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Gupta C, Wagh V. Exploring the Multifaceted Causes of Ischemic Stroke: A Narrative Review. Cureus 2023; 15:e47531. [PMID: 38021859 PMCID: PMC10664821 DOI: 10.7759/cureus.47531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Neurologists are well-versed with acute ischemic stroke, a serious public health concern. Effective acute stroke treatment is built on the rapid application of reperfusion therapy. This calls for prompt symptom recognition by the general population as well as emergency workers, proper referral to specialized stroke centers, and thorough examination and assessment by the on-site stroke team. The main goal of treatment for certain individuals is to restore blood flow to the ischemic penumbra by using intravenous thrombolysis and/or endovascular thrombectomy. Acute stroke patients must be hospitalized and continuously monitored for early neurological decline in order to avoid subsequent problems. After swiftly determining the stroke mechanism, patients can start the proper secondary preventative actions.
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Affiliation(s)
- Chirag Gupta
- Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vasant Wagh
- Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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2
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Buffagni D, Zamarron A, Melgosa I, Gutierrez-Gonzalez R. Long-term quality of life after decompressive craniectomy. Front Neurol 2023; 14:1222080. [PMID: 37564730 PMCID: PMC10410286 DOI: 10.3389/fneur.2023.1222080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/03/2023] [Indexed: 08/12/2023] Open
Abstract
Introduction This study aims to assess the quality of life (QoL) in patients who have undergone decompressive craniectomy (DC) for any pathology that has caused life-threatening intracranial hypertension. Similarly, it aims to evaluate QoL perceived by caregivers or external informants. In addition to that, the last purpose is to determine which clinical or therapeutic factors could correlate with a better QoL. Methods A single-center cross-sectional study was designed. All patients over 18 years old who underwent a supratentorial DC at our department due to intracranial hypertension of any etiology, from January 2015 to December 2021, were retrospectively selected. Patients with incomplete follow-up (under 1 year from the event or those who died) or who declined to participate in the study were excluded. QoL was assessed with SF-36 and CAVIDACE scales. The correlation between clinical and therapeutic variables and SF-36 subscales was studied with Spearman's correlation and the Mann-Whitney U-test. Results A total of 55 consecutive patients were recruited: 22 patients had died, three were missed for follow-up, and 15 declined to participate, thus 15 subjects were finally included. The mean follow-up was 47 months (IQR 21.5-67.5). A significant reduction in the "role physical" and "role emotional" subscales of SF-36 was observed compared with the general population. According to caregivers, a significant reduction was assigned to the "physical wellbeing" and "rights" domains. The "physical functioning" score was poorer in women, older patients, those with dominant hemisphere disease, those who required tracheostomy, and those with poor outcomes in the modified Rankin scale. A strong correlation was found between the QoL index at the CAVIDACE scale and the SF-36 subscales "physical functioning" and "role physical". Conclusion Most patients and caregivers reported acceptable QoL after DC due to a life-threatening disease. A significant reduction in SF- 36 subscales scores "role limitation due to physical problems" and "role limitation due to emotional problems" was referred by patients. According to caregivers' QoL perception, only 25% of the survey's participants showed low scores in the QoL index of the CAVIDACE scale. Only 26.7% of the patients showed mood disorders.
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Affiliation(s)
- Daniel Buffagni
- Department of Surgery, Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Alvaro Zamarron
- Department of Neurosurgery, Puerta de Hierro University Hospital, IDIPHISA, Madrid, Spain
| | - Isabel Melgosa
- Department of Anesthesiology, Marques de Valdecilla University Hospital, Santander, Spain
| | - Raquel Gutierrez-Gonzalez
- Department of Surgery, Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
- Department of Neurosurgery, Puerta de Hierro University Hospital, IDIPHISA, Madrid, Spain
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3
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Kumarasamy S, Garg K, Gurjar HK, Praneeth K, Meena R, Doddamani R, Kumar A, Mishra S, Tandon V, Singh P, Agrawal D. Complications of Decompressive Craniectomy: A Case-Based Review. INDIAN JOURNAL OF NEUROTRAUMA 2023. [DOI: 10.1055/s-0043-1760724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Abstract
Background Decompressive craniectomy (DC) is a frequently performed procedure to treat intracranial hypertension following traumatic brain injury (TBI) and stroke. DC is a salvage procedure that reduces mortality at the expense of severe disability and compromises the quality of life. The procedure is not without serious complications.
Methods We describe the complications following DC and its management in a case-based review in this article.
Results Complications after DC are classified as early or late complications based on the time of occurrence. Early complication includes hemorrhage, external cerebral herniation, wound complications, CSF leak/fistula, and seizures/epilepsy. Contusion expansion, new contralateral epidural, and subdural hematoma in the immediate postoperative period mandate surgical intervention. It is necessary to repeat non-contrast CT head at 24 hours and 48 hours following DC. Late complication includes subdural hygroma, hydrocephalus, syndrome of the trephined, bone resorption, and falls on the unprotected cranium. An early cranioplasty is an effective strategy to mitigate most of the late complications.
Conclusions DC can be associated with a number of complications. One should be aware of the possible complications, and timely intervention is required.
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Affiliation(s)
- Sivaraman Kumarasamy
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Kanwaljeet Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Hitesh Kumar Gurjar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Kokkula Praneeth
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Meena
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Ramesh Doddamani
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Amandeep Kumar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shashwat Mishra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Vivek Tandon
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Spreading Depolarization as a Therapeutic Target in Severe Ischemic Stroke: Physiological and Pharmacological Strategies. J Pers Med 2022; 12:jpm12091447. [PMID: 36143232 PMCID: PMC9502975 DOI: 10.3390/jpm12091447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/26/2022] [Accepted: 08/31/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Spreading depolarization (SD) occurs nearly ubiquitously in malignant hemispheric stroke (MHS) and is strongly implicated in edema progression and lesion expansion. Due to this high burden of SD after infarct, it is of great interest whether SD in MHS patients can be mitigated by physiologic or pharmacologic means and whether this intervention improves clinical outcomes. Here we describe the association between physiological variables and risk of SD in MHS patients who had undergone decompressive craniectomy and present an initial case of using ketamine to target SD in MHS. Methods: We recorded SD using subdural electrodes and time-linked with continuous physiological recordings in five subjects. We assessed physiologic variables in time bins preceding SD compared to those with no SD. Results: Using multivariable logistic regression, we found that increased ETCO2 (OR 0.772, 95% CI 0.655–0.910) and DBP (OR 0.958, 95% CI 0.941–0.991) were protective against SD, while elevated temperature (OR 2.048, 95% CI 1.442–2.909) and WBC (OR 1.113, 95% CI 1.081–1.922) were associated with increased risk of SD. In a subject with recurrent SD, ketamine at a dose of 2 mg/kg/h was found to completely inhibit SD. Conclusion: Fluctuations in physiological variables can be associated with risk of SD after MHS. Ketamine was also found to completely inhibit SD in one subject. These data suggest that use of physiological optimization strategies and/or pharmacologic therapy could inhibit SD in MHS patients, and thereby limit edema and infarct progression. Clinical trials using individualized approaches to target this novel mechanism are warranted.
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5
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Decompressive Craniectomy for Stroke: Who, When, and How. Neurol Clin 2022; 40:321-336. [DOI: 10.1016/j.ncl.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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6
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Decompressive Craniectomy for Infarction and Intracranial Hemorrhages. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00078-8] [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]
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7
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Giese H, Antritter J, Unterberg A, Beynon C. Long-Term Results of Neurological Outcome, Quality of Life, and Cosmetic Outcome After Cranioplastic Surgery: A Single Center Study of 202 Patients. Front Neurol 2021; 12:702339. [PMID: 34354667 PMCID: PMC8329417 DOI: 10.3389/fneur.2021.702339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 06/18/2021] [Indexed: 01/03/2023] Open
Abstract
Objective: An increased interest in the surgical procedures of decompressive craniectomy (DC) and subsequent cranioplasty (CP) has emerged during the last decades with specific focus on mortality and complication rates. The aim of the present study was to evaluate long-term neurological and cosmetic outcomes as well as Quality of Life (QoL) after CP surgery. Methods: We retrospectively reviewed the medical records of CP patients treated at our institution between 2004 and 2014 and performed a follow-up examination, with evaluation of neurological outcome using the modified Rankin Scale (mRS) and the Glasgow outcome scale (GOS), QoL (SF-36 and EQ-5D-3L). Furthermore, the cosmetic results after CP were analyzed. Results: A total of 202 CP-patients were included in the present study. The main indications for DC and subsequent CP were space-occupying cerebral ischemia (32%), traumatic brain injury (TBI, 26%), intracerebral or subarachnoid hemorrhage (32%) and infection (10%). During a mean follow-up period of 91.9 months 46/42.6% of patients had a favorable neurological outcome (mRS ≤ 3/GOS ≥ 4). Patients with ischemia had a significant worse outcome (mRS 4.3 ± 1.5) compared with patients after TBI (3.1 ± 2.3) and infectious diseases requiring CP (2.4 ± 2.3). The QoL analysis showed that <1/3rd of patients (31.2%) had a good QoL (SF-36) with a mean EQ-5D-VAS of 59 ± 26. Statistical analysis confirmed a significant worse QoL of ischemia patients compared to other groups whereas multivariate regression analysis showed no other factors which may had an impact on the QoL. The majority (86.5%) of patients were satisfied with the cosmetic result after CP and regression analysis showed no significant factors associated with unfavorable outcomes. Conclusion: Long-term outcome and QoL after CP were significantly influenced by the medical condition requiring DC. Early detection and evaluation of QoL after CP may improve the patient's outcome due to an immediate initiation of targeted therapies (e.g., occupational- or physiotherapy).
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Affiliation(s)
- Henrik Giese
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Jennifer Antritter
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Christopher Beynon
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
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8
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van der Worp HB, Hofmeijer J, Jüttler E, Lal A, Michel P, Santalucia P, Schönenberger S, Steiner T, Thomalla G. European Stroke Organisation (ESO) guidelines on the management of space-occupying brain infarction. Eur Stroke J 2021; 6:XC-CX. [PMID: 34414308 PMCID: PMC8370072 DOI: 10.1177/23969873211014112] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/13/2021] [Indexed: 01/29/2023] Open
Abstract
Space-occupying brain oedema is a potentially life-threatening complication in the first days after large hemispheric or cerebellar infarction. Several treatment strategies for this complication are available, but the size and quality of the scientific evidence on which these strategies are based vary considerably. The aim of this Guideline document is to assist physicians in their management decisions when treating patients with space-occupying hemispheric or cerebellar infarction. These Guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. A working group identified 13 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence-based recommendations. An expert consensus statement was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high-quality evidence to recommend surgical decompression to reduce the risk of death and to increase the chance of a favourable outcome in adult patients aged up to and including 60 years with space-occupying hemispheric infarction who can be treated within 48 hours of stroke onset, and low-quality evidence to support this treatment in older patients. There is continued uncertainty about the benefit and risks of surgical decompression in patients with space-occupying hemispheric infarction if this is done after the first 48 hours. There is also continued uncertainty about the selection of patients with space-occupying cerebellar infarction for surgical decompression or drainage of cerebrospinal fluid. These Guidelines further provide details on the management of specific subgroups of patients with space-occupying hemispheric infarction, on the value of monitoring of intracranial pressure, and on the benefits and risks of medical treatment options. We encourage new high-quality studies assessing the risks and benefits of different treatment strategies for patients with space-occupying brain infarction.
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Affiliation(s)
- H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
- Department of Clinical Neurophysiology, University of Twente, Enschede, the Netherlands
| | - Eric Jüttler
- Department of Neurology, Kliniken Ostalb, Aalen, Germany
| | - Avtar Lal
- European Stroke Organisation, Basel, Switzerland
| | - Patrik Michel
- Centre Cérébrovasculaire, Service de Neurologie, Département des Neurosciences Cliniques CHUV, Lausanne, Switzerland
| | - Paola Santalucia
- Neurology-Stroke Unit, San Giuseppe Hospital-Multimedica, Milan, Italy
| | | | - Thorsten Steiner
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Götz Thomalla
- Department of Neurology, Center for Clinical Neurosciences, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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9
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Zhang Z, He J, Wang B. Circular RNA circ_HECTD1 regulates cell injury after cerebral infarction by miR-27a-3p/FSTL1 axis. Cell Cycle 2021; 20:914-926. [PMID: 33843447 DOI: 10.1080/15384101.2021.1909885] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Cerebral infarction is a common cerebrovascular disease caused by neural cell injury, with high mortality worldwide. Circular RNAs HECT domain E3 ubiquitin-protein ligase 1 (circ_HECTD1) has been reported to be related to the oxygen-glucose deprivation/reperfusion (OGD/R)-caused neuronal damage in cerebral ischemia. This study is designed to explore the role and mechanism of circ_HECTD1 in OGD/R-induced cell injury in cerebral ischemia. Circ_HECTD1, microRNA-27a-3p (miR-27a-3p), and Follistatin-like 1 (FSTL1) level were detected by real-time quantitative polymerase chain reaction (RT-qPCR). The localization of circ_HECTD1 was analyzed by subcellular fractionation assay. Cell proliferative ability and apoptosis were assessed by 5-ethynyl-2'-deoxyuridine (EdU), 3-(4, 5-dimethyl-2-thiazolyl)-2, 5-diphenyl-2-H-tetrazolium bromide (MTT), and flow cytometry assays. The protein levels of proliferating cell nuclear antigen (PCNA), B-cell lymphoma-2 (Bcl-2), Bcl-2 related X protein (Bax), Cleaved poly-ADP-ribose polymerase (PARP), and FSTL1 were examined by western blot assay. The binding relationship between miR-27a-3p and circ_HECTD1 or FSTL1 was predicted by starbase 3.0 then verified by a dual-luciferase reporter assay. Circ_HECTD1 and FSTL1 were highly expressed, and miR-27a-3p was decreased in OGD/R-treated HT22 cells. Moreover, circ_HECTD1 knockdown could boost cell proliferative ability and repress apoptosis in OGD/R-triggered HT22 cells in vitro. Mechanical analysis discovered that circ_HECTD1 could regulate FSTL1 expression by sponging miR-27a-3p. Circ_HECTD1 deficiency could mitigate OGD/R-induced HT22 cell damage by modulating the miR-27a-3p/FSTL1 axis, providing a promising therapeutic target for cerebral infarction treatment.
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Affiliation(s)
- Zhenduo Zhang
- Department of Encephalopathy Third Ward, The First Affiliated Hospital of Henan University of CM, Zhengzhou, Henan, China
| | - Jinbo He
- Department of ICU, The First Affiliated Hospital of Henan University of CM, Zhengzhou, Henan, China
| | - Baoliang Wang
- Department of Encephalopathy Third Ward, The First Affiliated Hospital of Henan University of CM, Zhengzhou, Henan, China
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10
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Abstract
Large hemispheric infarcts occur in up to 10% of all ischemic strokes and can cause devastating disability. Significant research and clinical efforts have been made in hopes of mitigating the morbidity and mortality of this disease. Areas of interest include identifying predictors of malignant edema, optimizing medical and surgical techniques, selecting the patient population that would benefit most from decompressive hemicraniectomy, and studying the impact on quality of life of those who survive. Decompressive surgery can be a life-saving measure, and here we discuss the most up-to-date literature and provide a review on the surgical management of large hemispheric ischemic strokes.
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Affiliation(s)
- Jessica Lin
- Division of Neurocritical Care, Department of Neurology, New York University Langone Health (J.L., J.A.F.), New York, NY.,Department of Neurology, Bellevue Hospital Center (J.L.), New York, NY
| | - Jennifer A Frontera
- Division of Neurocritical Care, Department of Neurology, New York University Langone Health (J.L., J.A.F.), New York, NY
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11
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Reinink H, Jüttler E, Hacke W, Hofmeijer J, Vicaut E, Vahedi K, Slezins J, Su Y, Fan L, Kumral E, Greving JP, Algra A, Kappelle LJ, van der Worp HB, Neugebauer H. Surgical Decompression for Space-Occupying Hemispheric Infarction: A Systematic Review and Individual Patient Meta-analysis of Randomized Clinical Trials. JAMA Neurol 2021; 78:208-216. [PMID: 33044488 DOI: 10.1001/jamaneurol.2020.3745] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Importance In patients with space-occupying hemispheric infarction, surgical decompression reduces the risk of death and increases the chance of a favorable outcome. Uncertainties, however, still remain about the benefit of this treatment for specific patient groups. Objective To assess whether surgical decompression for space-occupying hemispheric infarction is associated with a reduced risk of death and an increased chance of favorable outcomes, as well as whether this association is modified by patient characteristics. Data Sources MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Stroke Trials Registry were searched from database inception to October 9, 2019, for English-language articles that reported on the results of randomized clinical trials of surgical decompression vs conservative treatment in patients with space-occupying hemispheric infarction. Study Selection Published and unpublished randomized clinical trials comparing surgical decompression with medical treatment alone were selected. Data Extraction and Synthesis Patient-level data were extracted from the trial databases according to a predefined protocol and statistical analysis plan. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and the Cochrane Collaboration's tool for assessing risk of bias were used. One-stage, mixed-effect logistic regression modeling was used for all analyses. Main Outcomes and Measures The primary outcome was a favorable outcome (modified Rankin Scale [mRS] score ≤3) at 1 year after stroke. Secondary outcomes included death, reasonable (mRS score ≤4) and excellent (mRS score ≤2) outcomes at 6 months and 1 year, and an ordinal shift analysis across all levels of the mRS. Variables for subgroup analyses were age, sex, presence of aphasia, stroke severity, time to randomization, and involved vascular territories. Results Data from 488 patients from 7 trials from 6 countries were available for analysis. The risk of bias was considered low to moderate for 6 studies. Surgical decompression was associated with a decreased chance of death (adjusted odds ratio, 0.16; 95% CI, 0.10-0.24) and increased chance of a favorable outcome (adjusted odds ratio, 2.95; 95% CI, 1.55-5.60), without evidence of heterogeneity of treatment effect across any of the prespecified subgroups. Too few patients were treated later than 48 hours after stroke onset to allow reliable conclusions in this subgroup, and the reported proportions of elderly patients reaching a favorable outcome differed considerably among studies. Conclusions and Relevance The results suggest that the benefit of surgical decompression for space-occupying hemispheric infarction is consistent across a wide range of patients. The benefit of surgery after day 2 and in elderly patients remains uncertain.
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Affiliation(s)
- Hendrik Reinink
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - Eric Jüttler
- Department of Neurology, University Hospital Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Werner Hacke
- Department of Neurology, University Hospital Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate, Arnhem, the Netherlands.,Faculty of Science and Technology, University of Twente, Enschede, the Netherlands
| | - Eric Vicaut
- Unité de Recherche Clinique, Assistance Publique-Hôpitaux de Paris, Lariboisière Hospital, Paris, France
| | - Katayoun Vahedi
- Department of Neurology, Assistance Publique-Hôpitaux de Paris, Lariboisière Hospital, Paris, France.,Neurology Centre, Ramsay-Générale de Sante, Hôpital Privé d'Antony, Antony, Paris, France
| | - Janis Slezins
- Neurosurgery Clinic, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Yingying Su
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Linlin Fan
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Emre Kumral
- Neurology Department, Medical School Hospital, Ege University, İzmir, Turkey
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center, Utrecht University, Utrecht, the Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center, Utrecht University, Utrecht, the Netherlands
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12
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Huang W, Zhou B, Li Y, Shao Y, Peng B, Jiang X, Xiang T. Effectiveness and Safety of Pressure Dressings on Reducing Subdural Effusion After Decompressive Craniectomy. Neuropsychiatr Dis Treat 2021; 17:3119-3125. [PMID: 34703231 PMCID: PMC8524178 DOI: 10.2147/ndt.s332653] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/08/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Decompressive craniectomy as a treatment is often used in the rescue treatment of critically ill patients in neurosurgery; however, there are many complications after this operation. Subdural effusion is a common complication after decompressive craniectomy. Once it occurs, it can cause further problems for the patient. Therefore, the purpose of this study was to explore the safety and effectiveness of pressure dressings for subdural effusion after decompressive craniectomy. METHODS Patients who underwent decompressive craniectomy in our hospital from January 2016 to January 2021 were included in this study, and all patients were followed up for 6 months or more. After the operation, the patients were divided into two groups according to whether they received a pressure dressing or a traditional dressing. Subdural effusion, cerebrospinal fluid leakage, hydrocephalus and other complications were compared between the two groups, and the differences in hospital duration, cost and prognosis between the two groups were analyzed. RESULTS A total of 123 patients were included in this study. Among them, 62 patients chose pressure dressings, and 61 patients chose traditional dressings. The incidence of subdural effusion in the pressure dressing group was significantly lower than that in the traditional dressing group (P<0.05). There was no difference between the two groups in cerebrospinal fluid leakage and hydrocephalus (P > 0.05). In addition, the length of hospital stay and the total cost in the pressure dressing group were significantly lower (P<0.05). CONCLUSION Pressure dressing can effectively reduce the occurrence of subdural effusion after decompressive craniectomy, and it does not increase the occurrence of other cerebrospinal fluid-related complications.
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Affiliation(s)
- Wanyong Huang
- Department of Neurosurgery, People's Hospital of Guanghan City, Guanghan City, Sichuan Province, People's Republic of China
| | - Bo Zhou
- Department of Neurosurgery, People's Hospital of Guanghan City, Guanghan City, Sichuan Province, People's Republic of China
| | - Yingwei Li
- Department of Neurosurgery, People's Hospital of Guanghan City, Guanghan City, Sichuan Province, People's Republic of China
| | - Yuansheng Shao
- Department of Neurosurgery, People's Hospital of Guanghan City, Guanghan City, Sichuan Province, People's Republic of China
| | - Bo Peng
- Department of Neurosurgery, People's Hospital of Guanghan City, Guanghan City, Sichuan Province, People's Republic of China
| | - Xianchun Jiang
- Department of Neurosurgery, People's Hospital of Guanghan City, Guanghan City, Sichuan Province, People's Republic of China
| | - Tao Xiang
- Department of Neurosurgery, People's Hospital of Guanghan City, Guanghan City, Sichuan Province, People's Republic of China
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13
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Mrosk F, Hecht N, Vajkoczy P. Decompressive hemicraniectomy in ischemic stroke. J Neurosurg Sci 2020; 65:249-258. [PMID: 33252206 DOI: 10.23736/s0390-5616.20.05103-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Malignant hemispheric stroke (MHS) is a life-threatening event, associated with high morbidity and mortality. Decompressive hemicraniectomy (DHS) is the treatment of choice to relieve the emerging space-occupying brain edema. This review details the pathophysiological and scientific background, considerations for clinical decision making, surgical treatment and impact on the patients' outcome. Although surgery reduces mortality significantly, the probability for unfavorable outcome is still high in selected cases. While former randomized controlled studies aimed for the prevention of the primary cause, the current research focuses on the treatment and prevention of secondary neurological injury.
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Affiliation(s)
- Friedrich Mrosk
- Department of Neurosurgery, Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany -
| | - Peter Vajkoczy
- Department of Neurosurgery, Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
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Hamamoto Filho PT, Gonçalves LB, Koetz NF, Silvestrin AML, Alves Júnior AC, Rocha LA, Módolo GP, de Avila MAG, Martin LC, Neugebauer H, Zanini MA, Bazan R. Long-term follow-up of patients undergoing decompressive hemicraniectomy for malignant stroke: Quality of life and caregiver's burden in a real-world setting. Clin Neurol Neurosurg 2020; 197:106168. [PMID: 32861040 DOI: 10.1016/j.clineuro.2020.106168] [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: 06/08/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND PURPOSE Decompressive hemicraniectomy is a life-saving procedure for the treatment of space-occupying middle cerebral artery infarctions (malignant stroke); however, patients may survive severely disabled. Comprehensive data on long-term sequelae outside randomized controlled trials are scarce. METHODS We retrospectively evaluated the survival rates, quality of life, ability to perform activities of daily living, and caregiver burden of 61 patients (aged from 37 to 83) who had previously undergone decompressive hemicraniectomy for malignant stroke between 2012 and 2017. RESULTS The mortality rate was higher among patients older than 60 years than among younger patients (71.0 % vs 36.7 %, p = 0.007; odds ratio 4.222, 95 % confidence interval 1.443-12.355). The mean survival time was 37.9 ± 6.0 months for 19 survivors of the younger group and 22.6 ± 5.7 months for 9 survivors of the older group. Among the 28 surviving patients, 22 (78.6 %) were interviewed, and we found that age was a determining factor for functional outcome (Barthel indices of 65.7 ± 10.6 for younger patients vs 48.0 ± 9.3 for older patients, p < 0.001), but not for quality of life. The caregiver burden was significantly correlated (R = -0.53, p < 0.01) with the severity of disability and age (R = 0.544, p = 0.011) of the patients. CONCLUSION Our findings show that the degree of impairment, as well as caregiver burden, is higher in patients older than 60 years than in younger patients.
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Affiliation(s)
- Pedro Tadao Hamamoto Filho
- UNESP - Univ Estadual Paulista, Botucatu Medical School, Department of Neurology, Psychology and Psychiatry, Brazil.
| | - Lucas Braz Gonçalves
- UNESP - Univ Estadual Paulista, Botucatu Medical School, Department of Neurology, Psychology and Psychiatry, Brazil
| | - Nicholas Falcomer Koetz
- UNESP - Univ Estadual Paulista, Botucatu Medical School, Department of Neurology, Psychology and Psychiatry, Brazil
| | | | - Aderaldo Costa Alves Júnior
- UNESP - Univ Estadual Paulista, Botucatu Medical School, Department of Neurology, Psychology and Psychiatry, Brazil
| | - Lilian Aline Rocha
- UNESP - Univ Estadual Paulista, Botucatu Medical School, Department of Neurology, Psychology and Psychiatry, Brazil
| | - Gabriel Pinheiro Módolo
- UNESP - Univ Estadual Paulista, Botucatu Medical School, Department of Neurology, Psychology and Psychiatry, Brazil
| | | | - Luis Cuadrado Martin
- UNESP - Univ Estadual Paulista, Botucatu Medical School, Department of Internal Medicine, Brazil
| | | | - Marco Antônio Zanini
- UNESP - Univ Estadual Paulista, Botucatu Medical School, Department of Neurology, Psychology and Psychiatry, Brazil
| | - Rodrigo Bazan
- UNESP - Univ Estadual Paulista, Botucatu Medical School, Department of Neurology, Psychology and Psychiatry, Brazil
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15
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Abstract
Acute ischaemic stroke is a major public health priority and will become increasingly relevant to neurologists of the future. The cornerstone of effective stroke care continues to be timely reperfusion treatment. This requires early recognition of symptoms by the public and first responders, triage to an appropriate stroke centre and efficient assessment and investigation by the attending stroke team. The aim of treatment is to achieve recanalisation and reperfusion of the ischaemic penumbra with intravenous thrombolysis and/or endovascular thrombectomy in appropriately selected patients. All patients should be admitted directly to an acute stroke unit for close monitoring for early neurological deterioration and prevention of secondary complications. Prompt investigation of the mechanism of stroke allows patients to start appropriate secondary preventative treatment. Future objectives include improving accessibility to endovascular thrombectomy, using advanced imaging to extend therapeutic windows and developing neuroprotective agents to prevent secondary neuronal damage.
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Affiliation(s)
- Robert Hurford
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Alakendu Sekhar
- Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Tom A T Hughes
- Department of Neurology, University Hospital of Wales Healthcare NHS Trust, Cardiff, UK
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
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16
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Abstract
Malignant hemispheric stroke occurs in 10% of ischemic strokes and has one of the highest mortality and morbidity rates. This stroke, also known as malignant middle cerebral artery stroke, may cause ischemia to an entire hemisphere causing edema, herniation, and death. A collaborative interdisciplinary team approach is needed to manage these complex stroke patients. The nurse plays a vital role in bedside management and support of the patient and family through this complex course of care. This article discusses malignant middle cerebral artery stroke pathophysiology, techniques to predict patients at risk for herniation, collaborative care strategies, and nursing care.
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Affiliation(s)
- Mary McKenna Guanci
- Massachusetts General Hospital, Lunder Building 6th Floor ICU, 55 Fruit St, Boston, MA 02114, USA.
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17
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Chen Q, Cao C, Gong L, Zhang Y. Health related quality of life in stroke patients and risk factors associated with patients for return to work. Medicine (Baltimore) 2019; 98:e15130. [PMID: 31008934 PMCID: PMC6494282 DOI: 10.1097/md.0000000000015130] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
To clarify dynamic change of quality of life (QOL) in patients with stroke after treatment, and to explore the predictors associated with return to work (RTW) within 48 weeks.Patients diagnosed with stroke were enrolled. All patients enrolled were asked to fill in the Short Form 36 Health Survey. For patients with stroke, SF-36 questionnaires were measured repeatedly 4 weeks after treatment. We used phone call to find out if the patient was RTW. The investigation time was 48 weeks.Patients with stroke had lower scores in terms of physiological dimensions, such as physical functional, role limitations due to physical problems, and general health (P < .001). While patients with strokes scored significantly lower in all mental dimensions including vitality, social functioning, role limitations due to emotional problems, and mental health (P < .001). After 4-weeks treatment, we found that, except for bodily pain, scores in dimensions like physical functioning, role limitations due to physical problems, and general health had increased significantly (P < .001). Multivariate logistic regression analysis was conducted, and the result showed that older age (P = .04) and singleness (P = .03) were risk factors associated with QOL improvement in stroke patients after treatment. Outcomes of stroke patients within 48 weeks were explored. The results showed that 108 out of 136 patients RTW within 48 weeks. Average days it took for patients with cerebral infarction to return to work were 77 ± 79, significantly less than patients with cerebral hemorrhage (206 ± 159 days) and patients with subarachnoid hemorrhage (117 ± 113 days, P < .001). Multivariate analysis indicated that only QOL improvement (P = .04) and subtype of stroke (P = .01) were independent factors associated with RTW within 48 weeks.QOL of stroke patients was significantly reduced. After treatments, the physiological quality of stroke patients increased, but the psychological quality remained low. In addition, patients with cerebral hemorrhage and patients with no significant improvement in QOL are independent risk factors for RTW. Therefore, for this subgroup of the population, early diagnosis, close follow-up and monitor of the psychological state should be provided to avoid the occurrence of adverse events.
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Affiliation(s)
| | - Chunni Cao
- Department of Hyperbaric Oxygen, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong Province, China
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18
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Attitudes of Nurses Toward Disability and Treatment in Space-Occupying Middle Cerebral Artery Stroke. Neurocrit Care 2019; 30:132-138. [PMID: 30073450 DOI: 10.1007/s12028-018-0586-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Attitudes toward the degree of acceptable disability and the importance of aphasia are critical in deciding on decompressive hemicraniectomy (DHC) in space-occupying middle cerebral artery stroke (SOS). The attitudes of nurses deserve strong attention, because of their close interaction with patients during acute stroke treatment. METHODS This is a multicenter survey among 627 nurses from 132 hospitals in Germany. Questions address the acceptance of disability, importance of aphasia, and the preferred treatment in the hypothetical case of SOS. RESULTS Modified Rankin Scale (mRS) scores of 1 and 2 were considered acceptable by the majority of all respondents (89.7%). A mRS of 3, 4, and 5 was considered acceptable by 60.0, 15.5, and 1.6%, respectively. DHC was indicated as the treatment of choice in 31.4%. Every third participant considered the presence of aphasia important for treatment decision (33.3%). Older respondents more often refrained from DHC, irrespective of the presence of aphasia (dominant hemisphere p = 0.001, non-dominant hemisphere p = 0.004). Differences regarding acceptable disability and treatment decision were dependent on age, sex, and having relatives with stroke. CONCLUSION Most German nurses indicate moderately severe disability after SOS not to be acceptable, without emphasizing the presence of aphasia. The results call for greater scientific efforts in order to find reliable predictors for outcome after SOS.
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Gopalakrishnan MS, Shanbhag NC, Shukla DP, Konar SK, Bhat DI, Devi BI. Complications of Decompressive Craniectomy. Front Neurol 2018; 9:977. [PMID: 30524359 PMCID: PMC6256258 DOI: 10.3389/fneur.2018.00977] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/30/2018] [Indexed: 11/13/2022] Open
Abstract
Decompressive craniectomy (DC) has become the definitive surgical procedure to manage medically intractable rise in intracranial pressure due to stroke and traumatic brain injury. With incoming evidence from recent multi-centric randomized controlled trials to support its use, we could expect a significant rise in the number of patients who undergo this procedure. Although one would argue that the procedure reduces mortality only at the expense of increasing the proportion of the severely disabled, what is not contested is that patients face the risk of a large number of complications after the operation and that can further compromise the quality of life. Decompressive craniectomy (DC), which is designed to overcome the space constraints of the Monro Kellie doctrine, perturbs the cerebral blood, and CSF flow dynamics. Resultant complications occur days to months after the surgical procedure in a time pattern that can be anticipated with advantage in managing them. New or expanding hematomas that occur within the first few days can be life-threatening and we recommend CT scans at 24 and 48 h postoperatively to detect them. Surgeons should also be mindful of the myriad manifestations of peculiar complications like the syndrome of the trephined and neurological deterioration due to paradoxical herniation which may occur many months after the decompression. A sufficiently large frontotemporoparietal craniectomy, 15 cm in diameter, increases the effectiveness of the procedure and reduces chances of external cerebral herniation. An early cranioplasty, as soon as the brain is lax, appears to be a reasonable choice to mitigate many of the late complications. Complications, their causes, consequences, and measures to manage them are described in this chapter.
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Affiliation(s)
- M S Gopalakrishnan
- Department of Neurosurgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Nagesh C Shanbhag
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Dhaval P Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Subhas K Konar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Dhananjaya I Bhat
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - B Indira Devi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India.,NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
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20
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Neugebauer H, Schnabl M, Lulé D, Heuschmann PU, Jüttler E. Attitudes of Patients and Relatives Toward Disability and Treatment in Malignant MCA Infarction. Neurocrit Care 2017; 26:311-318. [PMID: 27966092 DOI: 10.1007/s12028-016-0362-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Attitudes among patients and relatives toward the degree of acceptable disability and the importance of aphasia are critical in deciding on decompressive hemicraniectomy (DHC) in malignant middle cerebral artery infarction (MMI). However, most MMI patients are not able to communicate their will. Furthermore, attitudes of healthy individuals and relatives may not correspond to those of stroke patients. METHODS This is a multicenter survey among 355 patients and 199 relatives during treatment for acute minor or moderate severe ischemic stroke in Germany. Questions address the acceptance of disability, importance of aphasia, and the preferred treatment in the hypothetical case of future MMI. RESULTS mRS scores of 2 or better were considered acceptable by the majority of all respondents (72.9-88.1%). A mRS of 3, 4, and 5 was considered acceptable by 56.0, 24.5, and 6.8%, respectively. Except for a mRS of 1, relatives indicated each grade of disability significantly more often acceptable than patients. Differences regarding acceptable disability and treatment decision were depending on family status, housing situation, need of care, and disability. The presence of aphasia was considered important for treatment decision by both patients (46.5%) and relatives (39.2%). Older respondents more often refrained from DHC (p < 0.001). CONCLUSION In Germany, there is substantial heterogeneity in patients and relatives regarding acceptable disability, aphasia, and treatment decision in the hypothetical case of MMI. Relatives significantly overestimate the degree of disability that is acceptable to stroke patients. Further studies are warranted to determine whether differences in attitudes impact on the decision to undergo DHC.
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Affiliation(s)
- Hermann Neugebauer
- Department of Neurology, University of Ulm, Ulm, Germany.
- RKU - University and Rehabilitation Hospitals Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany.
| | - Matthias Schnabl
- Department of Trauma Surgery and Orthopedics, Community Hospital Kliniken Nordoberpfalz AG Klinikum Weiden, Weiden in der Oberpfalz, Germany
| | - Dorothée Lulé
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Peter U Heuschmann
- Institute for Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
| | - Eric Jüttler
- Department of Neurology, University of Ulm, Ulm, Germany
- Department of Neurology, Ostalb-Klinikum Aalen, Aalen, Germany
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21
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Budhdeo S, Kolias AG, Clark DJ, Chari A, Hutchinson PJ, Warburton EA. A Retrospective Cohort Study to Assess Patient and Physician Reported Outcome Measures After Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke. Cureus 2017; 9:e1237. [PMID: 28620567 PMCID: PMC5467774 DOI: 10.7759/cureus.1237] [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] [Indexed: 11/23/2022] Open
Abstract
Introduction Decompressive hemicraniectomy for malignant middle cerebral artery (MCA) infarction is known to reduce mortality. However, there are on-going concerns in terms of the quality of life in survivors. We aimed to examine the correlation between patient and physician reported outcome measures in decompressive hemicraniectomy. Patients and methods We analyzed outcomes in 21 patients who underwent decompressive hemicraniectomy for malignant MCA infarction between September 2003 and August 2013 within a regional health system. Patient and physician reported outcome measures were collected at follow-up. These were Stroke Impact Scale (SIS) Version 3, modified Rankin Scale (mRS), National Hospital Seizure Severity Scale, Headache Impact Test and Patient Health Questionnaire for depression. Results There was a good correlation between physician and patient reported outcome measures. The Spearman's rank correlation coefficient between mRS and structured SIS Version 3 was -0.887 (p < 0.001); with unstructured SIS results, the correlation coefficient was -0.663 (p = 0.001). There was no statistically significant correlation between life worth and modified Rankin Scale: r = -0.3383 (p = 0.087). Discussion Our findings of a statistically significant correlation between mRS and SIS have not previously been reported in patients with this condition. These findings provide further information to inform patient and next of kin discussions regarding outcomes from decompressive hemicraniectomy in malignant MCA infarction.
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Affiliation(s)
- Sanjay Budhdeo
- Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge
| | - Angelos G Kolias
- Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge
| | - David J Clark
- Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge
| | - Aswin Chari
- Division of Brain Sciences, Faculty of Medicine, Imperial College London
| | - Peter J Hutchinson
- Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge
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22
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Leung KY(Q, Jala S, Elliott R. Malignant middle cerebral artery infarct: A clinical case report. AUSTRALASIAN JOURNAL OF NEUROSCIENCE 2017. [DOI: 10.21307/ajon-2017-008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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23
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Abstract
Malignant cerebral edema is a potential consequence of large territory cerebral infarction, as the resultant elevation in intracranial pressure may progress to transtentorial herniation, brainstem compression, and death. In appropriate patients, decompressive hemicraniectomy (DHC) reduces mortality without increasing the risk of severe disability. However, as the foundational DHC randomized, controlled trials excluded patients greater than 60 years of age, the appropriateness of DHC in older adults remains controversial. Recent clinical trials among elderly participants, including DESTINY II, reported that DHC reduces mortality, but may leave patients with substantial morbidity. Nationwide analyses have demonstrated generalizability of such data. However, what constitutes an acceptable outcome - the perspective on quality of life after survival with substantial disability - varies between clinicians, patients, and caregivers. Consequently, quality of life measures are being increasingly incorporated into stroke research. This review summarizes the impact of DHC in space-occupying cerebral infarction, and the influence of patient age on postoperative survival, functional capacity, and quality of life-all key factors in the clinical decision process. Ultimately, these data underscore the inherent complexity in balancing scientific evidence, clinical expertise, and patient and family preference when pursuing hemicraniectomy among the elderly.
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Affiliation(s)
- Faith C Robertson
- Harvard Medical School, Boston, Massachusetts, United States of America.,Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Hormuzdiyar H Dasenbrock
- Harvard Medical School, Boston, Massachusetts, United States of America.,Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.,Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - William B Gormley
- Harvard Medical School, Boston, Massachusetts, United States of America.,Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.,Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
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24
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Braun LT, Grady KL, Kutner JS, Adler E, Berlinger N, Boss R, Butler J, Enguidanos S, Friebert S, Gardner TJ, Higgins P, Holloway R, Konig M, Meier D, Morrissey MB, Quest TE, Wiegand DL, Coombs-Lee B, Fitchett G, Gupta C, Roach WH. Palliative Care and Cardiovascular Disease and Stroke: A Policy Statement From the American Heart Association/American Stroke Association. Circulation 2016; 134:e198-225. [DOI: 10.1161/cir.0000000000000438] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The mission of the American Heart Association/American Stroke Association includes increasing access to high-quality, evidence-based care that improves patient outcomes such as health-related quality of life and is consistent with the patients’ values, preferences, and goals. Awareness of and access to palliative care interventions align with the American Heart Association/American Stroke Association mission. The purposes of this policy statement are to provide background on the importance of palliative care as it pertains to patients with advanced cardiovascular disease and stroke and their families and to make recommendations for policy decisions. Palliative care, defined as patient- and family-centered care that optimizes health-related quality of life by anticipating, preventing, and treating suffering, should be integrated into the care of all patients with advanced cardiovascular disease and stroke early in the disease trajectory. Palliative care focuses on communication, shared decision making about treatment options, advance care planning, and attention to physical, emotional, spiritual, and psychological distress with inclusion of the patient’s family and care system. Our policy recommendations address the following: reimbursement for comprehensive delivery of palliative care services for patients with advanced cardiovascular disease and stroke; strong payer-provider relationships that involve data sharing to identify patients in need of palliative care, identification of better care and payment models, and establishment of quality standards and outcome measurements; healthcare system policies for the provision of comprehensive palliative care services during hospitalization, including goals of care, treatment decisions, needs of family caregivers, and transition to other care settings; and health professional education in palliative care as part of licensure requirements.
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25
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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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26
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Patient Age and the Outcomes after Decompressive Hemicraniectomy for Stroke: A Nationwide Inpatient Sample Analysis. Neurocrit Care 2016; 25:371-383. [DOI: 10.1007/s12028-016-0287-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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27
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Streib CD, Hartman LM, Molyneaux BJ. Early decompressive craniectomy for malignant cerebral infarction: Meta-analysis and clinical decision algorithm. Neurol Clin Pract 2016; 6:433-443. [PMID: 27847685 DOI: 10.1212/cpj.0000000000000272] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Decompressive craniectomy (DC) is an aggressive life-saving surgical intervention for patients with malignant cerebral infarction (MCI). However, DC remains inconsistently and infrequently utilized, primarily due to enduring concern that increased survival occurs only at the cost of poor functional outcome. Our aim was to clarify the role of DC performed within 48 hours (early DC) for patients with MCI, including patients aged >60 years. METHODS We performed a meta-analysis of all available randomized controlled trials comparing early DC to best medical care for MCI. Studies were identified through literature searches of electronic databases including PubMed, EMBASE, and Scopus. We employed a Mantel-Haenszel fixed effects model to assess treatment effect on dichotomized modified Rankin Scale (mRS) outcomes at 12 months. RESULTS A total of 289 patients from 6 randomized controlled trials comparing early DC to best medical care were included. Early DC resulted in an increased rate of excellent outcomes, defined as mRS ≤2 (relative risk [RR] 2.81, 95% confidence interval [CI] 1.01-7.82, p = 0.047), and favorable outcomes, defined as mRS ≤3 (RR 2.06, 95% CI 1.25-3.40, p = 0.005). Early DC also increased the rate of survival with unfavorable outcomes, defined as mRS 4-5 (RR 3.03, 95% CI 1.98-4.65, p < 0.001). CONCLUSIONS Early DC increases the rate of excellent outcomes, i.e., functional independence, in addition to favorable and unfavorable outcomes; however, these findings must be interpreted within the context of patients' goals of care. We have developed a clinical decision algorithm that incorporates goals of care, which may guide consideration of early DC for MCI in clinical practice.
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Affiliation(s)
- Christopher D Streib
- Department of Neurology and UPMC Stroke Institute (CDS, BJM), Health Sciences Library System (LMH), and Department of Critical Care Medicine (BJM), University of Pittsburgh, PA. Dr. Streib is currently affiliated with the University of Minnesota, Minneapolis
| | - Linda M Hartman
- Department of Neurology and UPMC Stroke Institute (CDS, BJM), Health Sciences Library System (LMH), and Department of Critical Care Medicine (BJM), University of Pittsburgh, PA. Dr. Streib is currently affiliated with the University of Minnesota, Minneapolis
| | - Bradley J Molyneaux
- Department of Neurology and UPMC Stroke Institute (CDS, BJM), Health Sciences Library System (LMH), and Department of Critical Care Medicine (BJM), University of Pittsburgh, PA. Dr. Streib is currently affiliated with the University of Minnesota, Minneapolis
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28
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Back L, Nagaraja V, Kapur A, Eslick GD. Role of decompressive hemicraniectomy in extensive middle cerebral artery strokes: a meta-analysis of randomised trials. Intern Med J 2016; 45:711-7. [PMID: 25684396 DOI: 10.1111/imj.12724] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 02/02/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Prognosis for patients with 'malignant' or space-occupying oedema post middle cerebral artery infarct remains poor despite maximal medical therapy delivered in the intensive care setting. AIM We performed a meta-analysis to evaluate the value of surgical decompression versus medical management alone in patients suffering from malignant middle cerebral artery infarct. METHODS A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct and Web of Science. Original data was abstracted from each study and used to calculate a pooled odds ratio (OR) and 95% confidence interval (95% CI). RESULTS The overall OR for mRS 6 (death) at 6 months for decompressive surgery as compared with standard medical management revealed a statistically significant reduction with OR of 0.19 (95% CI: 0.10-0.37). The frequency of patients with mRS 2, 3 and 5 outcomes was higher in the decompressive surgery cohort; however, these outcomes did not reach statistical significance. On the other hand, the number of patients with a mRS score of 4 was significantly higher in the decompressive surgery cohort with an OR of 3.29 (95% CI: 1.76-6.13). The overall OR for mRS 6 (death) at 12 months for decompressive surgery as compared with standard medical management revealed a statistically significant reduction with OR of 0.17 (95% CI: 0.10-0.29). The frequency of patients with mRS 3 and 5 outcomes was higher in the decompressive surgery cohort; however, these outcomes did not reach statistical significance. On the other hand, the number of patients with a mRS score of 4 was significantly higher in the decompressive surgery cohort with an OR of 4.43 (95% CI: 2.27-8.66). In the long run it was also observed that the number of patients with a mRS score of 2 was significantly higher in the decompressive surgery cohort an OR of 4.51 (95% CI: 1.06-19.24). CONCLUSIONS Our results imply that surgical intervention decreased mortality of patients with fatal middle cerebral artery infarct at the expense of increasing the proportion suffering from substantial disability at the conclusion of follow up.
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Affiliation(s)
- L Back
- The Whiteley-Martin Research Centre, Discipline of Surgery, The University of Sydney, Nepean Hospital, Sydney, New South Wales, Australia
| | - V Nagaraja
- The Whiteley-Martin Research Centre, Discipline of Surgery, The University of Sydney, Nepean Hospital, Sydney, New South Wales, Australia
| | - A Kapur
- The Whiteley-Martin Research Centre, Discipline of Surgery, The University of Sydney, Nepean Hospital, Sydney, New South Wales, Australia
| | - G D Eslick
- The Whiteley-Martin Research Centre, Discipline of Surgery, The University of Sydney, Nepean Hospital, Sydney, New South Wales, Australia
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29
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Debiais S, Gaudron-Assor M, Sevin-Allouet M, de Toffol B, Lemoine M, Bonnaud I. Ethical considerations for craniectomy in malignant middle cerebral artery infarction: should we still deny our patient a life-saving procedure? Int J Stroke 2015; 10:E71. [PMID: 26404880 DOI: 10.1111/ijs.12562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Séverine Debiais
- Department of Neurology, University Hospital of Tours, Tours, France
| | | | | | - Bertrand de Toffol
- Department of Neurology, University Hospital of Tours, Tours, France.,University of Tours, Tours, France.,INSERM U930, Tours, France
| | - Mael Lemoine
- University of Tours, Tours, France.,INSERM U930, Tours, France.,IHPST, Paris, France
| | - Isabelle Bonnaud
- Department of Neurology, University Hospital of Tours, Tours, France
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van Middelaar T, Richard E, van der Worp HB, van den Munckhof P, Nieuwkerk PT, Visser MC, Stam J, Nederkoorn PJ. Quality of life after surgical decompression for a space-occupying middle cerebral artery infarct: A cohort study. BMC Neurol 2015; 15:156. [PMID: 26311142 PMCID: PMC4551524 DOI: 10.1186/s12883-015-0407-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 08/13/2015] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND In patients with a space-occupying middle cerebral artery (MCA) infarct surgical decompression reduces the risk of death, but increases the chance of survival with severe disability. We assessed quality of life (QoL), symptoms of depression, and caregiver burden at long-term follow-up. METHODS Patients treated in two academic centres between 2007 and 2012 were included. Follow-up was at least six months. Patients and caregivers were interviewed separately. QoL was assessed with a visual analogue scale and the 36-item Short-Form health survey (SF-36); depression with the Hospital Anxiety and Depression Scale; and caregiver burden with the Caregiver Strain Index. RESULTS Twenty five patients were enrolled, of whom seven had an infarct in the dominant hemisphere. After a median follow-up of 26 months (IQR 11-46) the median SF-36 mental component score was 54.4 (IQR 45-60), indicating a mental QoL comparable to that in the general population. The median SF-36 physical component score was 32.7 (IQR 22-38), indicating a worse physical QoL. Dominance of the hemisphere did not influence QoL. 79 % of patients and 65 % of caregivers would, in retrospect, again choose for surgery. 26 % of patients had signs of depression and 64 % of caregivers were substantially burdened in their daily life. CONCLUSIONS Mental QoL after surgical decompression for space-occupying MCA infarct is comparable to that in the general population, whereas physical QoL is worse. Dominance of the hemisphere did not influence QoL. The majority of caregivers experience substantial burden. Most patients and caregivers stand by their decision for hemicraniectomy.
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Affiliation(s)
- Tessa van Middelaar
- Department of Neurology, Academic Medical Center (AMC) Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Edo Richard
- Department of Neurology, Academic Medical Center (AMC) Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands.
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Academic Medical Center (AMC) Amsterdam, Amsterdam, The Netherlands.
| | - Pythia T Nieuwkerk
- Department of Medical Psychology, Academic Medical Center (AMC), Amsterdam, The Netherlands.
| | - Marieke C Visser
- Department of Neurology, VU University Medical Center (VUmc), Amsterdam, The Netherlands.
| | - Jan Stam
- Department of Neurology, Academic Medical Center (AMC) Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Paul J Nederkoorn
- Department of Neurology, Academic Medical Center (AMC) Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Maciel CB, Sheth KN. Malignant MCA Stroke: an Update on Surgical Decompression and Future Directions. Curr Atheroscler Rep 2015; 17:40. [DOI: 10.1007/s11883-015-0519-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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