1
|
Christianson D, Seaman SC, Ray E, Li L, Zanaty M, Lemoine P, Wilson G, Grimm D, Park BJ, Gold C, Andrews B, Grady S, Dlouhy K, Howard MA. The Adjustable Cranial Plate: A Novel Implant Designed to Eliminate the Need for Cranioplasty Surgery Following a Hemicraniectomy Operation. World Neurosurg 2023; 173:e306-e320. [PMID: 36804433 DOI: 10.1016/j.wneu.2023.02.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Decompressive hemicraniectomy (DHC) is performed to relieve life-threatening intracranial pressure elevations. After swelling abates, a cranioplasty is performed for mechanical integrity and cosmesis. Cranioplasty is costly with high complication rates. Prior attempts to obviate second-stage cranioplasty have been unsuccessful. The Adjustable Cranial Plate (ACP) is designed for implantation during DHC to afford maximal volumetric expansion with later repositioning without requiring a second major operation. METHODS The ACP has a mobile section held by a tripod fixation mechanism. Centrally located gears adjust the implant between the up and down positions. Cadaveric ACP implantation was performed. Virtual DHC and ACP placement were done using imaging data from 94 patients who had previously undergone DHC to corroborate our cadaveric results. Imaging analysis methods were used to calculate volumes of cranial expansion. RESULTS The ACP implantation and adjustment procedures are feasible in cadaveric testing without wound closure difficulties. Results of the cadaveric study showed total volumetric expansion achieved was 222 cm3. Results of the virtual DHC procedure showed the volume of cranial expansion achieved by removing a standardized bone flap was 132 cm3 (range, 89-171 cm3). Applied to virtual craniectomy patients, the total volume of expansion achieved with the ACP implantation operation was 222 cm3 (range, 181-263 cm3). CONCLUSIONS ACP implantation during DHC is technically feasible. It achieves a volume of cranial expansion that will accommodate that observed following survivable hemicraniectomy operations. Moving the implant from the up to the down position can easily be performed as a simple outpatient or inpatient bedside procedure, thus potentially eliminating second-stage cranioplasty procedures.
Collapse
Affiliation(s)
- David Christianson
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Scott C Seaman
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Emanuel Ray
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Luyuan Li
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mario Zanaty
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | | | - Daniel Grimm
- Karl Leibinger Medizintechnik GmbH & Co. KG, Mühlheim an der Donau, Germany
| | - Brian J Park
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Colin Gold
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Brian Andrews
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Sean Grady
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathleen Dlouhy
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
| |
Collapse
|
2
|
Krishnan R, Mays W, Elijovich L. Complications of Mechanical Thrombectomy in Acute Ischemic Stroke. Neurology 2021; 97:S115-S125. [PMID: 34785610 DOI: 10.1212/wnl.0000000000012803] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 06/23/2021] [Indexed: 01/01/2023] Open
Abstract
Multiple randomized clinical trials have supported the use of mechanical thrombectomy (MT) as standard of care in the treatment of large vessel occlusion acute ischemic stroke. Optimal outcomes depend not only on early reperfusion therapy but also on post thrombectomy care. Early recognition of post MT complications including reperfusion hemorrhage, cerebral edema and large space occupying infarcts, and access site complications can guide early initiation of lifesaving therapies that can improve neurologic outcomes. Knowledge of common complications and their management is essential for stroke neurologists and critical care providers to ensure optimal outcomes. We present a review of the available literature evaluating the common complications in patients undergoing MT with emphasis on early recognition and management.
Collapse
Affiliation(s)
- Rashi Krishnan
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - William Mays
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - Lucas Elijovich
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis.
| |
Collapse
|
3
|
Kitiş S, Çevik S, Köse KB, Baygül A, Cömert S, Ünsal ÜÜ, Papaker MG. Clinical Evaluation of Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarction using 3D Area and Volume Calculations. Ann Indian Acad Neurol 2021; 24:513-517. [PMID: 34728943 PMCID: PMC8513959 DOI: 10.4103/aian.aian_518_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/09/2020] [Accepted: 08/21/2020] [Indexed: 12/02/2022] Open
Abstract
Objective: We aimed to measure the craniectomy area using three-dimensional (3D) anatomic area and volume calculations to demonstrate that it can be an effective criterion for evaluating survival and functional outcomes of patients with malignant middle cerebral artery (MCA) infarction. Material and Methods: The patients diagnosed with malignant ischemic stroke between 2013 and 2018, for which they underwent surgery due to deterioration in their neurological function, were retrospectively reviewed. Radiological images of all patients were evaluated; total brain tissue volume, ischemic brain tissue volume, total calvarial bone area, and decompression bone area were measured using 3D anatomical area and volume calculations. Results: In total, 45 patients (27 males and 18 females) had been treated with decompressive craniectomy (DC). The removed bone area was found to be significantly related to the outcome in patients with MCA infarction. The average decompression bone area and mean bone removal rate for patients who died after DC were 112 ± 27 cm2 and 20%, whereas these values for surviving patients were 149 ± 29 cm2 and 26% (P = 0.001), respectively. At the 6-month follow-up, the average decompression bone area and mean bone removal rate for patients with severe disability were 126 ± 30 cm2 and 22.2%, whereas these values for patients without severe disability were 159 cm2 ± 26 and 28.4% (P = 0.001), respectively. Conclusion: In patients with malignant MCA infarction, the decompression area is associated with favorable functional outcomes, first, survival and second, 6-month modified Rankin scale score distribution after craniectomy.
Collapse
Affiliation(s)
- Serkan Kitiş
- Department of Neurosurgery, Bezmialem Vakıf University, Istanbul, Turkey
| | - Serdar Çevik
- Department of Neurosurgery, Memorial Şişli Hospital, Istanbul, Turkey.,Department of Physical Therapy and Rehabilitation, School of Health Sciences, Gelişim University, Istanbul, Turkey
| | - Kevser B Köse
- Department of Biomedical Engineering Department, Istanbul Medipol University, Istanbul, Turkey
| | - Arzu Baygül
- Department of Biostatistics and Medical Informatics, Koç University, Istanbul, Turkey
| | - Serhat Cömert
- Department of Neurosurgery, Yenimahalle Training and Research Hospital, Ankara, Turkey
| | - Ülkün Ü Ünsal
- Department of Neurosurgery, Manisa State Hospital, Manisa, Turkey
| | - Meliha G Papaker
- Department of Neurosurgery, Bezmialem Vakıf University, Istanbul, Turkey
| |
Collapse
|
4
|
Lammy S, Taylor A, Willetts S, St George EJ. Fifteen-Year Institutional Retrospective Case Series of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction. World Neurosurg 2020; 143:e456-e463. [PMID: 32750513 DOI: 10.1016/j.wneu.2020.07.185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/23/2020] [Accepted: 07/26/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE In the present study, we updated our previously reported case series of patients who had undergone decompressive craniectomy for malignant middle cerebral artery infarction (mMCAI) (2005-2020). To the best of our knowledge, the present case series constitutes the largest reported series from a UK neurosurgical unit of decompressive craniectomy for mMCAI. METHODS We extracted data regarding the clinical discriminators, surgical timescales, and functional outcomes of patients. RESULTS A total of 67 patients had undergone decompressive craniectomy. The 30-day mortality was 17.9% (n = 12). Of the 67 patients, 31 were male (46.3%) and 36 were female (53.7%). Their mean age was 45 years (range, 16-64 years). The mean age of the survivors was 43 years (range, 16-62 years) compared with 50 years (range, 38-64 years) for those who had died. The median ictal and preoperative Glasgow coma scale score was 14 (range, 7-15) and 8 (range, 3-15), respectively. The corresponding motor scores were 6 and 5. The mean interval from ictus to neurosurgical unit admission was 18.25 hours (range, 0.5-66 hours) and from admission to decompressive craniotomy was 7.30 hours (range, 0.5-46 hours). Of the 67 patients, 63% had undergone "early" craniectomy (<48 hours from mMCAI evolution), with 89% of these patients having undergone craniectomy <24 hours after neurosurgical unit admission. The mean maximum anteroposterior craniectomy diameter was 13.01 cm (range, 10.29-15.56 cm), and mean surface area was 94.38 cm2 (range, 74.75-132.32 cm2). Overall, 46% of patients had had a modified Rankin scale score of <3 (range, 0-6) from discharge to 12 months postoperatively. The median neurosurgical unit length of stay was 15 days (range, 6 hours to 365 days). CONCLUSIONS The findings from the present update have confirmed that local practice has remained consistent with current evidence. However, patient selection might be optimized if diffusion-weighted magnetic resonance imaging and computed tomography perfusion were used at the original middle cerebral artery infarct admission.
Collapse
Affiliation(s)
- Simon Lammy
- Department of Neurosurgery, Institute of Neurological Sciences, Glasgow, United Kingdom.
| | - Aaron Taylor
- Department of Neurosurgery, Institute of Neurological Sciences, Glasgow, United Kingdom
| | - Sarah Willetts
- Department of Neurosurgery, Institute of Neurological Sciences, Glasgow, United Kingdom
| | - Edward J St George
- Department of Neurosurgery, Institute of Neurological Sciences, Glasgow, United Kingdom
| |
Collapse
|
5
|
Das S, Mitchell P, Ross N, Whitfield PC. Decompressive Hemicraniectomy in the Treatment of Malignant Middle Cerebral Artery Infarction: A Meta-Analysis. World Neurosurg 2019; 123:8-16. [DOI: 10.1016/j.wneu.2018.11.176] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/18/2018] [Accepted: 11/19/2018] [Indexed: 11/29/2022]
|
6
|
Elsawaf A, Galhom A. Decompressive Craniotomy for Malignant Middle Cerebral Artery Infarction: Optimal Timing and Literature Review. World Neurosurg 2018; 116:e71-e78. [DOI: 10.1016/j.wneu.2018.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 04/01/2018] [Accepted: 04/02/2018] [Indexed: 10/17/2022]
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Lammy S, Fivey P, Sangra M. Decompressive craniectomy for malignant middle cerebral artery infarction in a 16-year old boy: a case report. J Med Case Rep 2016; 10:368. [PMID: 27998316 PMCID: PMC5175374 DOI: 10.1186/s13256-016-1145-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 11/17/2016] [Indexed: 11/30/2022] Open
Abstract
Background Cryptogenic stroke frequently occurs in younger patients and has a high risk of recurrence. Consequently, secondary prevention is often suboptimal as there is no known risk factor to target. This case demonstrates an unexpected finding of middle cerebral artery infarction and extensive malignant transformation in a 16-year-old boy more than a day post-admission. The lack of a proven culprit lesion makes this case even more intriguing and subsequently raises questions of cryptogenic mechanisms in the context of unrelated trauma. Case presentation A 16-year-old white boy had been stabbed in his chest but had a Glasgow Coma Scale score of 15. Over a day later he developed sudden signs and symptoms consistent with a neurological event of unknown etiology. Computed tomography demonstrated significant cerebral edema but was equivocal in its list of differentials. A computed tomography scan of his chest demonstrated no cardiac wall or vascular injury and he was transferred to our neurosurgical unit for intracranial pressure monitoring. A computed tomography angiogram revealed an unexpected finding of malignant middle cerebral artery infarction. Failure to medically manage his intracranial pressure resulted in a decompressive craniectomy less than 12-hours postictus. Despite extensive diagnostic investigations no culprit lesion was identified and no patent foramen ovale found. Since discharge he has returned to full functional status. He was the youngest patient (mean age of 43 years) out of a 10-year institutional retrospective on decompressive craniectomies for malignant middle cerebral artery infarction (n = 40) and had the singularly best Glasgow Outcome Scale score of 5. Conclusions This case highlights the preponderance of cryptogenic stroke in younger patients and its etiological elusiveness. It further demonstrates that age is predictive in terms of survival and functional outcome in the context of malignant middle cerebral artery infarction.
Collapse
Affiliation(s)
- Simon Lammy
- Neurological Surgery (Neurosurgery), Department of Neurosurgery, Institute of Neurological Sciences, 1345 Govan Road, Glasgow, G51 4TF, UK.
| | - Paul Fivey
- Neurological Surgery (Neurosurgery), Department of Neurosurgery, Institute of Neurological Sciences, 1345 Govan Road, Glasgow, G51 4TF, UK
| | - Meharpal Sangra
- Neurological Surgery (Neurosurgery), Department of Neurosurgery, Institute of Neurological Sciences, 1345 Govan Road, Glasgow, G51 4TF, UK
| |
Collapse
|
9
|
Lammy S, Al-Romhain B, Osborne L, St. George EJ. 10-Year Institutional Retrospective Case Series of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction (mMCAI). World Neurosurg 2016; 96:383-389. [PMID: 27639522 DOI: 10.1016/j.wneu.2016.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 08/31/2016] [Accepted: 09/01/2016] [Indexed: 10/21/2022]
|
10
|
Daou B, Kent AP, Montano M, Chalouhi N, Starke RM, Tjoumakaris S, Rosenwasser RH, Jabbour P. Decompressive hemicraniectomy: predictors of functional outcome in patients with ischemic stroke. J Neurosurg 2016; 124:1773-9. [DOI: 10.3171/2015.6.jns15729] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Patients presenting with large-territory ischemic strokes may develop intractable cerebral edema that puts them at risk of death unless intervention is performed. The purpose of this study was to identify predictors of outcome for decompressive hemicraniectomy (DH) in ischemic stroke.
METHODS
The authors conducted a retrospective electronic medical record review of 1624 patients from 2006 to 2014. Subjects were screened for DH secondary to ischemic stroke involving the middle cerebral artery, internal carotid artery, or both. Ninety-five individuals were identified. Univariate and multivariate analyses were performed for an array of clinical variables in relationship to functional outcome according to the modified Rankin Scale (mRS). Clinical outcome was assessed at 90 days and at the latest follow-up (mean duration 16.5 months).
RESULTS
The mean mRS score at 90 days and at the latest follow-up post-DH was 4. Good functional outcome was observed in 40% of patients at 90 days and in 48% of patient at the latest follow-up. The mortality rate at 90 days was 18% and at the last follow-up 20%. Univariate analysis identified a greater likelihood of poor functional outcome (mRS scores of 4–6) in patients with a history of stroke (OR 6.54 [95% CI1.39–30.66]; p = 0.017), peak midline shift (MLS) > 10 mm (OR 3.35 [95% CI 1.33–8.47]; p = 0.011), or a history of myocardial infarction (OR 8.95 [95% CI1.10–72.76]; p = 0.04). Multivariate analysis demonstrated elevated odds of poor functional outcome associated with a history of stroke (OR 9.14 [95% CI 1.78–47.05]; p = 0.008), MLS > 10 mm (OR 5.15 [95% CI 1.58–16.79; p = 0.007), a history of diabetes (OR 5.63 [95% CI 1.52–20.88]; p = 0.01), delayed time from onset of stroke to DH (OR 1.32 [95% CI 1.02–1.72]; p = 0.037), and evidence of pupillary dilation prior to DH (OR 4.19 [95% CI 1.06–16.51]; p = 0.04). Patients with infarction involving the dominant hemisphere had higher odds of unfavorable functional outcome at 90 days (OR 4.73 [95% CI 1.36–16.44]; p = 0.014), but at the latest follow-up, cerebral dominance was not significantly related to outcome (OR 1.63 [95% CI 0.61–4.34]; p = 0.328).
CONCLUSIONS
History of stroke, diabetes, myocardial infarction, peak MLS > 10 mm, increasing duration from onset of stroke to DH, and presence of pupillary dilation prior to intervention are associated with a worse functional outcome.
Collapse
Affiliation(s)
- Badih Daou
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia
| | - Anthony P. Kent
- 2Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - Maria Montano
- 2Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - Nohra Chalouhi
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia
| | - Robert M. Starke
- 3Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Stavropoula Tjoumakaris
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia
| | - Robert H. Rosenwasser
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia
| | - Pascal Jabbour
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia
| |
Collapse
|
11
|
Goto Y, Kumura E, Watabe T, Nakamura H, Nishino A, Koyama T, Taniwaki K, Yuguchi T, Yoshimine T. Prediction of Malignant Middle Cerebral Artery Infarction in Elderly Patients. J Stroke Cerebrovasc Dis 2016; 25:1389-95. [PMID: 27009609 DOI: 10.1016/j.jstrokecerebrovasdis.2015.12.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 12/17/2015] [Accepted: 12/27/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND We evaluated the clinical outcomes of malignant middle cerebral artery (MCA) infarction (MMI) and determined an infarcted brain volume (BV) threshold value for accurate MMI prediction in elderly patients. METHODS We analyzed 69 consecutive patients (mean, 75.6 ± 11.7) with internal carotid artery or MCA infarction within 48 hours from onset. Diffusion-weighted high-intensity volume (DHV) and BV were measured in all patients. The percentage of DHV within BV (DHV/BV ratio) was calculated to standardize the DHV difference for each individual BV. Patients were stratified based upon their MMI status and age, compared with the following: (1) MMI versus non-MMI groups and (2) age ≥75 years group versus age <75 years group, based on DHV values, DHV/BV ratio, Glasgow Coma Scale (GCS) scores on admission, and modified Rankin Scale (mRS) scores at 3 months after onset. RESULTS The MMI group (n = 14) showed significantly larger DHV values (P < .001), larger DHV/BV ratios (P < .001), lower GCS scores on admission (P < .01), and higher mRS scores at 3 months (P < .001) than the non-MMI group. The DHV threshold value predicting MMI was 102 cm(3) (sensitivity 85%, specificity 91%, P < .01) and DHV/BV threshold ratio was 7.8% (sensitivity 86%, specificity 87%, P < .01). Both the age ≥75 years group and the age <75 years group with MMI showed equally poor outcomes (mRS 5.7 ± .7 versus 5.3 ± 1.3). CONCLUSIONS DHV and DHV/BV can provide reliable information for MMI prediction in elderly patients.
Collapse
Affiliation(s)
- Yuko Goto
- Department of Neuromodulation and Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan; Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Eiji Kumura
- Department of Neurosurgery, Osaka Neurological Institute, Osaka, Japan.
| | - Tadashi Watabe
- Department of Molecular Imaging in Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hajime Nakamura
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Akio Nishino
- Department of Neurosurgery, Hanwa Memorial Hospital, Japan
| | - Takashi Koyama
- Department of Neurosurgery, Hanwa Memorial Hospital, Japan
| | | | | | - Toshiki Yoshimine
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| |
Collapse
|
12
|
Proceedings of the 2015 Autumn Meeting of the Society of British Neurological Surgeons. Br J Neurosurg 2015. [DOI: 10.3109/02688697.2015.1082855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
13
|
Nikitin AS, Krylov VV, Burov SA, Petrikov SS, Asratyan SA, Kamchatnov PR, Kemezh YV, Belkov MV, Zavalishin EE. [Dislocation syndrome in patients with severe massive ischemic stroke]. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:20-26. [PMID: 26120993 DOI: 10.17116/jnevro20151153220-26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare the severity of brain dislocation, the rate of its progression according to CT results and clinical signs of dislocation syndrome (DS) in patients with unfavorable form of massive ischemic stroke (MII). MATERIAL AND METHODS We analyzed the results of examination and treatment of 114 patients with unfavorable course of MII. Patients were stratified by the type of DS course into two groups: group 1 with unfavorable course (91 patients) and group 2 with favorable course (23 patients). Patients were compared by disease course and outcome as well as by progression rate and severity of brain dislocation. Twenty-seven patients of group 1 underwent decompressive craniectomy (DC). RESULTS All patients of group 1 had DS decompensation and, therefore DS course was assessed as unfavorable. All patients of group 1, who received only conservative treatment, died from brain dislocation. In patients treated with DC in addition to conservative treatment, the fatality rate was 48%. In this group, we singled out 3 variants of DS course: fulminant, progressive and delayed. In patients of group 2, the fatality rate was 52%. The patients died from non-cranial complications and DS course in this group was regarded as favorable. CONCLUSION In patients with unfavorable course of MII, the risk of fatal outcome from temporal-tentorial impaction is determined both by the severity and progression rate of transverse dislocation of the middle brain structures. DS in patients with unfavorable course of MII can have favorable or unfavorable course. The unfavorable course is characterized by fulminant, progressive or delayed DS progression rate. The unfavorable course of DS is an absolute indication of administration of DC.
Collapse
Affiliation(s)
| | - V V Krylov
- Evdokimov Moscow State Medical Dentistry University, Moscow; Sklifosovsky Emirgency Medicine Institute, Moscow
| | - S A Burov
- Central Clinical Military Hospital FSS, Moscow
| | - S S Petrikov
- Evdokimov Moscow State Medical Dentistry University, Moscow; Sklifosovsky Emirgency Medicine Institute, Moscow
| | | | - P R Kamchatnov
- Pirogov Russian National Research Medical University, Moscow
| | | | | | | |
Collapse
|
14
|
Hao Z, Chang X, Zhou H, Lin S, Liu M. A Cohort Study of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction: A Real-World Experience in Clinical Practice. Medicine (Baltimore) 2015; 94:e1039. [PMID: 26107675 PMCID: PMC4504625 DOI: 10.1097/md.0000000000001039] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Decompressive hemicraniectomy with malignant middle cerebral artery (MCA) infarction is effective but remains underutilized. The aim of this study was to observe the utilization of this intervention in mainland China.We included patients with malignant MCA infarction who admitted in West China Hospital between December 2007 to March 2011. The outcomes were death and favorable outcome (mRS < 4) at 1 month and 1 year. The multivariate logistic regression model was used to identify the independent predictors for outcomes.Ten percent (219/2174) of patients with acute ischemic stroke had malignant MCA infarction and 31.1% (68/219) patients meet the criteria that ≤60 years of age and the timing to hospital <48 hours after stroke onset. Of them, 18 patients (26.5%) underwent to decompressive hemicraniectomy. In total, 31 patients (14.2%) underwent the decompressive surgery. The average age was 53 ± 12 years; median NIHSS score was 21. The case fatality rate of patients in surgery group was significantly lower than those of in nonsurgery group at 1 month and 1 year follow-ups (32.3% and 38.7% vs. 51.1% and 61.2%, respectively, P < 0.05). Patients in surgery group had a higher proportion of good outcome at 1 year follow-up (32.2% vs. 13.3%, P = 0.006). After adjusting for confounders including age, sex, NIHSS score, and GCS score on admission, decompressive hemicraniectomy was an independent predictor of good outcome for 1 year (OR = 3.44, 95% CI, 1.27-9.31).This study shows better outcomes in the surgical group, which are consistent with findings in previous prospective randomized trials. However, this beneficial intervention remains underutilized in clinical settings.
Collapse
Affiliation(s)
- Zilong Hao
- From the Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (ZH, XC, HZ, ML); and Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (SL). Zilong Hao and Xueli Chang contributed equally to this study
| | | | | | | | | |
Collapse
|
15
|
van Middelaar T, Nederkoorn PJ, van der Worp HB, Stam J, Richard E. Quality of Life after Surgical Decompression for Space-Occupying Middle Cerebral Artery Infarction: Systematic Review. Int J Stroke 2014; 10:170-6. [DOI: 10.1111/ijs.12329] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 05/20/2014] [Indexed: 01/05/2023]
Abstract
Background and Purpose In patients with space-occupying middle cerebral artery infarction, surgical decompression strongly reduces risk of death and increases the chance of a favorable outcome. This comes at the expense of an increase in the risk of survival with (moderately) severe disability. We assessed quality of life, depression, and caregiver burden in these patients. Summary of Review We systematically reviewed the literature by searching MEDLINE, EMBASE, and PsycINFO up to March 2014. We included randomized controlled trials, cohort studies, case–control studies, and case series with quality of life, depression, or caregiver burden as primary or secondary outcome. Seventeen articles reporting on 459 patients were included. At final follow-up at 7 to 51 months, 1344 patients (30%) had died, and 34 (11%) were lost to follow up. Data on 291 patients were available, of whom 81 of 213 survivors (39%) achieved good functional outcome at final follow-up (modified Rankin Scale ⩽3). Mean quality of life was 46% to 67% of the best possible score when based on questionnaires or visual analogue scales. At final follow-up, 143 of 189 patients (76%) would in retrospect again choose for surgical decompression. Severe depressive symptoms were present in 14 of 113 patients (16%). Three studies investigated caregiver burden and reported substantial burden. Patients more than 60 years old had a lower quality of life in comparison with younger patients. Conclusions Most patients treated with surgical decompression for space-occupying infarction have a reasonable quality of life at long-term follow-up and are satisfied with the treatment received. Severe depressive symptoms are uncommon.
Collapse
Affiliation(s)
- Tessa van Middelaar
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Paul J. Nederkoorn
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - H. Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Stam
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Edo Richard
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
16
|
Morales-Vidal S, Schneck M, Golombieski E. Commonly asked questions in the management of perioperative stroke. Expert Rev Neurother 2014; 13:167-75. [DOI: 10.1586/ern.13.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
17
|
Shinozuka K, Dailey T, Tajiri N, Ishikawa H, Kim DW, Pabon M, Acosta S, Kaneko Y, Borlongan CV. Stem Cells for Neurovascular Repair in Stroke. ACTA ACUST UNITED AC 2012; 4:12912. [PMID: 24077523 DOI: 10.4172/2157-7633.s4-004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Stem cells exert therapeutic effects against ischemic stroke via transplantation of exogenous stem cells or stimulation of endogenous stem cells within the neurogenic niches of subventricular zone and subgranular zone, or recruited from the bone marrow through peripheral circulation. In this paper, we review the different sources of stem cells that have been tested in animal models of stroke. In addition, we discuss specific mechanisms of action, in particular neurovascular repair by endothelial progenitor cells, as key translational research for advancing the clinical applications of stem cells for ischemic stroke.
Collapse
Affiliation(s)
- Kazutaka Shinozuka
- Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, 12901 Bruce B. Downs Blvd. MDC78, Tampa, Florida 33612, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Ossi RG, Meschia JF, Barrett KM. Hospital-based management of acute ischemic stroke following intravenous thrombolysis. Expert Rev Cardiovasc Ther 2011; 9:463-72. [PMID: 21517730 DOI: 10.1586/erc.11.42] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Timely administration of proven therapies remains the primary goal in acute stroke care. Following reperfusion therapy with intravenous thrombolysis, medical and neurological complications may develop in the hospitalized patient with acute ischemic stroke. Medical complications may include deep venous thrombosis, pulmonary embolism, aspiration, systemic infections and neuropsychiatric disturbances. Neurologic complications may include symptomatic intracranial hemorrhage, cerebral edema with elevated intracranial pressure, and post-stroke seizures. Early initiation of preventative strategies and proper management of common complications may improve both short-term and long-term outcomes. Here we review evidence-based management strategies for hospitalized acute ischemic stroke patients following intravenous thrombolysis.
Collapse
Affiliation(s)
- Raid G Ossi
- Cerebrovascular Division, Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | | | | |
Collapse
|
19
|
Lukovits TG, Goddeau RP. Critical care of patients with acute ischemic and hemorrhagic stroke: update on recent evidence and international guidelines. Chest 2011; 139:694-700. [PMID: 21362658 DOI: 10.1378/chest.10-1530] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Patients with acute ischemic and hemorrhagic stroke are often managed in a critical care setting. Disturbances in BP, body temperature, and serum glucose are commonly observed but their management remains controversial. The reversal of antithrombotic medications and prognostication are especially challenging for intracerebral hemorrhages. This review highlights recent clinical trials and the recommendations found in international guidelines relevant to these topics. We aim to provide a practical and brief, yet current, review of these more problematic areas of stroke care.
Collapse
Affiliation(s)
| | - Richard P Goddeau
- Neurology Department, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| |
Collapse
|
20
|
García-Soler P, Morales Martínez A, Calvo Medina R, Milano-Manso G. [Decompressive craniectomy in a malignant cerebral infarction]. An Pediatr (Barc) 2011; 75:139-41. [PMID: 21501977 DOI: 10.1016/j.anpedi.2011.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Revised: 03/04/2011] [Accepted: 03/04/2011] [Indexed: 10/17/2022] Open
|
21
|
Liao YL, Lu CF, Sun YN, Wu CT, Lee JD, Lee ST, Wu YT. Three-dimensional reconstruction of cranial defect using active contour model and image registration. Med Biol Eng Comput 2010; 49:203-11. [DOI: 10.1007/s11517-010-0720-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Accepted: 11/20/2010] [Indexed: 10/18/2022]
|