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Haq IBI, Niantiarno FH, Arifianto MR, Nagm A, Susilo RI, Wahyuhadi J, Goto T, Ohata K. Lifesaving Decompressive Craniectomy for High Intracranial Pressure Attributed to Deep-Seated Meningioma: Emergency Management. Asian J Neurosurg 2021; 16:119-125. [PMID: 34211878 PMCID: PMC8202393 DOI: 10.4103/ajns.ajns_179_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/06/2020] [Accepted: 08/14/2020] [Indexed: 11/05/2022] Open
Abstract
Objects: As the most common intracranial extra-axial tumor among adults who tend to grow slowly with minimal clinical manifestation, the patients with meningioma could also fall in neurological emergency and even life-threatening status due to high intracranial pressure (ICP). In those circumstances, decompressive craniectomy (DC) without definitive tumor resection might offer an alternative treatment to alleviate acute increasing of ICP. The current report defines criteria for the indications of lifesaving DC for high ICP caused by deep-seated meningioma as an emergency management. Patients and Methods: This study collected the candidates from 2012 to 2018 at Dr. Soetomo General Hospital, Surabaya, Indonesia. The sample included all meningioma patients who came to our ER who fulfilled the clinical (life-threatening decrease in Glasgow Coma Scale [GCS]) and radiography (deep-seated meningioma, midline shift in brain computed tomography [CT] >0.5 cm, and diameter of tumor >4 cm or tumor that involves the temporal lobe) criteria for emergency DC as a lifesaving procedure. GCS, midline shift, tumor diameter, and volume based on CT were evaluated before DC. Immediate postoperative GCS, time to tumor resection, and Glasgow Outcome Scale (GOS) were also assessed postoperation. Results: The study enrolled 14 patients, with an average preoperative GCS being 9.29 ± 1.38, whereas the mean midline shift was 15.84 ± 7.02 mm. The average of number of tumor's diameter and volume was 5.59 ± 1.44 cm and 66.76 ± 49.44 cc, respectively. Postoperation, the average time interval between DC and definitive tumor resection surgery was 5.07 ± 3.12 days. The average immediate of GCS postoperation was 10.07 ± 2.97, and the average GOS was 3.93 ± 1.27. Conclusion: When emergency tumor resection could not be performed due to some limitation, as in developing countries, DC without tumor resection possibly offers lifesaving procedure in order to alleviate acute increasing ICP before the definitive surgical procedure is carried out. DC might also prevent a higher risk of morbidity and postoperative complications caused by peritumoral brain edema.
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Affiliation(s)
- Irwan Barlian Immadoel Haq
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Fajar Herbowo Niantiarno
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Muhammad Reza Arifianto
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Alhusain Nagm
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Osaka, Japan.,Department of Neurosurgery, Faculty of Medicine, Al-Azhar University, Nasr City, Cairo, Egypt
| | - Rahadian Indarto Susilo
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Joni Wahyuhadi
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Takeo Goto
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kenji Ohata
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Osaka, Japan
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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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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.
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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
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Acute supratentorial ischemic stroke: when surgery is mandatory. BIOMED RESEARCH INTERNATIONAL 2014; 2014:624126. [PMID: 24527453 PMCID: PMC3914548 DOI: 10.1155/2014/624126] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 12/09/2013] [Accepted: 12/11/2013] [Indexed: 11/17/2022]
Abstract
Acute occlusion of middle cerebral artery (MCA) leads to severe brain swelling and to a malignant, often fatal syndrome. The authors summarize the current knowledge about such a condition and review the main surgical issues involved. Decompressive hemicraniectomy keeps being a valid option in accurately selected patients.
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MacCallum C, Churilov L, Mitchell P, Dowling R, Yan B. Low Alberta Stroke Program Early CT Score (ASPECTS) Associated with Malignant Middle Cerebral Artery Infarction. Cerebrovasc Dis 2014; 38:39-45. [DOI: 10.1159/000363619] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 05/15/2014] [Indexed: 11/19/2022] Open
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Abstract
OBJECTIVES Treatment of acute, ischemic stroke has changed markedly during the last two decades. We review existing data for optimizing modern stroke care. RESULTS Implementation of stroke units, giving systematic treatment and observation to stroke patients, has lead to a significant reduction in death and dependency. Introduction of intravenous rt-PA (IVT) within 3 h for selected stroke patients and recent extension of the time window to 4.5 h improved the outcome even further. Still, one must consider that IVT has several limitations, such as a narrow time window and several contraindications, and the effect is modest, particularly in strokes with a large vessel occlusion. Recanalization of the occluded vessel is a major predictor for good outcome and should be set as a goal. Intra-arterial rt-PA (IAT) and the concept of bridging therapy (IVT prior to IAT or thrombectomy with a mechanical device) may improve recanalization rates and outcome. Randomized controlled trials (RCT) are available for IAT, but not for thrombectomy with devices, and we mostly have retrospective non-controlled data. The Merci- and Penumbra system are the most studied devices, for which recent studies report acceptable safety and efficacy. CONCLUSIONS Sufficiently powered RCTs to evaluate the effect of thrombectomy with mechanical devices are warranted, but as the natural course of a large vessel stroke carries a devastating prognosis, a proactive recanalization approach is justified based on today's knowledge.
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Affiliation(s)
- E Farbu
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway.
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Sobani ZA, Shamim MS, Zafar SN, Qadeer M, Bilal N, Murtaza SG, Enam SA, Bari ME. Cranioplasty after decompressive craniectomy: An institutional audit and analysis of factors related to complications. Surg Neurol Int 2011; 2:123. [PMID: 22059118 PMCID: PMC3205490 DOI: 10.4103/2152-7806.85055] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 08/15/2011] [Indexed: 11/16/2022] Open
Abstract
Background: Although a relatively simple procedure, cranioplasties have been associated with high complication rates. Keeping this in perspective, we aimed to determine the factors associated with immediate and long-term complications of cranioplasties at our institution. Methods: A retrospective review of patient records was carried out for patients having undergone reconstructive cranioplasties at our institution during the last 10 years (2001-2010). All case notes, records, and investigations were reviewed and the data were recorded in a predesigned questionnaire. Complications were recorded along with existing comorbids and measures taken for their prevention and management. Univariate and multivariate logistic regression analysis was performed to determine possible predictors of complications. Results: A total of 96 patients with a mean age of 33 + 15 years were included in the study. Of the sample, 76% (n = 73) had no comorbids. The leading primary pathology was blunt traumatic brain injuries in 46% (n = 44), followed by cerebrovascular incidents in 24% (n = 23), penetrating traumatic brain injuries in 12% (n = 11), and tumors in 10% (n = 10) of cases, with 41% (n = 39) of patients requiring multiple craniotomies. In a mean follow-up of 386 ± 615 days, complications were noted in 36.5% (n = 35) of the patients. Twenty six percent of patients (n = 25) had minor complications which included breakthrough seizures (15.6%, n = 15), subgaleal collections (3.1%, n = 3), and superficial wound infections (3.1%, n = 3), whereas major complications (10.4% n = 10) included hydrocephalus (3.1%, n = 3), transient neurological deficits (3.1%, n = 3), and osteomyelitis (2.1%, n = 2). Univariate and multivariate analysis revealed External Ventricular Drain (EVD) placement and parietal flaps to be associated with complications. This could be explained by the fact that the patients requiring EVD usually have relatively severe head injuries, increasing the possibility of hydrocephalus. Conclusion: We have found a higher risk of complications of cranioplasty in patients who had EVD placement and removal prior to their constructive surgery. We however did not find any association between risks of complications in any other studied variable. We also did not find any association between intraoperative placement of subgaleal drains and postoperative risk of subgaleal fluid collections. Overall, our results are comparable with other reported series on cranioplasties.
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Affiliation(s)
- Zain A Sobani
- Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
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Wang DZ, Nair DS, Talkad AV. Acute Decompressive Hemicraniectomy to Control High Intracranial Pressure in Patients with Malignant MCA Ischemic Strokes. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2011; 13:225-32. [PMID: 21360089 DOI: 10.1007/s11936-011-0121-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OPINION STATEMENT Malignant middle cerebral artery (MCA) infarction occurs in about 10% of all patients with supratentorial ischemic strokes. The infarction involves the entire MCA territory. Due to the consequences of severe brain edema, brain herniation, elevated intracranial pressure (ICP), and midline shift, these events carry a mortality rate of up to 80%. No clinical trials have been conducted to study the efficacy of the osmotic agents such as mannitol or hypertonic saline. Furthermore, aggressive use of such treatments may be detrimental. Surgical decompression has previously been proposed as a way to relieve the vicious cycle of malignant cerebral edema and reduced cerebral perfusion. Its use in relieving ICP is also controversial. Recently, a pooled analysis of three independent European trials has shown that decompressive hemicraniectomy is clearly beneficial in reducing mortality from large hemispheric infarctions. Although controversies still exist on its indications, surgical decompression can effectively reduce ICP, reduce mortality, and improve neurologic outcomes in selected patients with a malignant MCA stroke syndrome.
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Affiliation(s)
- David Z Wang
- INI Stroke Network, OSF Healthcare System, Department of Neurology, University of Illinois College of Medicine At Peoria, 530 NE Glen Oak Avenue, Peoria, IL, 61637, USA,
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Simard JM, Sahuquillo J, Sheth KN, Kahle KT, Walcott BP. Managing malignant cerebral infarction. Curr Treat Options Neurol 2011; 13:217-29. [PMID: 21190097 DOI: 10.1007/s11940-010-0110-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OPINION STATEMENT Managing patients with malignant cerebral infarction remains one of the foremost challenges in medicine. These patients are at high risk for progressive neurologic deterioration and death due to malignant cerebral edema, and they are best cared for in the intensive care unit of a comprehensive stroke center. Careful initial assessment of neurologic function and of findings on MRI, coupled with frequent reassessment of clinical and radiologic findings using CT or MRI are mandatory to promote the prompt initiation of treatments that will ensure the best outcome in these patients. Significant deterioration in either neurologic function or radiologic findings or both demand timely treatment using the best medical management, which may include osmotherapy (mannitol or hypertonic saline), endotracheal intubation, and mechanical ventilation. Under appropriate circumstances, decompressive craniectomy may be warranted to improve outcome or to prevent death.
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Affiliation(s)
- J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
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Tasker RC. Paediatric neurointensive care and decompressive craniectomy for malignant middle cerebral artery infarction. Dev Med Child Neurol 2011; 53:5-6. [PMID: 21171214 DOI: 10.1111/j.1469-8749.2010.03817.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Robert C Tasker
- Department of Paediatrics, Cambridge University Clinical School, Addenbrooke's Hospital, Cambridge, UK
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Current World Literature. Curr Opin Support Palliat Care 2010; 4:293-304. [DOI: 10.1097/spc.0b013e328340e983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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