C, Luo J, Sun S, Lu X. Stereotactic Aspiration Acts as an Effective Treatment for Malignant Middle Cerebral Artery Infarction. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:4373404. [PMID: 35469230 PMCID: PMC9034930 DOI: 10.1155/2022/4373404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/15/2022] [Accepted: 03/24/2022] [Indexed: 11/21/2022]
Abstract
Objective This study seeks to explore the efficacy and prognosis of stereotactic aspiration for malignant middle cerebral artery infarction (mMCAI). Methods A total of 50 mMCAI patients who were diagnosed and treated in our hospital from January 2018 to June 2020 were collected and then randomly divided into control group (decompressive craniectomy, n = 24) and study group (stereotactic aspiration, n = 26). After 1 and 6 months of treatment, the scores of the National Institutes of Health Stroke Scale (NIHSS), Glasgow Coma Scale (GCS), Barthel Index, and modified Rankin Scale (mRS) were used to evaluate the therapeutic effect. Additionally, the mortality and survival rates after treatment were recorded to compare the prognostic effect between the two groups. Results One month after treatment, the GCS scores and Barthel Index score increased in both the control and study groups and were significantly higher in the study group. The follow-up results at 1 and 6 months after treatment showed that in comparison with the control group, stereotactic aspiration led to a higher survival rate and lower mortality rate; the latter had superior NIHSS score and mRS score and better prognosis. Conclusion In comparison with decompressive craniectomy, stereotactic aspiration shows outstanding clinical efficacy and more advantages in the treatment of mMCAI. Therefore, stereotactic aspiration is more worthy of clinical application.
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Affiliation(s)
- Zhiyu Wang
- Department of Neurosurgery, Xuhui Central Hospital, Zhongshan-Xuhui Hospital, Affiliated to Fudan University, Shanghai Clinical Center CAS, Shanghai 200031, China
| | - Maogang Chen
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu 211299, China
- Department of Emergency, The People's Hospital of Suzhou New District, Suzhou, Jiangsu 215129, China
| | - Chong Wang
- Department of Neurosurgery, Xuhui Central Hospital, Zhongshan-Xuhui Hospital, Affiliated to Fudan University, Shanghai Clinical Center CAS, Shanghai 200031, China
| | - Jinbiao Luo
- Department of Neurosurgery, Guangzhou First People's Hospital, Guangzhou, Guangdong 510180, China
| | - Shujie Sun
- Department of Neurosurgery, Xuhui Central Hospital, Zhongshan-Xuhui Hospital, Affiliated to Fudan University, Shanghai Clinical Center CAS, Shanghai 200031, China
| | - Xiangui Lu
- Department of Neurosurgery, Xuhui Central Hospital, Zhongshan-Xuhui Hospital, Affiliated to Fudan University, Shanghai Clinical Center CAS, Shanghai 200031, China
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Tsao N, Hou Q, Chen SY, Messe SR. A Real-World Assessment of Outcomes, Health Resource Utilization, and Costs Associated with Cerebral Edema in US Patients with Large Hemispheric Infarction. PHARMACOECONOMICS - OPEN 2022; 6:63-72. [PMID: 34420191 PMCID: PMC8807772 DOI: 10.1007/s41669-021-00294-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 07/25/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Patients with large hemispheric infarction (LHI) are at risk of cerebral edema (CED). This study analyzed health resource use, costs, and outcomes during and after acute hospitalization for LHI in US patients with and without CED. METHODS Using IBM® MarketScan® Commercial, Medicaid, and Medicare databases, patients with incident hospitalization for LHI (International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes of I63.03x, I63.13x, I63.23x, I63.31x, I63.41x, I63.51x) from 31 March 2016 through 31 December 2018 were identified and further categorized by the presence or absence of CED based on related diagnosis codes or a procedure code of craniectomy. Health resource use, costs, and outcomes were compared in patients with and without CED during hospitalization and after discharge. RESULTS Of 7336 Commercial, 1946 Medicaid, and 5015 Medicare patients with LHI, 7.8%, 6.9%, and 4.3% had CED, respectively. After adjusting for age, sex, and baseline comorbidities, differences (95% confidence intervals) in mean total costs of the index hospitalization in patients with CED versus without CED were $65,572 ($56,506-$76,335), $44,395 ($26,442-$63,495), and $31,417 ($18,982-$48,543) in the Commercial, Medicaid, and Medicare groups, respectively. Similarly, the adjusted differences (95% confidence intervals) in mean lengths of stay between patients with CED and without CED were 11.75 (10.17-13.48), 10.84 (7.59-14.17), and 3.69 (2.40-5.19) days, respectively. Mortality during index hospitalization was 10-20 times greater in patients with CED versus without CED (p < 0.0001). In those patients who survived and had at least 30-days of follow-up after discharge, CED was also associated with higher post-discharge resource utilization and costs in the commercially insured population who were younger than Medicare patients, and had fewer comorbidities than Medicare and Medicaid patients. This indicates the effect of CED after discharge was particularly burdensome for younger individuals. CONCLUSIONS In this large cohort study, inpatient mortality, health resource utilization and costs were consistently higher in patients with LHI who developed CED than in those without CED. These findings underscore the need for greater awareness of CED among policymakers and healthcare practitioners.
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Affiliation(s)
| | | | | | - Steven R Messe
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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11
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Garcia-Estrada E, Morales-Gómez JA, Romero-González M, Martínez-Ortíz RG, García-Hernández MA, Ramos-Delgado CA, López-Hernández PA, Palacios-Ortiz IJ, Martínez-Ponce de León AR. Decompressive Craniectomy for Hemispheric Infarction in a Low-Income Population. World Neurosurg 2021; 156:e152-e159. [PMID: 34517142 DOI: 10.1016/j.wneu.2021.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 09/02/2021] [Accepted: 09/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Stroke is a worldwide leading cause of mortality and disability, and there are substantial economic costs for poststroke care. Disadvantaged populations show increased incidence, severity, and unfavorable outcomes. This study aimed to report the survival, functional outcome, and caregiver satisfaction of low-income patients diagnosed with a large hemispheric infarction (LHI) who underwent decompressive craniectomy (DC). METHODS A retrospective analysis was conducted in consecutive adult patients with an LHI who underwent DC at a single center between October 2015 and September 2019. Demographic, clinical, and radiologic data were reviewed. The primary outcomes were 1-year survival and favorable functional outcome. RESULTS Forty-nine patients were included; those <60 years of age showed a higher proportion of favorable functional outcomes (76% vs. 33%; P = 0.031) but similar survival (52% vs. 56%; P = 0.645) than older patients, respectively. Performing the craniectomy in <48 hours from stroke onset compared with ≥48 hours showed no statistically significant differences in survival (59% vs. 46%; P = 0.352) and favorable functional outcomes (56% vs. 70%; P = 0.683), respectively. In retrospective thinking, 79% of caregivers would decide to perform the surgery again. CONCLUSIONS Age group and time from stroke onset to craniectomy were not associated with survival; notwithstanding, a higher proportion of patients <60 years of age were associated with a favorable functional outcome compared with older patients. Additionally, if given the option, most caregivers would decide to perform the surgery again, independently of the grade of disability of the patient.
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Affiliation(s)
- Everardo Garcia-Estrada
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Jesús Alberto Morales-Gómez
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México.
| | - Mariana Romero-González
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Ricardo Gerardo Martínez-Ortíz
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Marco Antonio García-Hernández
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - César Alessandro Ramos-Delgado
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Paúl André López-Hernández
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Isaac Jair Palacios-Ortiz
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Angel Raymundo Martínez-Ponce de León
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
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12
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Xia H, Sun H, He S, Zhao M, Huang W, Zhang Z, Xue Y, Fu P, Chen W. Absent Cortical Venous Filling Is Associated with Aggravated Brain Edema in Acute Ischemic Stroke. AJNR Am J Neuroradiol 2021; 42:1023-1029. [PMID: 33737267 DOI: 10.3174/ajnr.a7039] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/01/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Predicting malignant cerebral edema can help identify patients who may benefit from appropriate evidence-based interventions. We investigated whether absent cortical venous filling is associated with more pronounced early brain edema, which leads to malignant cerebral edema. MATERIALS AND METHODS Patients with acute ischemic stroke caused by large-vessel occlusion in the MCA territory who presented between July 2017 and September 2019 to our hospital were included. Collateral filling was rated using the modified Tan scale on CTA, and good collaterals were defined as a score of 2-3. The Cortical Vein Opacification Score (COVES) was calculated, and absent cortical venous filling was defined as a score of 0. Early brain edema was determined using net water uptake on baseline CT images. Malignant cerebral edema was defined as a midline shift of ≥5 mm on follow-up imaging or a massive cerebral swelling leading to decompressive hemicraniectomy or death. Multivariate linear and logistic regression models were performed to analyze data. RESULTS A total of 163 patients were included. Net water uptake was significantly higher in patients with absent than in those with favorable cortical venous filling (8.1% versus 4.2%; P < .001). In the multivariable regression analysis, absent cortical venous filling (β = 2.04; 95% CI, 0.75-3.32; P = .002) was significantly and independently associated with higher net water uptake. Absent cortical venous filling (OR, 14.68; 95% CI, 4.03-53.45; P < .001) and higher net water uptake (OR, 1.29; 95% CI, 1.05-1.58; P = .016) were significantly associated with increased likelihood of malignant cerebral edema. CONCLUSIONS Patients with absent cortical venous filling were associated with an increased early brain edema and a higher risk of malignant cerebral edema. These patients may be targeted for optimized adjuvant antiedematous treatment.
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Affiliation(s)
- H Xia
- From the Department of Radiology (H.X.), Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, Zhejiang, China
| | - H Sun
- Department of Radiology (H.S., S.H., M.Z., W.H., Z.Z., Y.X., P.F., W.C.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - S He
- Department of Radiology (H.S., S.H., M.Z., W.H., Z.Z., Y.X., P.F., W.C.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - M Zhao
- Department of Radiology (H.S., S.H., M.Z., W.H., Z.Z., Y.X., P.F., W.C.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - W Huang
- Department of Radiology (H.S., S.H., M.Z., W.H., Z.Z., Y.X., P.F., W.C.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Z Zhang
- Department of Radiology (H.S., S.H., M.Z., W.H., Z.Z., Y.X., P.F., W.C.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Y Xue
- Department of Radiology (H.S., S.H., M.Z., W.H., Z.Z., Y.X., P.F., W.C.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - P Fu
- Department of Radiology (H.S., S.H., M.Z., W.H., Z.Z., Y.X., P.F., W.C.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - W Chen
- Department of Radiology (H.S., S.H., M.Z., W.H., Z.Z., Y.X., P.F., W.C.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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13
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Fu B, Qi S, Tao L, Xu H, Kang Y, Yao Y, Yang B, Duan Y, Chen H. Image Patch-Based Net Water Uptake and Radiomics Models Predict Malignant Cerebral Edema After Ischemic Stroke. Front Neurol 2021; 11:609747. [PMID: 33424759 PMCID: PMC7786250 DOI: 10.3389/fneur.2020.609747] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/26/2020] [Indexed: 12/12/2022] Open
Abstract
Malignant cerebral edema (MCE) after an ischemic stroke results in a poor outcome or death. Early prediction of MCE helps to identify subjects that could benefit from a surgical decompressive craniectomy. Net water uptake (NWU) in an ischemic lesion is a predictor of MCE; however, CT perfusion and lesion segmentation are required. This paper proposes a new Image Patch-based Net Water Uptake (IP-NWU) procedure that only uses non-enhanced admission CT and does not need lesion segmentation. IP-NWU is calculated by comparing the density of ischemic and contralateral normal patches selected from the middle cerebral artery (MCA) area using standard reference images. We also compared IP-NWU with the Segmented Region-based NWU (SR-NWU) procedure in which segmented ischemic regions from follow-up CT images are overlaid onto admission images. Furthermore, IP-NWU and its combination with imaging features are used to construct predictive models of MCE with a radiomics approach. In total, 116 patients with an MCA infarction (39 with MCE and 77 without MCE) were included in the study. IP-NWU was significantly higher for patients with MCE than those without MCE (p < 0.05). IP-NWU can predict MCE with an AUC of 0.86. There was no significant difference between IP-NWU and SR-NWU, nor between their predictive efficacy for MCE. The inter-reader and interoperation agreement of IP-NWU was exceptional according to the Intraclass Correlation Coefficient (ICC) analysis (inter-reader: ICC = 0.92; interoperation: ICC = 0.95). By combining IP-NWU with imaging features through a random forest classifier, the radiomics model achieved the highest AUC (0.96). In summary, IP-NWU and radiomics models that combine IP-NWU with imaging features can precisely predict MCE using only admission non-enhanced CT images scanned within 24 h from onset.
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Affiliation(s)
- Bowen Fu
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang, China
| | - Shouliang Qi
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang, China.,Key Laboratory of Intelligent Computing in Medical Image, Ministry of Education, Northeastern University, Shenyang, China
| | - Lin Tao
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Haibin Xu
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yan Kang
- College of Health Science and Environment Engineering, Shenzhen Technology University, Shenzhen, China
| | - Yudong Yao
- Department of Electrical and Computer Engineering, Stevens Institute of Technology, Hoboken, NJ, United States
| | - Benqiang Yang
- Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yang Duan
- Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Huisheng Chen
- Department of Electrical and Computer Engineering, Stevens Institute of Technology, Hoboken, NJ, United States
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Comparison of equiosmolar doses of 10% hypertonic saline and 20% mannitol for controlling intracranial hypertention in patients with large hemispheric infarction. Clin Neurol Neurosurg 2020; 200:106359. [PMID: 33246252 DOI: 10.1016/j.clineuro.2020.106359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We conducted this prospective self-crossover controlled trial to compare the efficacy and safety of 10 % hypertonic saline (HS) and 20 % mannitol in doses of similar osmotic burden for the treatment of increased intracranial pressure (ICP) in patients with large hemispheric infarction (LHI). PATIENTS AND METHODS Patients with LHI were enrolled from January 2017 to January 2018. We used an alternating treatment protocol to compare the effects of HS with mannitol given for episodes of increased ICP in patients with LHI. Indicators such as ICP, mean arterial pressure (MAP) and cerebral perfusion pressure (CPP) were continuously monitored at regular intervals for 240 min after initiation of infusion. Electrolytes, plasma osmolality and renal functions were measured before and 240 min after initiation of infusion to compare the efficacy and safety of the two drugs. RESULTS A total of 49 episodes of increased ICP occurred in 14 patients with LHI, of which 24 were infused with 10 % HS and 25 with 20 % mannitol. Both the treatments were equally effective in reducing ICP (P < 0.01). The differences in the duration and degree of reduction were not significant between the groups (P > 0.05). Although both the osmolar agents decreased MAP, the degree was greater in the mannitol group (P < 0.05) at T120. The increase in CPP was greater in the HS group compared with the mannitol group (P < 0.05) at T120. However, HS was associated with faster heart rate (HR) and higher serum chloride levels (P < 0.05). Changes in serum sodium levels and osmolality were not significant between the groups in spite of being higher in the HS group. CONCLUSIONS Both the drugs can serve as first-line agents for treating intracranial hypertension caused by LHI and should be selected rationally according to the differences in efficacy and adverse effects.
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15
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The Clinical Usefulness of Targeted Temperature Management in Acute Ischemic Stroke with Malignant Trait After Endovascular Thrombectomy. Neurocrit Care 2020; 34:990-999. [PMID: 32812197 DOI: 10.1007/s12028-020-01069-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/27/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND/OBJECTIVE Targeted temperature management (TTM) may be more beneficial after endovascular treatment (EVT) in patients with a large ischemic core. Therefore, we assessed the usefulness of TTM for such patients from a multicenter endovascular registry. METHODS Anterior circulation stroke patients who underwent endovascular recanalization were included; acute ischemic stroke with malignant traits was designated as (1) baseline Alberta Stroke Program Early CT Score (ASPECTS) below 6 and (2) diffusion-weighted imaging (DWI) lesion volume measurement (> 82 ml) or National Institutes of Health Stroke Scale score > 20 and item Ia > 0. TTM (34.5 °C) was maintained for at least 48 h. RESULTS We evaluated baseline demographics, risk factors, EVT parameters, and clinical outcomes between the TTM and non-TTM groups. Among the 548 patients, the TTM group (n = 91) significantly had a lower baseline ASPECTS (p < 0.001) and a higher DWI volume (p < 0.001) than the non-TTM group (n = 457). TTM group had a lower prevalence of favorable outcome (0-2 of modified Rankin Scale at 3 months; p = 0.008) than the non-TTM group. In a subgroup analysis of malignant trait patients (n = 80), TTM patients (n = 28) had more favorable outcome (32.1% vs. 7.7% p = 0.009) and less hemorrhagic transformation (none vs. any hemorrhage, p = 0.007) than non-TTM patients (n = 52). After adjusting for potential outcome predictors, TTM (odds ratio [OR] 4.63; confidence interval [CI] 1.20-17.89; p = 0.026) and hypertension (OR 0.18; CI 0.04-0.74; p = 0.018) were found to be independent determinants. CONCLUSIONS Our data suggest that TTM attenuates impending hemorrhagic transformation and leads to favorable clinical outcomes in EVT patients with malignant trait.
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16
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Maia IHM, Melo TPD, Lima FO, Carvalho JJDF, Mont'alverne FJA, Lopes JÚnior E, DiÓgenes MB, Cunha TSL, Queiroz BMA, Tamietti MF, Maia FM. Decompressive craniectomy versus conservative treatment: limits and possibilities in malignant stroke. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 78:349-355. [PMID: 32609190 DOI: 10.1590/0004-282x20200006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 01/08/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Malignant infarction of the middle cerebral artery (MCA) occurs in a subgroup of patients with ischemic stroke and early decompressive craniectomy (DC) is one of its treatments. OBJECTIVE To investigate the functional outcome of patients with malignant ischemic stroke treated with decompressive craniectomy at a neurological emergency center in Northeastern Brazil. METHODS Prospective cohort study, in which 25 patients were divided into two groups: those undergoing surgical treatment with DC and those who continued to receive standard conservative treatment (CT). Functionality was assessed using the modified Rankin Scale (mRS), at follow-up after six months. RESULTS A favorable outcome (mRS≤3) was observed in 37.5% of the DC patients and 29.4% of CT patients (p=0.42). Fewer patients who underwent surgical treatment died (25%), compared to those treated conservatively (52.8%); however, with no statistical significance. Nonetheless, the proportion of patients with moderate to severe disability (mRS 4‒5) was higher in the surgical group (37.5%) than in the non-surgical group (17.7%). CONCLUSION In absolute values, superiority in the effectiveness of DC over CT was perceived, showing that the reduction in mortality was at the expense of increased disability.
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Affiliation(s)
| | | | | | | | | | - Edson Lopes JÚnior
- Hospital Geral de Fortaleza, Serviço de Neurocirurgia, Fortaleza CE, Brazil
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17
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Thorén M, Dixit A, Escudero-Martínez I, Gdovinová Z, Klecka L, Rand VM, Toni D, Vilionskis A, Wahlgren N, Ahmed N. Effect of Recanalization on Cerebral Edema in Ischemic Stroke Treated With Thrombolysis and/or Endovascular Therapy. Stroke 2019; 51:216-223. [PMID: 31818228 DOI: 10.1161/strokeaha.119.026692] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background and Purpose- A large infarct and expanding cerebral edema (CED) due to a middle cerebral artery occlusion confers a 70% mortality unless treated surgically. Reperfusion may cause blood-brain barrier disruption and a risk for cerebral edema and secondary parenchymal hemorrhage (PH). We aimed to investigate the effect of recanalization on development of early CED and PH after recanalization therapy. Methods- From the SITS-International Stroke Treatment Registry, we selected patients with signs of artery occlusion at baseline (either Hyperdense Artery Sign or computed tomography/magnetic resonance imaging angiographic occlusion). We defined recanalization as the disappearance of radiological signs of occlusion at 22 to 36 hours. Primary outcome was moderate to severe CED and secondary outcome was PH on 22- to 36-hour imaging scans. We used logistic regression with adjustment for baseline variables and PH. Results- Twenty two thousand one hundred eighty-four patients fulfilled the inclusion criteria (n=18 318 received intravenous thrombolysis, n=3071 received intravenous thrombolysis+thrombectomy, n=795 received thrombectomy). Recanalization occurred in 64.1%. Median age was 71 versus 71 years and National Institutes of Health Stroke Scale score 15 versus 16 in the recanalized versus nonrecanalized patients respectively. Recanalized patients had a lower risk for CED (13.0% versus 23.6%), adjusted odds ratio (aOR), 0.52 (95% CI, 0.46-0.59), and a higher risk for PH (8.9% versus 6.5%), adjusted odds ratio, 1.37 (95% CI, 1.22-1.55), than nonrecanalized patients. Conclusions- In patients with acute ischemic stroke, recanalization was associated with a lower risk for early CED even after adjustment for higher rate for PH in recanalized patients.
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Affiliation(s)
- Magnus Thorén
- From the Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden (M.T., N.A.)
| | - Anand Dixit
- Newcastle upon Tyne NHS Foundation Trust, University of Newcastle upon Tyne, United Kingdom (A.D.)
| | - Irene Escudero-Martínez
- Department of Neurology, University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain (I.E.-M.)
| | - Zuzana Gdovinová
- Department of Neurology, Faculty of Medicine, P.J. Safarik University Košice, Slovak republic (Z.G.)
| | - Lukas Klecka
- Departement of Neurology, Municipal hospital of Ostrava, Czech Republic (L.K.)
| | - Viiu-Marika Rand
- Department of Neurology, North Estonia Medical Centre, Tallinn (V.-M.R.)
| | - Danilo Toni
- Unità di Trattamento Neurovascolare, University La Sapienza Rome, Italy (D.T.)
| | - Aleksandras Vilionskis
- Department of Neurology, Institute of Clinical Medicine, Vilnius University, Republican Vilnius University hospital, Lithuania (A.V.)
| | - Nils Wahlgren
- Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.)
| | - Niaz Ahmed
- From the Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden (M.T., N.A.)
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Wu J, Wei W, Gao YH, Liang FT, Gao YL, Yu HG, Huang QL, Long XQ, Zhou YF. Surgical Decompression versus Conservative Treatment in Patients with Malignant Infarction of the Middle Cerebral Artery: Direct Comparison of Death-Related Complications. World Neurosurg 2019; 135:e366-e374. [PMID: 31816452 DOI: 10.1016/j.wneu.2019.11.170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/28/2019] [Accepted: 11/29/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Surgical decompression and conservative treatment are routinely used in the treatment of patients with malignant infarction of the middle cerebral artery (MIMCA). However, efficacy and safety are controversial. The purpose of this study is to systematically compare the clinical outcomes between surgical decompression and conservative treatment in patients with MIMCA. METHODS This study retrieved available academic randomized controlled trials (RCTs) comparing the clinical outcomes between surgical decompression and conservative treatment in patients with MIMCA from the databases of ScienceDirect, Cochrane Library, Embase, and PubMed. The references of previous reviews and related clinical studies were manually checked to retrieve potential literature that was not involved in our electronic search results. RESULTS A total of 7 RCTs were included in the study. The overall number of participants in the surgical decompression group was 165, whereas it was 173 in the conservative treatment group. The results revealed that the surgical decompression group was related to a lower incidence of 1-year death (odds ratio [OR], 0.192; 95% confidence interval [CI], 0.119-0.309; P < 0.001), 1-year death in patients >60 years of age (OR, 0.202; 95% CI, 0.097-0.421; P < 0.001), 1-year death in patients <60 years of age (OR, 0.145; 95% CI, 0.069-0.301; P < 0.001), 1-year death in patients treated within 48 hours of stroke onset (OR, 0.159; 95% CI, 0.090-0.282; P < 0.001), and modified Rankin Scale (mRS) score ≤3 (OR, 2.082; 95% CI, 1.185-3.658; P < 0.001). CONCLUSIONS Based on current evidence for patients with MIMCA, decompressive surgery not only is a life-saving therapy but also reduces the incidence of mortality without increasing the risk of severe disability.
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Affiliation(s)
- Jun Wu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (The First People's Hospital of Fuzhou), Fuzhou, Jiangxi, China
| | - Wei Wei
- Department of Neurology, Mianyang Central Hospital, Sichuan, R.P. China
| | - Yue-Hua Gao
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, R.P. China
| | - Fang-Te Liang
- Department of Anesthesiology, Guangxi Medical University, Nanning, Guangxi, R.P. China
| | - Yun-Long Gao
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (The First People's Hospital of Fuzhou), Fuzhou, Jiangxi, China
| | - Hai-Guang Yu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (The First People's Hospital of Fuzhou), Fuzhou, Jiangxi, China
| | - Qing-Liang Huang
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (The First People's Hospital of Fuzhou), Fuzhou, Jiangxi, China
| | - Xin-Quan Long
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (The First People's Hospital of Fuzhou), Fuzhou, Jiangxi, China
| | - Yu-Fan Zhou
- Department of Neurosurgery, The Fifth Affiliated Hospital of Nanchang University (The First People's Hospital of Fuzhou), Fuzhou, Jiangxi, China.
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Lee CL, Kandasamy R, Mohammad Raffiq MAB. Computed tomography perfusion in detecting malignant middle cerebral artery infarct. Surg Neurol Int 2019; 10:159. [PMID: 31528494 PMCID: PMC6744784 DOI: 10.25259/sni_64_2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/02/2019] [Indexed: 12/04/2022] Open
Abstract
Background: Computed tomography perfusion (CTP) is an emerging modality which produces maps of time-to- peak (TTP), cerebral blood flow (CBF), and cerebral blood volume (CBV), with a computerized automated map of the infarct and penumbra. This modality provides a better evaluation of the extent of infarction, making it a potential method for assessing patients suffering from large middle cerebral artery (MCA) infarctions. Methods: A prospective cohort study of all patients in Hospital Kuala Lumpur, Malaysia, who presented with the clinical diagnosis of a large MCA infarction within 48 h of onset were subjected to CT brain, and CTP scans on admission and were followed up to determine the development of malignant infarction requiring surgical decompression. Results: CTP parameters were generally lower in patients with malignant brain infarct (MBI) group compared to the nonMBI group. The largest mean difference between the group was noted in the TTP values (P = 0.005). CTP parameters had a comparable positive predictive value (83%–90%) and high net present value (88–93). CBF with cutoff value of >32.85 of the hemisphere could accurately predict malignant infarctions in 81.4% of cases. The National Institutes of Health Stroke Scale score of more than 13.5 was also found to be able to accurately determine malignant infarct (97.6%). Functional outcome of patients based on Glasgow outcome scale was similar on discharge, however, showed improvement at 6 months during reviewed base on modified Rankin scale (P < 0.001). Conclusion: CTP parameters should be included in the initial evaluation of patients to predict malignant brain infarction and facilitate surgical treatment of large MCA infarctions. Key messages: CT perfusion parameters have an important role in predicting malignant brain infarction and should be included in the initial evaluation of patients to facilitate the early identification and surgical treatment of large middle cerebral artery infarctions, to improve patient’s prognosis.
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Affiliation(s)
- Chun Lin Lee
- Department of Neurosurgery, Hospital Kuala Lumpur, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur
| | - Regunath Kandasamy
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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Liebeskind DS, Jüttler E, Shapovalov Y, Yegin A, Landen J, Jauch EC. Cerebral Edema Associated With Large Hemispheric Infarction. Stroke 2019; 50:2619-2625. [DOI: 10.1161/strokeaha.118.024766] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- David S. Liebeskind
- From the Department of Neurology, Neurovascular Imaging Research Core and UCLA Stroke Center, University of California Los Angeles (D.S.L.)
| | - Eric Jüttler
- Department of Neurology, University of Heidelberg, Germany (E.J.)
- Department of Neurology, University of Ulm, University and Rehabilitation Hospitals, Ulm, and the Center for Stroke Research Berlin, Germany (E.J.)
| | | | | | | | - Edward C. Jauch
- Mission Research Institute, Mission Health System, Asheville, NC (E.C.J.)
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21
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Pelz JO, Fischer MM, Bungert-Kahl P, Lindner D, Fricke C, Michalski D. Fluid Balance Variations During the Early Phase of Large Hemispheric Stroke Are Associated With Patients' Functional Outcome. Front Neurol 2019; 10:720. [PMID: 31333571 PMCID: PMC6616133 DOI: 10.3389/fneur.2019.00720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 06/18/2019] [Indexed: 12/23/2022] Open
Abstract
Background: From the variety of factors underlying the ischemia-associated edema formation in large hemispheric stroke (LHS), an increased brain water content during the early phase seems to have a pivotal role for long-lasting tissue damage. However, the importance of the fluid management during the acute phase of LHS has so far not been adequately studied. Therefore, this study explored the association between the fluid balance and functional outcome in patients suffering from LHS. Methods: We analyzed hospital-based medical records of 39 consecutive patients with LHS and decompressive hemicraniectomy. Over the first 10 days after admission, the volumes of all administered fluids were assessed daily and corrected for daily urinary output and insensible loss. Functional outcome at 3 months was assessed with the modified Rankin Scale (mRS) and dichotomized into an acceptable (mRS ≤ 4) vs. a poor outcome (mRS ≥ 5). Results: Compared to patients with a poor functional outcome (n = 19), those with an acceptable outcome (n = 20) were characterized by a significantly lower cumulative net fluid balance at day 5 (1.6 ± 2.5 vs. 3.4 ± 4.4 l), day 7 (2.0 ± 2.9 vs. 4.6 ± 5.2 l), and day 10 (0 ± 2.5 vs. 5.6 ± 6.2 l). In addition to age, only the cumulative net fluid balance at day 10 served as an independent factor for poor functional outcome in multiple regression analyses. Conclusion: These data provide evidence for a critical role of the early phase net fluid balance with respect to the functional outcome after LHS. This observation leads to the hypothesis that patients with LHS might benefit from a more restrictive volume therapy. However, prospective studies are warranted to establish a causal relationship and recommendations for treatment strategies.
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Affiliation(s)
- Johann Otto Pelz
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | | | - Peggy Bungert-Kahl
- Neurologisches Rehabilitationszentrum Leipzig, University of Leipzig, Leipzig, Germany
| | - Dirk Lindner
- Department of Neurosurgery, University of Leipzig, Leipzig, Germany
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Ding M, Guan L, Zhang C, Yang P, Yang H. (3R)‑5,6,7‑trihydroxy‑3‑isopropyl‑3‑methylisochroman‑1‑one attenuates cardiac dysfunction via the apelin/APJ signaling pathway. Mol Med Rep 2019; 19:5007-5014. [PMID: 30942406 DOI: 10.3892/mmr.2019.10122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 03/26/2019] [Indexed: 11/05/2022] Open
Abstract
Myocardial infarction (MI) is associated with a high risk of mortality and is a major global health concern. The present study aimed to investigate the protective effects of (3R)‑5,6,7‑trihydroxy‑3‑isopropyl‑3‑methylisochroman‑1‑one (TIM) against MI induced by isoproterenol (ISO) in a rat model and the underlying mechanisms. Wistar rats were assigned to 4 groups (n=10): The control group received saline treatment; the ISO group received an intraperitoneal injection of ISO (100 mg/kg); and the TIM (low) and TIM (high) groups received an intraperitoneal injection of ISO, plus a 1 and 2 mg/kg dose of TIM orally, respectively. TIM rats were treated with TIM daily for 12 days and received ISO injections on the final 2 days to induce MI. Cardiac function, apoptosis index and protein expression were subsequently determined. The levels of oxidative stress markers were determined by ELISAs, whereas DNA damage was detected using a Cell Death Detection ELISA kit. Gene and protein expression were determined via reverse transcription‑quantitative polymerase chain reaction and western blot analyses, respectively. Following treatment with ISO, the maximum left ventricular contraction/relaxation velocity and left ventricular systolic pressure were significantly decreased, whereas the left ventricular end‑diastolic pressure was increased; however, treatment with TIM significantly ameliorated ISO‑induced cardiac dysfunction. Additionally, TIM treatment significantly decreased oxidative stress and inhibited the apoptosis of cardiomyocytes, as determined by a decrease in caspase activities, increased expression of B‑cell lymphoma 2 (Bcl‑2) and reduced expression of cleaved caspase‑3, cleaved caspase‑9 and Bcl‑2‑associated X. Furthermore, treatment with TIM upregulated the levels of apelin in the plasma and myocardium of ISO‑treated rats. The results indicated that TIM protected cardiomyocytes against ISO‑induced MI, potentially via the apelin/apelin receptor signaling pathway. The results of the present study suggested that TIM may be a potential novel therapy for the treatment of MI.
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Affiliation(s)
- Mei Ding
- Department of Cardiology, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Lianyue Guan
- Department of Hepatobiliary‑Pancreatic Surgery, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Chunmei Zhang
- Department of Emergency, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Ping Yang
- Department of Cardiology, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Hailing Yang
- Department of Emergency, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
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23
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Chen FH, Wang Y, Jiang YX, Zhang GH, Wang ZM, Yang H. Clinical determination of serum nardilysin levels in predicting 30-day mortality among adults with malignant cerebral infarction. Clin Chim Acta 2019; 494:8-13. [PMID: 30871973 DOI: 10.1016/j.cca.2019.03.1608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Nardilysin, a kind of metalloendopeptidase, plays an important role in numerous inflammatory diseases. Malignant cerebral infarction (Glasgow coma scale score of <9) is associated with a high mortality risk. Here, we intended to investigate the relationship between serum nardilysin levels and prognosis of patients with malignant cerebral infarction. METHODS Serum nardilysin concentrations were quantified at malignant cerebral infarction diagnosis moment in 105 patients and at study entrance in 105 healthy controls. Association of nardilysin concentrations with 30-day mortality and overall survival was estimated using multivariate analyses. RESULTS The patients exhibited substantially increased serum nardilysin concentrations, as compared to the controls. Nardilysin concentrations were in pronounced correlation with Glasgow coma scale scores and serum C-reactive protein concentrations. Serum nardilysin was independently predictive of 30-day mortality and overall survival. Under receiver operating characteristic curve, its high discriminatory ability was found. CONCLUSIONS Rising serum nardilysin concentrations following malignant cerebral infarction are strongly related to stroke severity, inflammatory extent and a higher risk of mortality, substantializing serum nardilysin as a potential prognostic biomarker for malignant cerebral infarction.
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Affiliation(s)
- Fang-Hui Chen
- Department of Emergency Medicine, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, 261 Huansha Road, Hangzhou 310006, China.
| | - Yi Wang
- Department of Emergency Medicine, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, 261 Huansha Road, Hangzhou 310006, China
| | - Yi-Xiang Jiang
- Department of Neurology, The Huangyan Hospital of Wenzhou Medical University, 218 Hengjie Road, Taizhou 318020, China
| | - Gui-Hong Zhang
- Department of Neurology, The Huangyan Hospital of Wenzhou Medical University, 218 Hengjie Road, Taizhou 318020, China
| | - Zhi-Min Wang
- Department of Neurology, The Huangyan Hospital of Wenzhou Medical University, 218 Hengjie Road, Taizhou 318020, China
| | - Hui Yang
- Department of Neurologic Intensive Care Unit, The Huangyan Hospital of Wenzhou Medical University, 218 Hengjie Road, Taizhou 318020, China
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Kilic M, Ertem DH, Ozdemir B. Timing of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction: A Single-Center Analysis. ACTA ACUST UNITED AC 2019; 55:medicina55020031. [PMID: 30704138 PMCID: PMC6409760 DOI: 10.3390/medicina55020031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 01/27/2019] [Accepted: 01/28/2019] [Indexed: 12/02/2022]
Abstract
Background and aim: Malignant middle cerebral artery infarction (MMCAI) usually leads to brain edema that may result in transtentorial herniation and brainstem compression. The prognosis of MMCAI is generally poor. The aim of this study was to discuss our experience with surgical decompression for MMCAI, and determine the association between timing of craniectomy and neurological outcomes. Methods: We identified consecutive patients diagnosed with MMCAI who underwent decompressive craniectomy (DC). Clinical and demographic data were obtained from electronic medical records, including: age, sex, preoperative Glasgow Coma Scale (GCS) score, surgery timing, postoperative GCS scores, and modified Rankin Scale (mRS) scores. Results: This study included 27 stroke patients (aged 38–80 years) operated within 72 h of the onset of neurological symptoms. Sixteen, five, and six patients underwent DC within 24 h, between 24 and 48 h, and after 48 h after onset of symptoms, respectively. Five patients died after the surgery. Patients who underwent DC within 24 h and 24–48 h had better mean GCS scores than those who underwent DC after 48 h (p = 0.000, p = 0.015). In addition, patients who underwent DC within 24 h had better mean postoperative mRS scores (p = 0.000) than other patients. Patients older than 60 years had significantly lower GCS scores (p = 0.027) and higher mRS scores (p = 0.033) than younger patients. Conclusion: Our findings support that DC had satisfying outcomes in patients who underwent DC within 24 h. Older age and lower Glasgow Coma Scale scores among DC patients with MMCAI are associated with high morbidity and mortality.
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Affiliation(s)
- Mustafa Kilic
- University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital, Department of Neurosurgery, Istanbul 34371, Turkey.
| | - Devrimsel Harika Ertem
- University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital, Department of Neurology, Istanbul 34371, Turkey.
| | - Burak Ozdemir
- University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital, Department of Neurosurgery, Istanbul 34371, Turkey.
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25
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Li J, Zhang P, Wu S, Yi X, Wang C, Liu M. Factors associated with favourable outcome in large hemispheric infarctions. BMC Neurol 2018; 18:152. [PMID: 30236075 PMCID: PMC6149207 DOI: 10.1186/s12883-018-1148-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/07/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Large hemispheric infarction (LHI) is a devastating condition with high mortality and poor functional outcome in most conservatively treated patients. The purpose of this study was to explore factors associated with favorable outcome in patients with LHI. METHODS We prospectively enrolled consecutive patients with LHI. Favorable outcome was defined as a modified Rankin Scale (mRS) score of 0 to 3 at 90 days. Multivariate logistic regression analysis was employed to identify the independent factors associated with favorable outcome. RESULTS Two hundred fifty-six cases with LHI were identified: 41 (16.0%) died during hospitalization, 94 (36.7%) died at 3 month, and 113 (44.1%) survived with favorable outcome at day 90. Compared with patients with unfavorable outcome, the favorable cases were younger (55.8 ± 14.7 vs. 66.2 ± 14.1), had less history of hypertension (38.9% vs. 59.3%), lower baseline NIHSS score (median NIHSS score 11 vs. 17), lower blood pressure on admission (systolic 134.7 ± 24.9 vs. 145.1 ± 26.1 mmHg; diastolic 80.2 ± 14.9 vs. 86.9 ± 16.2 mmHg; respectively), lower level of baseline serum glucose (7.2 ± 3.3 vs. 8.2 ± 3.3 mmol/L), a lower frequency of stroke-related complications (55.8% vs. 91.4%), more use of antiplatelets (93.8% vs. 57.1%) and statins (46.9% vs. 25.7%) in the acute phase of stroke, but less use of osmotic agents (69.9% vs. 89.3%), mechanical ventilation (1.8% vs. 20.0%) or decompressive hemicraniectomy (1.8% vs. 15.7%). Multivariable analysis identified the following factors associated with favorable outcome: age (odds ratio, OR 0.95, 95% confidence interval [CI] 0.92-0.98, p < 0.001), baseline NIHSS score (OR 0.90, 95% CI 0.84-0.96, p = 0.002), statins used in acute phase (OR 2.49, 95% CI 1.10-5.65, p = 0.029), brain edema (OR 0.05, 95% CI 0.01-0.21, p < 0.001) and pneumonia (OR 0.42, 95% CI 0.19-0.93, p = 0.032). CONCLUSION More than one third of patients with LHI have relatively favorable clinical outcomes at 90 days. Younger age, lower baseline NIHSS score, absence of brain edema and pneumonia, and statins used in the acute phase were associated with favorable outcome of patients with LHI at 90 days.
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Affiliation(s)
- Jie Li
- Department of Neurology, People's Hospital of Deyang City, No.173, North Taishan Road, Deyang, 618000, Sichuan Province, People's Republic of China
| | - Ping Zhang
- Department of Neurology, People's Hospital of Deyang City, No.173, North Taishan Road, Deyang, 618000, Sichuan Province, People's Republic of China
| | - Simiao Wu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, No. 37, GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Xingyang Yi
- Department of Neurology, People's Hospital of Deyang City, No.173, North Taishan Road, Deyang, 618000, Sichuan Province, People's Republic of China
| | - Chun Wang
- Department of Neurology, People's Hospital of Deyang City, No.173, North Taishan Road, Deyang, 618000, Sichuan Province, People's Republic of China.
| | - Ming Liu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, No. 37, GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China.
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27
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Hayat TTA, Myers MA, Hell J, Cordingly M, Bulters DO, Weir N, Pengas G. The Wessex modified Richmond Sedation Scale as a novel tool for monitoring patients at risk of malignant MCA syndrome. Acta Neurochir (Wien) 2018; 160:1115-1119. [PMID: 29644406 DOI: 10.1007/s00701-018-3531-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 04/04/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND The Wessex Modified Richmond Sedation Scale (WMRSS) has been developed with the aim of improving the early identification of patients requiring decompressive hemicraniectomy for malignant middle cerebral artery syndrome (MMS). The objective of this study was to evaluate the WMRSS against the Glasgow Coma Scale (GCS). METHODS A retrospective study was conducted of patients admitted to our unit for observation of MMS. Data were obtained on WMRSS and GCS recordings from admission up to 120-h post-ictus. Patients' meeting inclusion criteria were recommended for theatre based on subsequent deteriorations in consciousness on either WMRSS or GCS from a 6-h post-stroke baseline, after ruling out non-neurological causes. RESULTS Approximately, 60% of those eligible for monitoring were not recommended for theatre, and none died; however, these patients continued to demonstrate some variability in recorded conscious level. Patients requiring surgical intervention showed earlier drops in WMRSS compared to GCS. Neither the GCS nor the WMRSS on admission predicted the subsequent need for decompressive surgery. There was no increase in mortality with the introduction of WMRSS. CONCLUSIONS WMRSS adds value to monitoring MMS by indicating need for surgery prior to GCS. Early reduction in consciousness may not be sufficient for proceeding to surgical intervention, but subsequent reduction in consciousness may be a more appropriate criterion for surgery.
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28
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Zhang Z, Zhang L, Ding Y, Han Z, Ji X. Effects of Therapeutic Hypothermia Combined with Other Neuroprotective Strategies on Ischemic Stroke: Review of Evidence. Aging Dis 2018; 9:507-522. [PMID: 29896438 PMCID: PMC5988605 DOI: 10.14336/ad.2017.0628] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 06/28/2017] [Indexed: 12/19/2022] Open
Abstract
Ischemic stroke is a major cause of death and disability globally, and its incidence is increasing. The only treatment approved by the US Food and Drug Administration for acute ischemic stroke is thrombolytic treatment with recombinant tissue plasminogen activator. As an alternative, therapeutic hypothermia has shown excellent potential in preclinical and small clinical studies, but it has largely failed in large clinical studies. This has led clinicians to explore the combination of therapeutic hypothermia with other neuroprotective strategies. This review examines preclinical and clinical progress towards developing highly effective combination therapy involving hypothermia for stroke patients.
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Affiliation(s)
- Zheng Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, the First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Linlei Zhang
- Department of Neurology, the Second Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Yuchuan Ding
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Zhao Han
- Department of Neurology, the Second Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
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Yang G, Min D, Yan J, Yang M, Lin G. Protective role and mechanism of snakegourd peel against myocardial infarction in rats. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2018; 42:18-24. [PMID: 29655684 DOI: 10.1016/j.phymed.2018.03.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 11/06/2017] [Accepted: 03/07/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Injection of snakegourd peel (SP), an herb used in traditional Chinese medicine, is used to treat coronary artery disease and stable angina in China. However, its therapeutic role and mechanism of action for the treatment of myocardial infarction (MI) is not fully understood. PURPOSE The present study was designed to investigate the effect of SP on MI-induced cardiac injury and elucidate its underlying molecular mechanisms. METHODS To create an in vivo model of MI, we ligated the left coronary artery of Wistar rats. For our in vitro model of MI, we treated primary neonatal rat ventricular myocytes with hypoxia. Myocardial infarct size was measured by triphenyltetrazolium chloride (TTC) staining. Intracellular calcium concentration (Ca2+) was measured by confocal microscopy, and cardiomyocyte apoptosis was assessed by TUNEL assay. Western blot was applied to determine protein levels. RESULTS Three days post-MI, SP significantly improved MI-induced impairment of cardiac function, as indicated by increased left ventricular systolic pressure (LVSP), maximum rate of left ventricular pressure rise and fall (± dp/dt max), and decreased left ventricular end-diastolic pressure (LVEDP). In addition, SP treatment markedly reduced the infarct size and serum lactate dehydrogenase (LDH) activity; inhibited cardiomyocyte apoptosis and Caspase-3 activation both in vivo and in vitro; and decreased intracellular calcium overload, Cav1.2, phosphorylated JNK (p-JNK), and p38 MAPK (p-p38 MAPK) levels in ischemic myocardium. CONCLUSION SP alleviated cardiac ischemic injury and inhibited cardiomyocyte apoptosis by attenuating intracellular calcium overload, suppressing Caspase-3 activation, and downregulating protein expression of p-JNK and p-p38MAPK. These results suggest that SP may serve as a potential novel therapeutic drug for MI.
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Affiliation(s)
- Guanlin Yang
- Liaoning University of Traditional Chinese Medicine, Shenyang 110032, China
| | - Dongyu Min
- The Affiliated Hospital of Liaoning University of Traditional Chinese Medicine, Shenyang 110032, China
| | - Junwei Yan
- The Affiliated Hospital of Tsingtao University of Vascular Surgery, Tsingtao 266070, China
| | - Ming Yang
- The Affiliated Hospital of Tsingtao University of Intensive Care Unit, Tsingtao 266070, China
| | - Guijun Lin
- Department of Anatomy, Harbin Medical University-Daqing, Daqing, Heilongjiang 163319, China.
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Bustamante A, Giralt D, García-Berrocoso T, Rubiera M, Álvarez-Sabín J, Molina C, Serena J, Montaner J. The impact of post-stroke complications on in-hospital mortality depends on stroke severity. Eur Stroke J 2017; 2:54-63. [PMID: 31008302 PMCID: PMC6453178 DOI: 10.1177/2396987316681872] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 10/23/2016] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Controversies remain on whether post-stroke complications represent an independent predictor of poor outcome or just a reflection of stroke severity. We aimed to identify which post-stroke complications have the highest impact on in-hospital mortality by using machine learning techniques. Secondary aim was identification of patient's subgroups in which complications have the highest impact. PATIENTS AND METHODS Registro Nacional de Ictus de la Sociedad Española de Neurología is a stroke registry from 42 centers from the Spanish Neurological Society. Data from ischemic stroke patients were used to build a random forest by combining 500 classification and regression trees, to weight up the impact of baseline characteristics and post-stroke complications on in-hospital mortality. With the selected variables, a logistic regression analysis was performed to test for interactions. RESULTS 12,227 ischemic stroke patients were included. In-hospital mortality was 5.9% and median hospital stay was 7(4-10) days. Stroke severity [National Institutes of Health Stroke Scale > 10, OR = 5.54(4.55-6.99)], brain edema [OR = 18.93(14.65-24.46)], respiratory infections [OR = 3.67(3.02-4.45)] and age [OR = 2.50(2.07-3.03) for >77 years] had the highest impact on in-hospital mortality in random forest, being independently associated with in-hospital mortality. Complications have higher odds ratios in patients with baseline National Institutes of Health Stroke Scale <10. DISCUSSION Our study identified brain edema and respiratory infections as independent predictors of in-hospital mortality, rather than just markers of more severe strokes. Moreover, its impact was higher in less severe strokes, despite lower frequency. CONCLUSION Brain edema and respiratory infections were the complications with a greater impact on in-hospital mortality, with the highest impact in patients with mild strokes. Further efforts on the prediction of these complications could improve stroke outcome.
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Affiliation(s)
- Alejandro Bustamante
- Neurovascular Research Laboratory,
Institut de Recerca, Hospital Universitari Vall d’Hebron-Universitat Autónoma de
Barcelona, Spain
| | - Dolors Giralt
- Neurovascular Research Laboratory,
Institut de Recerca, Hospital Universitari Vall d’Hebron-Universitat Autónoma de
Barcelona, Spain
| | - Teresa García-Berrocoso
- Neurovascular Research Laboratory,
Institut de Recerca, Hospital Universitari Vall d’Hebron-Universitat Autónoma de
Barcelona, Spain
| | - Marta Rubiera
- Stroke Unit, Department of Neurology,
Hospital Universitari Vall d’Hebron, Spain
| | - José Álvarez-Sabín
- Stroke Unit, Department of Neurology,
Hospital Universitari Vall d’Hebron, Spain
| | - Carlos Molina
- Stroke Unit, Department of Neurology,
Hospital Universitari Vall d’Hebron, Spain
| | - Joaquín Serena
- Department of Neurology, Hospital
Universitario Dr. Josep Trueta, IdIBGi (Institut d'Investigació Biomèdica de
Girona), Spain
| | - Joan Montaner
- Neurovascular Research Laboratory,
Institut de Recerca, Hospital Universitari Vall d’Hebron-Universitat Autónoma de
Barcelona, Spain
- Stroke Unit, Department of Neurology,
Hospital Universitari Vall d’Hebron, Spain
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31
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Kamal Alam B, Bukhari AS, Assad S, Muhammad Siddique P, Ghazanfar H, Niaz MJ, Kundi M, Shah S, Siddiqui M. Functional Outcome After Decompressive Craniectomy in Patients with Dominant or Non-Dominant Malignant Middle Cerebral Infarcts. Cureus 2017; 9:e997. [PMID: 28286721 PMCID: PMC5338989 DOI: 10.7759/cureus.997] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Bilal Kamal Alam
- Department of Internal Medicine, Fairview Hospital, Cleveland Clinic, USA
| | - Ahmed S Bukhari
- Research Associate, Department of Neurology, Shifa International Hospital, Islamabad, Pakistan
| | - Salman Assad
- Department of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | | | - Haider Ghazanfar
- Department of Neurology, Shifa International Hospital, Islamabad, Pakistan
| | - Muhammad Junaid Niaz
- Department of Genito-urinary Oncology, Weill Medical College of Cornell University
| | - Maryam Kundi
- Department of Internal Medicine, Carthage Area Hospital, New York, USA
| | - Saima Shah
- Department of General Medicine, Hayatabad Medical Complex, Peshawar, Pakistan
| | - Maimoona Siddiqui
- Consultant Neurologist, Department of Neurology, Shifa International Hospital, Islamabad, Pakistan
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Brown DA, Wijdicks EFM. Decompressive craniectomy in acute brain injury. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:299-318. [PMID: 28187804 DOI: 10.1016/b978-0-444-63600-3.00016-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Decompressive surgery to reduce pressure under the skull varies from a burrhole, bone flap to removal of a large skull segment. Decompressive craniectomy is the removal of a large enough segment of skull to reduce refractory intracranial pressure and to maintain cerebral compliance for the purpose of preventing neurologic deterioration. Decompressive hemicraniectomy and bifrontal craniectomy are the most commonly performed procedures. Bifrontal craniectomy is most often utilized with generalized cerebral edema in the absence of a focal mass lesion and when there are bilateral frontal contusions. Decompressive hemicraniectomy is most commonly considered for malignant middle cerebral artery infarcts. The ethical predicament of deciding to go ahead with a major neurosurgical procedure with the purpose of avoiding brain death from displacement, but resulting in prolonged severe disability in many, are addressed. This chapter describes indications, surgical techniques, and complications. It reviews results of recent clinical trials and provides a reasonable assessment for practice.
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Affiliation(s)
- D A Brown
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - E F M Wijdicks
- Division of Critical Care Neurology, Mayo Clinic and Neurosciences Intensive Care Unit, Mayo Clinic Campus, Saint Marys Hospital, Rochester, MN, USA.
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Jeon SB, Park JC, Kwon SU, Kim YJ, Lee S, Kang DW, Kim JS. Intracranial Pressure Soon After Hemicraniectomy in Malignant Middle Cerebral Artery Infarction. J Intensive Care Med 2016; 33:310-316. [PMID: 28523953 DOI: 10.1177/0885066616675598] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Decompressive hemicraniectomy reduces secondary brain injury related to brain edema and increased intracranial pressure (ICP) in patients with malignant middle cerebral artery infarction (MMI). However, a substantial proportion of patients still die despite hemicraniectomy due to refractory brain swelling. OBJECTIVE We aim to investigate whether ICP measured immediately after hemicraniectomy may indicate decompression effects and predict survival in patients with MMI. METHODS We included 25 patients with MMI who underwent ICP monitoring and brain computed tomography within the first hour of hemicraniectomy. Midline shifts were measured as radiological surrogates of decompression. The Glasgow Coma Scale and pupillary enlargements during the first day after hemicraniectomy were assessed as clinical surrogates of decompression. Long-term survival status at 6 months was used as the final outcome. We analyzed the relationships between early ICP and findings of midline shift, Glasgow Coma Scale, pupillary enlargement, and survival. RESULTS Initial ICP was correlated with mean ICP ( P < .001) and maximal ICP ( P < .001) during the first postoperative day. Intracranial pressure was associated with midline shifts ( P = .009), lower Glasgow Coma Scale scores ( P = .025), and the pupillary enlargement ( P = .015). Sixteen (64.0%) patients survived at 6 months. In a Cox proportional hazard model, elevated ICP was associated with mortality at 6 months (hazard ratio: 1.13; 95% confidence interval: 1.03-1.24; P = .008). CONCLUSION Increase in ICP soon after hemicraniectomy was associated with midline shift, poor neurological status, and mortality in patients with MMI. Measurements of ICP soon after hemicraniectomy may permit earlier interventions as well as more refined clinical assessments.
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Affiliation(s)
- Sang-Beom Jeon
- 1 Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung Cheol Park
- 2 Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sun U Kwon
- 1 Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yeon-Jung Kim
- 1 Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seungjoo Lee
- 2 Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Wha Kang
- 1 Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong S Kim
- 1 Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Jeon SB, Kwon SU, Park JC, Lee DH, Yun SC, Kim YJ, Ahn JS, Kwun BD, Kang DW, Choi HA, Lee K, Kim JS. Reduction of Midline Shift Following Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction. J Stroke 2016; 18:328-336. [PMID: 27733025 PMCID: PMC5066438 DOI: 10.5853/jos.2016.00262] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 06/04/2016] [Accepted: 06/30/2016] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose Hemicraniectomy is a decompressive surgery used to remove a large bone flap to allow edematous brain tissue to bulge extracranially. However, early indicators of the decompressive effects of hemicraniectomy are unclear. We investigated whether reduction of midline shift following hemicraniectomy is associated with improved consciousness and survival in patients with malignant middle cerebral artery infarctions. Methods We studied 70 patients with malignant middle cerebral artery infarctions (MMI) who underwent hemicraniectomies. Midline shift was measured preoperatively and postoperatively using computed tomography (CT). Consciousness level was evaluated using the Glasgow Coma Scale on postoperative day 1. Patient survival was assessed six months after stroke onset. Results The median time interval between preoperative and postoperative CT was 8.3 hours (interquartile range, 6.1–10.2 hours). Reduction in midline shift was associated with higher postoperative Glasgow Coma Scale scores (P<0.05). Forty-three patients (61.4%) were alive at six months after the stroke. Patients with reductions in midline shifts following hemicraniectomy were more likely to be alive at six months post-stroke than those without (P<0.001). Reduction of midline shift was associated with lower mortality at six months after stroke, after adjusting for age, sex, National Institutes of Health Stroke Scale score, and preoperative midline shift (adjusted hazard ratio, 0.71; 95% confidence interval, 0.62–0.81; P<0.001). Conclusions Reduction in midline shift following hemicraniectomy was associated with improved consciousness and six-month survival in patients with MMI. Hence, it may be an early indicator of effective decompression following hemicraniectomy.
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Affiliation(s)
- Sang-Beom Jeon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok Hee Lee
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Cheol Yun
- Division of Epidemiology and Biostatistics Clinical Research Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeon-Jung Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Sung Ahn
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung-Duk Kwun
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - H Alex Choi
- Departments of Neurology and Neurosurgery, TheUniversity of Texas Medical School at Houston, Houston, Texas, USA
| | - Kiwon Lee
- Departments of Neurology and Neurosurgery, TheUniversity of Texas Medical School at Houston, Houston, Texas, USA
| | - Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Lin TK, Chen SM, Huang YC, Chen PY, Chen MC, Tsai HC, Lee TH, Chen KT, Lee MH, Yang JT, Huang KL. The Outcome Predictors of Malignant Large Infarction and the Functional Outcome of Survivors Following Decompressive Craniectomy. World Neurosurg 2016; 93:133-8. [DOI: 10.1016/j.wneu.2016.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 06/01/2016] [Accepted: 06/02/2016] [Indexed: 11/15/2022]
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Lin TC, Lee JD, Lin YH, Yuan RY, Weng HH, Huang YC, Lee M, Wu CY, Hsu HL, Hsu CY, Lee TH, Liu SJ, Chang YJ, Chang CH, Peng TI, Liou CW, Chang KC, Pan YT, Huang YC. Timing of Symptomatic Infarct Swelling Following Intravenous Thrombolysis in Acute Middle Cerebral Artery Infarction: A Case–Control Study. Clin Appl Thromb Hemost 2016; 23:814-820. [DOI: 10.1177/1076029616659693] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The risk of symptomatic infarct swelling has been reported to be higher in patients treated with recombinant tissue plasminogen activator (rt-PA). The aim of this study was to evaluate the timing of symptomatic infarct swelling after rt-PA treatment. Methods: We retrospectively analyzed 14 868 patients with acute ischemic stroke from a stroke registry databank. We recruited patients with massive middle cerebral artery (MCA) infarction and symptomatic infarct swelling and excluded those with parenchymal or symptomatic hemorrhage. Multiple linear regression and multivariate logistic regression analyses were used to estimate the impact of rt-PA on the timing of symptomatic infarct swelling. Results: A total of 23 patients with rt-PA treatment and 117 patients without rt-PA treatment were included. The rt-PA treatment group had a lower rate of coronary artery disease (8.7% vs 32.5%; P = .023), lower severity of baseline National Institutes of Health Stroke Scale score (19 vs 23; P = .014), shorter duration of infarct swelling (27.6 vs 45.4 hours; P < .001), and higher rate of hemicraniectomy surgery (65.2% vs 28.2%; P =.001) than those without rt-PA treatment. After adjusting for variables in multiple linear regression analysis, rt-PA treatment and an elevated C-reactive protein level were associated with early symptomatic infarct swelling ( P = .014 and P = .041, respectively). The rt-PA treatment was an independent factor related to early symptomatic infarct swelling within 36 hours ( P = .005; odds ratio [OR]: 5.3; confidence interval [CI]: 1.65-17.0) or 48 hours ( P = .009; OR: 16.4; CI: 2.00-134). Conclusion: Intravenous rt-PA treatment may hasten the onset of cerebral edema and subsequent cerebral herniation in large MCA territory infarction.
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Affiliation(s)
- Ting-Chun Lin
- Department of Neurology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Jiann-Der Lee
- Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University College of Medicine, Chiayi, Taiwan
| | - Ya-Hui Lin
- Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University College of Medicine, Chiayi, Taiwan
| | - Rey-Yue Yuan
- Department of Neurology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Hsu-Huei Weng
- Department of Diagnostic Radiology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University College of Medicine, Taiwan
| | - Ying-Chih Huang
- Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University College of Medicine, Chiayi, Taiwan
| | - Meng Lee
- Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University College of Medicine, Chiayi, Taiwan
| | - Chih-Ying Wu
- Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University College of Medicine, Chiayi, Taiwan
| | - Huan-Lin Hsu
- Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University College of Medicine, Chiayi, Taiwan
| | - Chia-Yu Hsu
- Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University College of Medicine, Chiayi, Taiwan
| | - Tsong-Hai Lee
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Shan-Jin Liu
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yeu-Jhy Chang
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chien-Hung Chang
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tsung-I Peng
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital at Keelung, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chia-Wei Liou
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ku-Chou Chang
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Ting Pan
- Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University College of Medicine, Chiayi, Taiwan
| | - Yen-Chu Huang
- Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University College of Medicine, Chiayi, Taiwan
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Ong CT, Wong YS, Wu CS, Su YH. Atrial fibrillation is a predictor of in-hospital mortality in ischemic stroke patients. Ther Clin Risk Manag 2016; 12:1057-64. [PMID: 27418830 PMCID: PMC4935087 DOI: 10.2147/tcrm.s105703] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND/PURPOSE In-hospital mortality rate of acute ischemic stroke patients remains between 3% and 18%. For improving the quality of stroke care, we investigated the factors that contribute to the risk of in-hospital mortality in acute ischemic stroke patients. MATERIALS AND METHODS Between January 1, 2007, and December 31, 2011, 2,556 acute ischemic stroke patients admitted to a stroke unit were included in this study. Factors such as demographic characteristics, clinical characteristics, comorbidities, and complications related to in-hospital mortality were assessed. RESULTS Of the 2,556 ischemic stroke patients, 157 received thrombolytic therapy. Eighty of the 2,556 patients (3.1%) died during hospitalization. Of the 157 patients who received thrombolytic therapy, 14 (8.9%) died during hospitalization. History of atrial fibrillation (AF, P<0.01) and stroke severity (P<0.01) were independent risk factors of in-hospital mortality. AF, stroke severity, cardioembolism stroke, and diabetes mellitus were independent risk factors of hemorrhagic transformation. Herniation and sepsis were the most common complications of stroke that were attributed to in-hospital mortality. Approximately 70% of in-hospital mortality was related to stroke severity (total middle cerebral artery occlusion with herniation, basilar artery occlusion, and hemorrhagic transformation). The other 30% of in-hospital mortality was related to sepsis, heart disease, and other complications. CONCLUSION AF is associated with higher in-hospital mortality rate than in patients without AF. For improving outcome of stroke patients, we also need to focus to reduce serious neurological or medical complications.
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Affiliation(s)
- Cheung-Ter Ong
- Department of Neurology, Chia-Yi Christian Hospital; Department of Nursing, Chung Jen Junior College of Nursing, Health Science and Management, Chiayi
| | - Yi-Sin Wong
- Department of Family Medicine, Chia-Yi Christian Hospital, Chiayi, Taiwan, Republic of China
| | - Chi-Shun Wu
- Department of Neurology, Chia-Yi Christian Hospital
| | - Yu-Hsiang Su
- Department of Neurology, Chia-Yi Christian Hospital
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Godoy D, Piñero G, Cruz-Flores S, Alcalá Cerra G, Rabinstein A. Malignant hemispheric infarction of the middle cerebral artery. Diagnostic considerations and treatment options. NEUROLOGÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.nrleng.2013.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Risk Factors for In-Hospital Mortality among Ischemic Stroke Patients in Southern Taiwan. INT J GERONTOL 2016. [DOI: 10.1016/j.ijge.2014.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Horsch AD, Dankbaar JW, Stemerdink TA, Bennink E, van Seeters T, Kappelle LJ, Hofmeijer J, de Jong HW, van der Graaf Y, Velthuis BK. Imaging Findings Associated with Space-Occupying Edema in Patients with Large Middle Cerebral Artery Infarcts. AJNR Am J Neuroradiol 2016; 37:831-7. [PMID: 26797136 DOI: 10.3174/ajnr.a4637] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 10/30/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Prominent space-occupying cerebral edema is a devastating complication occurring in some but not all patients with large MCA infarcts. It is unclear why differences in the extent of edema exist. Better knowledge of factors related to prominent edema formation could aid treatment strategies. This study aimed to identify variables associated with the development of prominent edema in patients with large MCA infarcts. MATERIALS AND METHODS From the Dutch Acute Stroke Study (DUST), 137 patients were selected with large MCA infarcts on follow-up NCCT (3 ± 2 days after stroke onset), defined as ASPECTS ≤4. Prominent edema was defined as a midline shift of ≥5 mm on follow-up. Admission patient and treatment characteristics were collected. Admission CT parameters used were ASPECTS on NCCT and CBV and MTT maps, and occlusion site, clot burden, and collaterals on CTA. Permeability on admission CTP, and day 3 recanalization and reperfusion statuses were obtained if available. Unadjusted and adjusted (age and NIHSS) odds ratios were calculated for all variables in relation to prominent edema. RESULTS Prominent edema developed in 51 patients (37%). Adjusted odds ratios for prominent edema were higher with lower ASPECTS on NCCT (adjusted odds ratio, 1.32; 95% CI, 1.13-1.55) and CBV (adjusted odds ratio, 1.26; 95% CI, 1.07-1.49), higher permeability (adjusted odds ratio, 2.35; 95% CI, 1.30-4.24), more proximal thrombus location (adjusted odds ratio, 3.40; 95% CI, 1.57-7.37), higher clot burden (adjusted odds ratio, 2.88; 95% CI, 1.11-7.45), and poor collaterals (adjusted odds ratio, 3.93; 95% CI, 1.78-8.69). CONCLUSIONS Extensive proximal occlusion, poor collaterals, and larger ischemic deficits with higher permeability play a role in the development of prominent edema in large MCA infarcts.
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Affiliation(s)
- A D Horsch
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - J W Dankbaar
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - T A Stemerdink
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - E Bennink
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - T van Seeters
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - L J Kappelle
- Neurology (L.J.K.), Utrecht Stroke Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J Hofmeijer
- Department of Neurology (J.H.), Rijnstate Hospital, Arnhem, the Netherlands
| | - H W de Jong
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - Y van der Graaf
- Julius Center for Health Sciences and Primary Care (Y.v.d.G.), Utrecht, the Netherlands
| | - B K Velthuis
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
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Wang JW, Li JP, Song YL, Tan K, Wang Y, Li T, Guo P, Li X, Wang Y, Zhao QH. Decompressive craniectomy in neurocritical care. J Clin Neurosci 2016; 27:1-7. [DOI: 10.1016/j.jocn.2015.06.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Revised: 06/16/2015] [Accepted: 06/20/2015] [Indexed: 10/22/2022]
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Bustamante A, García-Berrocoso T, Rodriguez N, Llombart V, Ribó M, Molina C, Montaner J. Ischemic stroke outcome: A review of the influence of post-stroke complications within the different scenarios of stroke care. Eur J Intern Med 2016; 29:9-21. [PMID: 26723523 DOI: 10.1016/j.ejim.2015.11.030] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 09/28/2015] [Accepted: 11/30/2015] [Indexed: 12/21/2022]
Abstract
Stroke remains one of the main causes of death and disability worldwide. The challenge of predicting stroke outcome has been traditionally assessed from a general point of view, where baseline non-modifiable factors such as age or stroke severity are considered the most relevant factors. However, after stroke occurrence, some specific complications such as hemorrhagic transformations or post stroke infections, which lead to a poor outcome, could be developed. An early prediction or identification of these circumstances, based on predictive models including clinical information, could be useful for physicians to individualize and improve stroke care. Furthermore, the addition of biological information such as blood biomarkers or genetic polymorphisms over these predictive models could improve their prognostic value. In this review, we focus on describing the different post-stroke complications that have an impact in short and long-term outcome across different time points in its natural history and on the clinical-biological information that might be useful in their prediction.
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Affiliation(s)
- Alejandro Bustamante
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain
| | - Teresa García-Berrocoso
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain
| | - Noelia Rodriguez
- Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Victor Llombart
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Carlos Molina
- Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain; Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
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Huang W, Tian SS, Hang PZ, Sun C, Guo J, Du ZM. Combination of microRNA-21 and microRNA-146a Attenuates Cardiac Dysfunction and Apoptosis During Acute Myocardial Infarction in Mice. MOLECULAR THERAPY. NUCLEIC ACIDS 2016; 5:e296. [PMID: 26978580 PMCID: PMC5014454 DOI: 10.1038/mtna.2016.12] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 01/28/2016] [Indexed: 11/28/2022]
Abstract
Recent studies have revealed the cytoprotective roles of microRNAs (miRNAs) miR-21 and miR-146a against ischemic cardiac injuries. While these studies investigated each of these miRNAs as an independent individual factor, our previous study has suggested the possible interaction between these two miRNAs. The present study was designed to investigate this possibility by evaluating the effects of miR-21 and miR-146a combination on cardiac ischemic injuries and the underlying mechanisms. MiR-21 and miR-146a synergistically decreased apoptosis under ischemia/hypoxic conditions in cardiomyocytes compared with either miR-21 or miR-146a alone. Mice coinjected with agomiR-21 and agomiR-146a had decreased infarct size, increased ejection fraction (EF), and fractional shortening (FS). These effects were greater than those induced by either of the two agomiRs. Furthermore, greater decreases in p38 mitogen-associated protein kinase phosphorylation (p-p38 MAPK) were observed with miR-21: miR-146a combination as compared to application of either of the miRNAs. These data suggest that combination of miR-21 and miR-146a has a greater protective effect against cardiac ischemia/hypoxia-induced apoptosis as compared to these miRNAs applied individually. This synergistic action is mediated by enhanced potency of inhibition of cardiomyocyte apoptosis by the miR-21—PTEN/AKT—p-p38—caspase-3 and miR-146a—TRAF6—p-p38—caspase-3 signal pathways.
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Affiliation(s)
- Wei Huang
- Institute of Clinical Pharmacology of the Second Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Shan-Shan Tian
- Institute of Clinical Pharmacology of the Second Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Peng-Zhou Hang
- Institute of Clinical Pharmacology of the Second Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Chuan Sun
- Institute of Clinical Pharmacology of the Second Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Jing Guo
- Institute of Clinical Pharmacology of the Second Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Zhi-Min Du
- Institute of Clinical Pharmacology of the Second Affiliated Hospital, Harbin Medical University, Harbin, China.,The University Key Laboratory of Drug Research, Heilongjiang Province, Harbin, China
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Neugebauer H, Wiedmann S, Jüttler E. [Survey regarding the treatment of malignant middle cerebral artery infarction in German hospitals]. DER NERVENARZT 2016; 87:426-32. [PMID: 26818024 DOI: 10.1007/s00115-016-0073-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are a variety of intensive care therapies in the treatment of malignant middle cerebral artery infarction (MMI) besides hemicraniectomy (HC), the only treatment with proven efficacy. It is, however, not known how HC and conservative treatments are utilized in German hospitals, Furthermore, data on the care-situation of patients with MMI in Germany is scarce. METHODS An anonymous questionnaire was sent to 297 neurological and 133 neurosurgical hospitals in Germany. RESULTS The Response rate was 24,7%. Most respondents indicated personal experience in the treatment of MMI (83,3%). HC is usually performed early on site (83,3%). Indication to HC is confirmed on a high level of hierarchy and profession using clinical and radiological criteria in 78,2% of hospitals. Inherent standardized treatment protocols are established in 70,8% of hospitals. Patients are treated on an intensive care unit in 74,5% of hospitals after DHC and in 42,5% of hospitals under non-surgical treatment. Intracranial pressure monitoring is not performed on a regular basis. Differing opinions were observed concerning diagnosis and treatment of MMI without recognizable consensus. CONCLUSION Basically, structural requirements for the treatment of MMI exist in the participating hospitals. Heterogeneity in the treatment of MMI is striking. The implementation of treatment protocols and adherence to guidelines are desirable steps to optimize treatment.
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Affiliation(s)
- H Neugebauer
- Klinik für Neurologie, Universitätsklinikum Ulm, Oberer Eselsberg 45, 89081, Ulm, Deutschland.
| | - S Wiedmann
- Institut für klinische Epidemiologie und Biometrie, Universitätsklinik Würzburg, Deutsches Zentrum für Herzinsuffizienz, Josef-Schneider-Str. 2/Haus D7, 97080, Würzburg, Deutschland
| | - E Jüttler
- Neurologische Klinik, Ostalb-Klinikum Aalen, Im Kälblesrain 1, 73043, Aalen, Deutschland
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Ibatullin MM, Kalinin MN, Curado AT, Khasanova DR. [Neurovisualisation predictors of malignant cerebral infarction and hemorrhagic transformation]. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:3-11. [PMID: 26120991 DOI: 10.17116/jnevro2015115323-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neuroimaging plays a central role in the assessment of patients with acute ischemic stroke. Within a few minutes, modern multimodal imaging protocols can provide one with comprehensive information about prognosis, management, and outcome of the disease, and may detect changes in the intracranial structures reflecting severity of the ischemic injury depicted by four Ps: parenchyma (of the brain), pipes (i.e., the cerebral blood vessels), penumbra, and permeability (of the blood brain barrier). In this article, we have reviewed neuroradiological predictors of malignant middle cerebral artery infarction and hemorrhagic transformation in light of the aforementioned four Ps.
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Affiliation(s)
| | | | - A T Curado
- Interregional Clinical Diagnostic Center, Kazan
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Han Z, Liu X, Luo Y, Ji X. Therapeutic hypothermia for stroke: Where to go? Exp Neurol 2015; 272:67-77. [PMID: 26057949 DOI: 10.1016/j.expneurol.2015.06.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 05/16/2015] [Accepted: 06/04/2015] [Indexed: 01/08/2023]
Abstract
Ischemic stroke is a major cause of death and long-term disability worldwide. Thrombolysis with recombinant tissue plasminogen activator is the only proven and effective treatment for acute ischemic stroke; however, therapeutic hypothermia is increasingly recognized as having a tissue-protective function and positively influencing neurological outcome, especially in cases of ischemia caused by cardiac arrest or hypoxic-ischemic encephalopathy in newborns. Yet, many aspects of hypothermia as a treatment for ischemic stroke remain unknown. Large-scale studies examining the effects of hypothermia on stroke are currently underway. This review discusses the mechanisms underlying the effect of hypothermia, as well as trends in hypothermia induction methods, methods for achieving optimal protection, side effects, and therapeutic strategies combining hypothermia with other neuroprotective treatments. Finally, outstanding issues that must be addressed before hypothermia treatment is implemented at a clinical level are also presented.
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Affiliation(s)
- Ziping Han
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Xiangrong Liu
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Yumin Luo
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100053, China
| | - Xunming Ji
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100053, China; Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing 100053, China.
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Rastogi V, Lamb DG, Williamson JB, Stead TS, Penumudi R, Bidari S, Ganti L, Heilman KM, Hedna VS. Hemispheric differences in malignant middle cerebral artery stroke. J Neurol Sci 2015; 353:20-7. [PMID: 25959980 DOI: 10.1016/j.jns.2015.04.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 04/21/2015] [Accepted: 04/23/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND We recently reported that left versus right hemisphere cerebral infarctions patients more frequently have worse outcomes. However our clinical experience led us to suspect that the incidence of malignant middle cerebral artery infarctions (MMCA) was higher in the right compared to the left hemispheric strokes. OBJECTIVE To determine whether laterality in MMCA stroke is an important determinant of stroke sequelae. METHODS A systematic search was performed for publications in PubMed using "malignant middle cerebral artery and infarction". A total of 73 relevant studies were abstracted. RESULTS MMCA laterality data were available for 2673 patients, with 1687 (63%) right hemispheric involvement, thus right being more commonly associated with MMCA (binomial test, p<0.05). While mortality rates were similar, right hemispheric MMCA (n=271) had mortality of 31% (n=85) whereas left hemispheric MMCA (n=144) had mortality of 36% (n=53), morbidity rates were worse on the right. CONCLUSION MMCA stroke appears to be more common on the right, and this laterality is also associated with significantly higher morbidity. Further prospective studies are needed to more completely understand the nature of this laterality as well as test possible new treatments to reduce mortality and morbidity associated with MMCA.
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Affiliation(s)
- Vaibhav Rastogi
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States
| | - Damon G Lamb
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States; Malcom Randall VAMC, Gainesville, FL 32608, United States
| | - John B Williamson
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States; Malcom Randall VAMC, Gainesville, FL 32608, United States
| | - Thor S Stead
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States
| | - Rachel Penumudi
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States
| | - Sharathchandra Bidari
- Department of Radiology, University of Florida College of Medicine, Gainesville, FL 32611, United States
| | - Latha Ganti
- Lake City VAMC, NF/SGVHS, Lake City, FL 32025-5808, United States
| | - Kenneth M Heilman
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States; Malcom Randall VAMC, Gainesville, FL 32608, United States
| | - Vishnumurthy S Hedna
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States.
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Wiszniewska M, Kasprzak H, Waliszek G, Woźniak B. Value of early decompressive hemicraniectomy in patients with malignant infarction in the middle cerebral artery region treated with intravenous rt-PA: A retrospective analysis of six patients. POSTEPY PSYCHIATRII I NEUROLOGII 2014. [DOI: 10.1016/j.pin.2014.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yang TW, Son S, Choi DS, Oh MK, Lee CH, Kim SK, Kang H, Park KJ, Choi NC, Kwon OY, Lim BH. Factors Affecting Acceptable Behavior Toward Decompressive Craniectomy For Malignant Middle Cerebral Artery Infarction. JOURNAL OF NEUROCRITICAL CARE 2014. [DOI: 10.18700/jnc.2014.7.1.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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50
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Raffiq MAM, Haspani MSM, Kandasamy R, Abdullah JM. Decompressive craniectomy for malignant middle cerebral artery infarction: Impact on mortality and functional outcome. Surg Neurol Int 2014; 5:102. [PMID: 25101197 PMCID: PMC4123249 DOI: 10.4103/2152-7806.135342] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Accepted: 05/13/2014] [Indexed: 12/03/2022] Open
Abstract
Background: Malignant middle cerebral artery (MCA) infarction is a devastating clinical entity affecting about 10% of stroke patients. Decompressive craniectomy has been found to reduce mortality rates and improve outcome in patients. Methods: A retrospective case review study was conducted to compare patients treated with medical therapy and decompressive surgery for malignant MCA infarction in Hospital Kuala Lumpur over a period of 5 years (from January 2007 to December 2012). A total of 125 patients were included in this study; 90 (72%) patients were treated with surgery, while 35 (28%) patients were treated with medical therapy. Outcome was assessed in terms of mortality rate at 30 days, Glasgow Outcome Score (GOS) on discharge, and modified Rankin scale (mRS) at 3 and 6 months. Results: Decompressive craniectomy resulted in a significant reduction in mortality rate at 30 days (P < 0.05) and favorable GOS outcome at discharge (P < 0.05). Good functional outcome based on mRS was seen in 48.9% of patients at 3 months and in 64.4% of patients at 6 months (P < 0.05). Factors associated with good outcome include infarct volume of less than 250 ml, midline shift of less than 10 mm, absence of additional vascular territory involvement, good preoperative Glasgow Coma Scale (GCS) score, and early surgical intervention (within 24 h) (P < 0.05). Age and dominant hemisphere infarction had no significant association with functional outcome. Conclusion: Decompressive craniectomy achieves good functional outcome in, young patients with good preoperative GCS score and favorable radiological findings treated with surgery within 24 h of ictus.
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Affiliation(s)
| | | | - Regunath Kandasamy
- Department of Neurosciences, Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Jafri Malin Abdullah
- Department of Neurosciences, Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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