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Hua X, Liu M, Wu S. Definition, prediction, prevention and management of patients with severe ischemic stroke and large infarction. Chin Med J (Engl) 2023; 136:2912-2922. [PMID: 38030579 PMCID: PMC10752492 DOI: 10.1097/cm9.0000000000002885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Indexed: 12/01/2023] Open
Abstract
ABSTRACT Severe ischemic stroke carries a high rate of disability and death. The severity of stroke is often assessed by the degree of neurological deficits or the extent of brain infarct, defined as severe stroke and large infarction, respectively. Critically severe stroke is a life-threatening condition that requires neurocritical care or neurosurgical intervention, which includes stroke with malignant brain edema, a leading cause of death during the acute phase, and stroke with severe complications of other vital systems. Early prediction of high-risk patients with critically severe stroke would inform early prevention and treatment to interrupt the malignant course to fatal status. Selected patients with severe stroke could benefit from intravenous thrombolysis and endovascular treatment in improving functional outcome. There is insufficient evidence to inform dual antiplatelet therapy and the timing of anticoagulation initiation after severe stroke. Decompressive hemicraniectomy (DHC) <48 h improves survival in patients aged <60 years with large hemispheric infarction. Studies are ongoing to provide evidence to inform more precise prediction of malignant brain edema, optimal indications for acute reperfusion therapies and neurosurgery, and the individualized management of complications and secondary prevention. We present an evidence-based review for severe ischemic stroke, with the aims of proposing operational definitions, emphasizing the importance of early prediction and prevention of the evolution to critically severe status, summarizing specialized treatment for severe stroke, and proposing directions for future research.
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Affiliation(s)
- Xing Hua
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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Lehrieder D, Müller HP, Kassubek J, Hecht N, Thomalla G, Michalski D, Gattringer T, Wartenberg KE, Schultze-Amberger J, Huttner H, Kuramatsu JB, Wunderlich S, Steiner HH, Weissenborn K, Heck S, Günther A, Schneider H, Poli S, Dohmen C, Woitzik J, Jüttler E, Neugebauer H. Large diameter hemicraniectomy does not improve long-term outcome in malignant infarction. J Neurol 2023:10.1007/s00415-023-11766-3. [PMID: 37162579 DOI: 10.1007/s00415-023-11766-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/11/2023]
Abstract
INTRODUCTION In malignant cerebral infarction decompressive hemicraniectomy has demonstrated beneficial effects, but the optimum size of hemicraniectomy is still a matter of debate. Some surgeons prefer a large-sized hemicraniectomy with a diameter of more than 14 cm (HC > 14). We investigated whether this approach is associated with reduced mortality and an improved long-term functional outcome compared to a standard hemicraniectomy with a diameter of less than 14 cm (HC ≤ 14). METHODS Patients from the DESTINY (DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY) registry who received hemicraniectomy were dichotomized according to the hemicraniectomy diameter (HC ≤ 14 cm vs. HC > 14 cm). The primary outcome was modified Rankin scale (mRS) score ≤ 4 after 12 months. Secondary outcomes were in-hospital mortality, mRS ≤ 3 and mortality after 12 months, and the rate of hemicraniectomy-related complications. The diameter of the hemicraniectomy was examined as an independent predictor of functional outcome in multivariable analyses. RESULTS Among 130 patients (32.3% female, mean (SD) age 55 (11) years), the mean hemicraniectomy diameter was 13.6 cm. 42 patients (32.3%) had HC > 14. There were no significant differences in the primary outcome and mortality by size of hemicraniectomy. Rate of complications did not differ (HC ≤ 14 27.6% vs. HC > 14 36.6%, p = 0.302). Age and infarct volume but not hemicraniectomy diameter were associated with outcome in multivariable analyses. CONCLUSION In this post-hoc analysis, large hemicraniectomy was not associated with an improved outcome or lower mortality in unselected patients with malignant middle cerebral artery infarction. Randomized trials should further examine whether individual patients could benefit from a large-sized hemicraniectomy. CLINICAL TRIAL REGISTRATION INFORMATION German Clinical Trials Register (URL: https://www.drks.de ; Unique Identifier: DRKS00000624).
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Affiliation(s)
- Dominik Lehrieder
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany.
| | | | - Jan Kassubek
- Department of Neurology, University Hospital Ulm, Ulm, Germany
| | - Nils Hecht
- Department of Neurosurgery and Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dominik Michalski
- Department of Neurology, University Hospital Leipzig, Leipzig, Germany
| | | | - Katja E Wartenberg
- Department of Neurology, University Hospital Leipzig, Leipzig, Germany
- Department of Neurology, University of Halle-Wittenberg, Halle/Saale, Germany
| | | | - Hagen Huttner
- Department of Neurology, University Hospital Giessen, Giessen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Silke Wunderlich
- Department of Neurology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | | | - Suzette Heck
- Department of Neurology, University of Munich, Ludwig Maximilian University, Munich, Germany
| | - Albrecht Günther
- Department of Neurology, University Hospital Jena, Jena, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital Dresden, Dresden, Germany
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Sven Poli
- Department of Neurology and Stroke, Eberhard-Karls University Tuebingen, Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Christian Dohmen
- Department of Neurology, University Hospital Cologne, Cologne, Germany
- Department for Neurology and Neurological Intensive Care, LVR Clinic Bonn, Bonn, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, University Hospital Oldenburg, Oldenburg, Germany
| | - Eric Jüttler
- Department of Neurology, Ostalb-Klinikum Aalen, Aalen, Germany
| | - Hermann Neugebauer
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
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Michalski D, Jungk C, Brenner T, Nusshag C, Reuß CJ, Fiedler MO, Schmitt FCF, Bernhard M, Beynon C, Weigand MA, Dietrich M. Fokus Neurologische Intensivmedizin 2021/2022. DIE ANAESTHESIOLOGIE 2022; 71:872-881. [PMID: 36125510 PMCID: PMC9486788 DOI: 10.1007/s00101-022-01196-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- D Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland.
| | - C Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - T Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
| | - C Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C J Reuß
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Stuttgart, Deutschland
| | - M O Fiedler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - F C F Schmitt
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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Kitiş S, Çevik S, Köse KB, Baygül A, Cömert S, Ünsal ÜÜ, Papaker MG. Clinical Evaluation of Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarction using 3D Area and Volume Calculations. Ann Indian Acad Neurol 2021; 24:513-517. [PMID: 34728943 PMCID: PMC8513959 DOI: 10.4103/aian.aian_518_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/09/2020] [Accepted: 08/21/2020] [Indexed: 12/02/2022] Open
Abstract
Objective: We aimed to measure the craniectomy area using three-dimensional (3D) anatomic area and volume calculations to demonstrate that it can be an effective criterion for evaluating survival and functional outcomes of patients with malignant middle cerebral artery (MCA) infarction. Material and Methods: The patients diagnosed with malignant ischemic stroke between 2013 and 2018, for which they underwent surgery due to deterioration in their neurological function, were retrospectively reviewed. Radiological images of all patients were evaluated; total brain tissue volume, ischemic brain tissue volume, total calvarial bone area, and decompression bone area were measured using 3D anatomical area and volume calculations. Results: In total, 45 patients (27 males and 18 females) had been treated with decompressive craniectomy (DC). The removed bone area was found to be significantly related to the outcome in patients with MCA infarction. The average decompression bone area and mean bone removal rate for patients who died after DC were 112 ± 27 cm2 and 20%, whereas these values for surviving patients were 149 ± 29 cm2 and 26% (P = 0.001), respectively. At the 6-month follow-up, the average decompression bone area and mean bone removal rate for patients with severe disability were 126 ± 30 cm2 and 22.2%, whereas these values for patients without severe disability were 159 cm2 ± 26 and 28.4% (P = 0.001), respectively. Conclusion: In patients with malignant MCA infarction, the decompression area is associated with favorable functional outcomes, first, survival and second, 6-month modified Rankin scale score distribution after craniectomy.
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Affiliation(s)
- Serkan Kitiş
- Department of Neurosurgery, Bezmialem Vakıf University, Istanbul, Turkey
| | - Serdar Çevik
- Department of Neurosurgery, Memorial Şişli Hospital, Istanbul, Turkey.,Department of Physical Therapy and Rehabilitation, School of Health Sciences, Gelişim University, Istanbul, Turkey
| | - Kevser B Köse
- Department of Biomedical Engineering Department, Istanbul Medipol University, Istanbul, Turkey
| | - Arzu Baygül
- Department of Biostatistics and Medical Informatics, Koç University, Istanbul, Turkey
| | - Serhat Cömert
- Department of Neurosurgery, Yenimahalle Training and Research Hospital, Ankara, Turkey
| | - Ülkün Ü Ünsal
- Department of Neurosurgery, Manisa State Hospital, Manisa, Turkey
| | - Meliha G Papaker
- Department of Neurosurgery, Bezmialem Vakıf University, Istanbul, Turkey
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Lehrieder D, Layer K, Müller HP, Rücker V, Kassubek J, Juettler E, Neugebauer H. Association of Infarct Volume Before Hemicraniectomy and Outcome After Malignant Infarction. Neurology 2021; 96:e2704-e2713. [PMID: 33875557 DOI: 10.1212/wnl.0000000000011987] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/26/2021] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo determine the impact of infarct volume before hemicraniectomy in malignant middle cerebral artery infarction (MMI) as an independent predictor for patient selection and outcome prediction, we retrospectively analyzed data of 140 patients from a prospective multi-center study.MethodsPatients from the DESTINY-Registry that underwent hemicraniectomy after ischemic infarction of >50% of the middle cerebral artery territory were included. Functional outcome according to the modified Rankin Scale (mRS) was assessed at 12 months. Unfavorable outcome was defined as mRS 4-6. Infarct size was quantified semi-automatically from computed tomography or magnetic resonance imaging before hemicraniectomy. Subgroup analyses in patients fulfilling inclusion criteria of randomized trials in younger patients (age≤60y) were predefined.ResultsAmong 140 patients with complete datasets (34% female, mean (SD) age 54 (11) years), 105 (75%) had an unfavorable outcome (mRS > 3). Mean (SD) infarct volume was 238 (63) ml. Multivariable logistic regression identified age (OR 1.08 per 1 year increase; 95%-CI 1.02-1.13; p=0.004), infarct size (OR 1.27 per 10ml increase; 95%-CI 1.12-1.44; p<0.001) and NIHSS (OR 1.10; 95%-CI 1.01-1.20; p=0.030) before hemicraniectomy as independent predictors for unfavorable outcome. Findings were reproduced in patients fulfilling inclusion criteria of randomized trials in younger patients. Infarct volume thresholds for prediction of unfavorable outcome with high specificity (94% in overall cohort and 92% in younger patients) were more than 258 ml before hemicraniectomy.ConclusionOutcome in MMI strongly depends on age and infarct size before hemicraniectomy. Standardized volumetry may be helpful in the process of decision making concerning hemicraniectomy.
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Affiliation(s)
| | | | | | - Viktoria Rücker
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg
| | - Jan Kassubek
- Department of Neurology, University Hospital of Ulm, Ulm
| | - Eric Juettler
- Department of Neurology, Ostalb-Klinikum Aalen, Aalen
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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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7
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Decompressive Hemicraniectomy in Elderly Patients With Space-Occupying Infarction (DECAP): A Prospective Observational Study. Neurocrit Care 2018; 31:97-106. [DOI: 10.1007/s12028-018-0660-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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8
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Bongiorni GT, Hockmuller MCJ, Klein C, Antunes ÁCM. Decompressive craniotomy for the treatment of malignant infarction of the middle cerebral artery: mortality and outcome. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:424-428. [PMID: 28746427 DOI: 10.1590/0004-282x20170053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 02/14/2017] [Indexed: 11/22/2022]
Abstract
Objective To assess, by Rankin scale, the functional disability of patients who had a malignant middle cerebral artery (MCA) ischemic stroke, who underwent decompressive craniotomy (DC) within the first 30 days. Methods A cross-sectional study in a University hospital. Between June 2007 and December 2014, we retrospectively analyzed the records of all patients submitted to DC due to a malignant MCA infarction. The mortality rate was defined during the hospitalization period. The modified outcome Rankin score (mRS) was measured 30 days after the procedure, for stratification of the quality of life. Results The DC mortality rate was 30% (95% CI 14.5 to 51.9) for the 20 patients reported. The mRS 30 days postoperatively was ≥ 4 [3.3 to 6] for all patients thereafter. Conclusion DC is to be considered a real alternative for the treatment of patients with a malignant ischemic MCA infarction.
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Affiliation(s)
- Gianise Toboliski Bongiorni
- Universidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Ciências Médicas - Ciência Cirúrgica, Porto Alegre RS, Brasil
| | | | - Cristini Klein
- Universidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Ciências Médicas, Porto Alegre RS, Brasil
| | - Ápio Cláudio Martins Antunes
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Serviço de Neurocirurgia, Porto Alegre RS, Brasil
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Sutherland AI, Oniscu GC. Challenges and advances in optimizing liver allografts from donation after circulatory death donors. J Nat Sci Biol Med 2016; 7:10-5. [PMID: 27003962 PMCID: PMC4780154 DOI: 10.4103/0976-9668.175017] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
In recent years, there has been a shift in the donor demographics with an increase in donation after circulatory death (DCD). Livers obtained from DCD donors are known to have poorer outcomes when compared to donors after brainstem death and currently only a small proportion of DCD livers are used. This review outlines the recent technological developments in liver DCD donation, including clinical studies using normothermic regional perfusion and extracorporal machine perfusion of livers from DCD donors.
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Affiliation(s)
| | - Gabriel C Oniscu
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
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10
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Sutherland AI, IJzermans JNM, Forsythe JLR, Dor FJMF. Kidney and liver transplantation in the elderly. Br J Surg 2015; 103:e62-72. [PMID: 26662845 DOI: 10.1002/bjs.10064] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 10/27/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transplant surgery is facing a shortage of deceased donor organs. In response, the criteria for organ donation have been extended, and an increasing number of organs from older donors are being used. For recipients, the benefits of transplantation are great, and the growing ageing population has led to increasing numbers of elderly patients being accepted for transplantation. METHODS The literature was reviewed to investigate the impact of age of donors and recipients in abdominal organ transplantation, and to highlight aspects of the fine balance in donor and recipient selection and screening, as well as allocation policies fair to young and old alike. RESULTS Overall, kidney and liver transplantation from older deceased donors have good outcomes, but are not as good as those from younger donors. Careful donor selection based on risk indices, and potentially biomarkers, special allocation schemes to match elderly donors with elderly recipients, and vigorous recipient selection, allows good outcomes with increasing age of both donors and recipients. The results of live kidney donation have been excellent for donor and recipient, and there is a trend towards inclusion of older donors. Future strategies, including personalized immunosuppression for older recipients as well as machine preservation and reconditioning of donor organs, are promising ways to improve the outcome of transplantation between older donors and older recipients. CONCLUSION Kidney and liver transplantation in the elderly is a clinical reality. Outcomes are good, but can be optimized by using strategies that modify donor risk factors and recipient co-morbidities, and personalized approaches to organ allocation and immunosuppression.
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Affiliation(s)
- A I Sutherland
- Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - J N M IJzermans
- Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - J L R Forsythe
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - F J M F Dor
- Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Giese H, Sauvigny T, Sakowitz OW, Bierschneider M, Güresir E, Henker C, Höhne J, Lindner D, Mielke D, Pannewitz R, Rohde V, Scholz M, Schuss P, Regelsberger J. German Cranial Reconstruction Registry (GCRR): protocol for a prospective, multicentre, open registry. BMJ Open 2015; 5:e009273. [PMID: 26423857 PMCID: PMC4593169 DOI: 10.1136/bmjopen-2015-009273] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Owing to increasing numbers of decompressive craniectomies in patients with malignant middle cerebral artery infarction, cranioplastic surgery becomes more relevant. However, the current literature mainly consists of retrospective single-centre (evidence class III) studies. This leads to a wide variability of technical approaches and clinical outcomes. To improve our knowledge about the key elements of cranioplasty, which may help optimising clinical treatment and long-term outcome, a prospective multicentre registry across Germany, Austria and Switzerland will be established. METHODS All patients undergoing cranioplastic surgery in participating centres will be invited to join the registry. Technical methods, materials, medical history, adverse events and clinical outcome measures, including modified Rankin scale and EQ-5D, will be assessed at several time points. Patients will be accessible to inclusion either at initial decompressive surgery or when cranioplasty is planned. Scheduled monitoring will be carried out at time of inclusion and subsequently at time of discharge, if any readmission is necessary, and at follow-up presentation. Cosmetic results and patient satisfaction will also be assessed. Collected data will be managed and statistically analysed by an independent biometric institute. The primary endpoint will be mortality, need for operative revision and neurological status at 3 months following cranioplasty. ETHICS AND DISSEMINATION Ethics approval was obtained at all participating centres. The registry will provide reliable prospective evidence on surgical techniques, used materials, adverse events and functional outcome, to optimise patient treatment. We expect this study to give new insights in the treatment of skull defects and to provide a basis for future evidence-based therapy regarding cranioplastic surgery. TRIAL REGISTRATION NUMBER This trial is indexed in the German Clinical Trials Register (DRKS-ID: DRKS00007931). The Universal Trial Number (UTN) is U1111-1168-7425.
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Affiliation(s)
- Henrik Giese
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Thomas Sauvigny
- Department of Neurological Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver W Sakowitz
- Department of Neurosurgery, Klinikum Ludwigsburg, University of Heidelberg, Ludwigsburg, Germany
| | | | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Christian Henker
- Department of Neurosurgery, University Hospital Rostock, Rostock, Germany
| | - Julius Höhne
- Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Lindner
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Robert Pannewitz
- Department of Neurosurgery, Heinrich-Heine-University, Düsseldorf, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Martin Scholz
- Department of Neurosurgery, Duisburg Medical Center, Duisburg, Germany
| | - Patrick Schuss
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Jan Regelsberger
- Department of Neurological Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Tanrikulu L, Oez-Tanrikulu A, Weiss C, Scholz T, Schiefer J, Clusmann H, Schubert G. The bigger, the better? About the size of decompressive hemicraniectomies. Clin Neurol Neurosurg 2015; 135:15-21. [DOI: 10.1016/j.clineuro.2015.04.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/02/2015] [Accepted: 04/25/2015] [Indexed: 10/23/2022]
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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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Nationwide survey of decompressive hemicraniectomy for malignant middle cerebral artery infarction in Japan. World Neurosurg 2014; 82:1158-63. [PMID: 25045787 DOI: 10.1016/j.wneu.2014.07.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 06/03/2014] [Accepted: 07/16/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Decompressive hemicraniectomy (DHC) for malignant middle cerebral artery (MCA) infarction has been shown to reduce mortality and improve functional outcomes in young adults; however, there is currently debate regarding how routinely such surgery should be performed in the clinical setting, considering the very high rate of disability and functional dependence among survivors. We herein report the current status of the frequency of and indications for DHC for malignant MCA infarction in Japan. METHODS We retrospectively studied of cohort cases of DHC for malignant MCA infarction treated at pivotal teaching neurosurgical departments in Japan between January 2011 and December 2011. Information was obtained regarding patient characteristics, radiologic features, and outcomes during follow-up. The end points included 30-day mortality rate and functional outcomes, as measured according to the modified Rankin scale (mRS) score at 3 months. RESULTS Three hundred fifty-five patients underwent DHC at 259 neurosurgical departments who replied to the survey, corresponding to a rate of 8.7% of the 4092 candidates with malignant MCA infarction, the latter being equivalent to 8.5% of patients with acute ischemic stroke identified during the same period. Among the patients undergoing DHC, the mean age was 67.0 years, and those ≥60 years of age comprised 80.2% of all DHC patients. The most frequently used modality for vascular imaging was magnetic resonance angiography (77.2%). DHC generally was performed between 24 and 48 hours after onset (38.9%), with 36.9% of patients undergoing surgery at ≥48 hours. At the time of surgery, 26.1% of the patients had a Glasgow Coma Scale score of ≤6. Presurgical midbrain compression was noted in 52.1% of the patients. The 30-day mortality after DHC was 18.6%, and factors affecting death were a Glasgow Coma Scale score of ≤6 (odds ratio [OR] 1.88, 95% confidence interval [95% CI] 1.05-3.32, P = 0.03) and midbrain compression (OR 2.28, 95% CI 1.31-4.09, P = 0.005). According to the multivariate analysis, only midbrain compression was an independent risk factor (OR 2.12, 95% CI 1.16-3.95, P = 0.01) for 30-day mortality. Modified Rankin scale scores at 3 months were available in 175 patients (49.3%), only 5.2% of whom exhibited a favorable functional outcome (mRS score ≤3). Meanwhile, 22.9% of the patients had an mRS score of 4, 26.9% had an mRS score of 5, and 45.1% were found to have died. CONCLUSIONS In the present study, less than one-tenth of candidates with malignant MCA infarction in Japan underwent decompressive surgery, and the vast majority of patients were elderly. Age was not found to be an independent factor for immediate mortality in this study, and performing surgery in the elderly may be justified based on additional evidence of functional improvements.
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Wiszniewska M, Kasprzak H, Waliszek G, Woźniak B. Value of early decompressive hemicraniectomy in patients with malignant infarction in the middle cerebral artery region treated with intravenous rt-PA: A retrospective analysis of six patients. POSTEPY PSYCHIATRII I NEUROLOGII 2014. [DOI: 10.1016/j.pin.2014.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Neugebauer H, Jüttler E. Hemicraniectomy for malignant middle cerebral artery infarction: current status and future directions. Int J Stroke 2014; 9:460-7. [PMID: 24725828 DOI: 10.1111/ijs.12211] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 09/08/2013] [Indexed: 12/01/2022]
Abstract
Malignant middle cerebral artery infarction is a life-threatening sub-type of ischemic stroke that may only be survived at the expense of permanent disability. Decompressive hemicraniectomy is an effective surgical therapy to reduce mortality and improve functional outcome without promoting most severe disability. Evidence derives from three European randomized controlled trials in patients up to 60 years. The recently finished DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY - II trial gives now high-level evidence for the effectiveness of decompressive hemicraniectomy in patients older than 60 years. Nevertheless, pressing issues persist that need to be answered in future clinical trials, e.g. the acceptable degree of disability in survivors of malignant middle cerebral artery infarction, the importance of aphasia, and the best timing for decompressive hemicraniectomy. This review provides an overview of the current diagnosis and treatment of malignant middle cerebral artery infarction with a focus on decompressive hemicraniectomy and outlines future perspectives.
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Affiliation(s)
- Hermann Neugebauer
- Department of Neurology, RKU - University and Rehabilitation Hospitals, Ulm, Germany
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Agarwalla PK, Stapleton CJ, Ogilvy CS. Craniectomy in Acute Ischemic Stroke. Neurosurgery 2014; 74 Suppl 1:S151-62. [DOI: 10.1227/neu.0000000000000226] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Anterior and posterior circulation acute ischemic stroke carries significant morbidity and mortality as a result of malignant cerebral edema. Decompressive craniectomy has evolved as a viable neurosurgical intervention in the armamentarium of treatment options for this life-threatening edema. In this review, we highlight the history of craniectomy for stroke and discuss recent data relevant to its efficacy in modern neurosurgical practice.
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Affiliation(s)
- Pankaj K. Agarwalla
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Christopher J. Stapleton
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Christopher S. Ogilvy
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Kolias AG, Kirkpatrick PJ, Hutchinson PJ. Decompressive craniectomy: past, present and future. Nat Rev Neurol 2013; 9:405-15. [PMID: 23752906 DOI: 10.1038/nrneurol.2013.106] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Decompressive craniectomy (DC)--a surgical procedure that involves removal of part of the skull to accommodate brain swelling--has been used for many years in the management of patients with brain oedema and/or intracranial hypertension, but its place in contemporary practice remains controversial. Results from a recent trial showed that early (neuroprotective) DC was not superior to medical management in patients with diffuse traumatic brain injury. An ongoing trial is investigating the clinical and cost effectiveness of secondary DC as a last-tier therapy for post-traumatic refractory intracranial hypertension. With regard to ischaemic stroke (malignant middle cerebral artery infarction), a recent Cochrane review concluded that DC improves survival compared with medical management, but that a higher proportion of DC survivors experience moderately severe or severe disability. Although many patients have a good outcome, the issue of DC-related disability raises important ethical issues. As DC and subsequent cranioplasty are associated with a number of complications, indiscriminate use of this surgery is not appropriate. Here, we review the evidence and present considerations regarding surgical technique, ethics and cost-effectiveness of DC. Prospective clinical trials and cohort studies are essential to enable optimization of patient care and outcomes.
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Affiliation(s)
- Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, CB2 0QQ, UK.
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