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Im SH, Yoo DS, Park HK. Proper Indication of Decompressive Craniectomy for the Patients with Massive Brain Edema after Intra-arterial Thrombectomy. J Korean Neurosurg Soc 2024; 67:227-236. [PMID: 38173228 PMCID: PMC10924906 DOI: 10.3340/jkns.2023.0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 08/21/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE Numerous studies have indicated that early decompressive craniectomy (DC) for patients with major infarction can be life-saving and enhance neurological outcomes. However, most of these studies were conducted by neurologists before the advent of intra-arterial thrombectomy (IA-Tx). This study aims to determine whether neurological status significantly impacts the final clinical outcome of patients who underwent DC following IA-Tx in major infarction. METHODS This analysis included 67 patients with major anterior circulation major infarction who underwent DC after IA-Tx, with or without intravenous tissue plasminogen activator. We retrospectively reviewed the medical records, radiological findings, and compared the neurological outcomes based on the "surgical time window" and neurological status at the time of surgery. RESULTS For patients treated with DC following IA-Tx, a Glasgow coma scale (GCS) score of 7 was the lowest score correlated with a favorable outcome (p=0.013). Favorable outcomes were significantly associated with successful recanalization after IA-Tx (p=0.001) and perfusion/diffusion (P/D)-mismatch evident on magnetic resonance imaging performed immediately prior to IA-Tx (p=0.007). However, the surgical time window (within 36 hours, p=0.389; within 48 hours, p=0.283) did not correlate with neurological outcomes. CONCLUSION To date, early DC surgery after major infarction is crucial for patient outcomes. However, this study suggests that the indication for DC following IA-Tx should include neurological status (GCS ≤7), as some patients treated with early DC without considering the neurological status may undergo unnecessary surgery. Recanalization of the occluded vessel and P/D-mismatch are important for long-term neurological outcomes.
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Affiliation(s)
- Sang-Hyuk Im
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do-Sung Yoo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hae-Kwan Park
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Pershin ME, Yenaldiev GK, Shagal LV, Timchenko LV, Muzlaev GG, Tkachev VV. [Staged treatment of a patient with malignant ischemic cerebral infarction]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:85-93. [PMID: 37830473 DOI: 10.17116/neiro20238705185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
The authors discuss surgical decompression of the brain in patients with malignant ischemic cerebral infarcts. Successful staged treatment of a middle-aged patient with malignant ischemic stroke in the middle cerebral artery basin is presented.
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Affiliation(s)
- M E Pershin
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russia
| | - G K Yenaldiev
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russia
| | - L V Shagal
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russia
| | - L V Timchenko
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russia
| | - G G Muzlaev
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russia
| | - V V Tkachev
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russia
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Pilato F, Pellegrino G, Calandrelli R, Broccolini A, Marca GD, Frisullo G, Morosetti R, Profice P, Brunetti V, Capone F, D'Apolito G, Quinci V, Albanese A, Mangiola A, Marchese E, Pompucci A, Di Lazzaro V. Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: A real-world study. J Neurol Sci 2022; 441:120376. [DOI: 10.1016/j.jns.2022.120376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/03/2022] [Accepted: 07/31/2022] [Indexed: 10/16/2022]
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Decompressive Hemicraniectomy in the Modern Era of Mechanical Thrombectomy. World Neurosurg 2021; 156:e77-e84. [PMID: 34500100 DOI: 10.1016/j.wneu.2021.08.138] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES We aim to determine the incidence of decompressive hemicraniectomy (DHC) in the modern era of mechanical thrombectomy techniques and improved revascularization outcomes. METHODS We performed a retrospective analysis of 512 patients admitted with acute ischemic strokes with anterior circulation large-vessel occlusion that were treated by mechanical thrombectomy from 2010-2019. The primary endpoint was the need for surgical decompression. Secondary endpoints were infarct size, hemorrhagic conversion, and functional outcome at hospital discharge. RESULTS Of the 512 patients, 18 (3.5%) underwent DHC at a median 2.0 days from stroke onset. The DHC group was significantly younger than the non-DHC group (P < 0.001), had worse reperfusion rates (P = 0.024) and larger infarct size (P < 0.001). Hemorrhagic conversion was more frequent in the DHC group but did not reach statistical significance (P = 0.08). From 2010-2015, 196 patients underwent a mechanical thrombectomy, 13 of whom (6.6%) required a DHC, while 316 patients underwent mechanical thrombectomy from 2016-2019 and only 5 patients required a DHC (1.6%; P = 0.002). Younger age (P < 0.001), urinary tract infection (P < 0.001) and increasing infarct size were significantly associated with needing a DHC. When controlling for other risk factors, higher thrombolysis in cerebral infarction score significantly reduced the need for decompressive hemicraniectomy (P = 0.004). CONCLUSIONS This is one of the largest single-center experiences demonstrating that improved recanalization decreased the need for DHC without increasing the risk of hemorrhagic conversion.
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Naidu PB, Vivek V, Shareef MH, tilak S, Ganesh K. Decompressive hemicraniectomy in malignant MCA infarct in a tertiary centre. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.101019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Soltani A, Mashari MA, Mohammadianinejad SE, Pishva SA, Pishva SM, Hooshmandi E. Effects of early decompressive craniectomy on functional outcome of patients with malignant middle cerebral artery infarctions. CURRENT JOURNAL OF NEUROLOGY 2020; 19:215-219. [PMID: 38011395 PMCID: PMC8236429 DOI: 10.18502/cjn.v19i4.5550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 07/26/2020] [Indexed: 11/24/2022]
Abstract
Background: This study aimed to compare the functional outcome of patients with malignant middle cerebral artery (MCA) infarction who had undergone either early decompressive craniectomy (DC) or optimal medical therapy (OMT). Methods: This study was conducted during a 2-year period in Golestan Hospital of Ahvaz, Iran. The selected patients with malignant MCA infarction who were admitted within 48 hours of presenting signs were included. The patients were randomly assigned to undergo either early DC (n = 12) or OMT (n = 12) in the neurosurgical intensive care unit (ICU). The functional outcomes in the subjects were evaluated with the Glasgow Outcome Scale (GOS) and the National Institutes of Health Stroke Scale (NIHSS) at discharge, 6, and 12-month intervals. Results: The patients who underwent DC had significantly higher GOS at discharge (P = 0.013), 6 (P = 0.022), and 12 (P = 0.042) months as compared to the medical therapy group. However, the NIHSS score did not show any significant difference between the two groups during the study. Likewise, DC was associated with lower mortality at 6 (P = 0.027) and 12 (P = 0.014) months; moreover, the lower mortality rate (P = 0.014), severe disability (P = 0.040), higher good recovery (P < 0.001), and moderate disability (P < 0.001) were observed after 12 months of follow-up. Conclusion: These findings suggest that early DC in patients with malignant MCA can decrease mortality and improve the functional outcome according to GOS criteria compared to medical therapy.
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Affiliation(s)
- Ahmad Soltani
- Department of Neurosurgery, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | | | | | - Seyedeh Maryam Pishva
- Department of Neurosurgery, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Etrat Hooshmandi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Lee CL, Kandasamy R, Mohammad Raffiq MAB. Computed tomography perfusion in detecting malignant middle cerebral artery infarct. Surg Neurol Int 2019; 10:159. [PMID: 31528494 PMCID: PMC6744784 DOI: 10.25259/sni_64_2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/02/2019] [Indexed: 12/04/2022] Open
Abstract
Background: Computed tomography perfusion (CTP) is an emerging modality which produces maps of time-to- peak (TTP), cerebral blood flow (CBF), and cerebral blood volume (CBV), with a computerized automated map of the infarct and penumbra. This modality provides a better evaluation of the extent of infarction, making it a potential method for assessing patients suffering from large middle cerebral artery (MCA) infarctions. Methods: A prospective cohort study of all patients in Hospital Kuala Lumpur, Malaysia, who presented with the clinical diagnosis of a large MCA infarction within 48 h of onset were subjected to CT brain, and CTP scans on admission and were followed up to determine the development of malignant infarction requiring surgical decompression. Results: CTP parameters were generally lower in patients with malignant brain infarct (MBI) group compared to the nonMBI group. The largest mean difference between the group was noted in the TTP values (P = 0.005). CTP parameters had a comparable positive predictive value (83%–90%) and high net present value (88–93). CBF with cutoff value of >32.85 of the hemisphere could accurately predict malignant infarctions in 81.4% of cases. The National Institutes of Health Stroke Scale score of more than 13.5 was also found to be able to accurately determine malignant infarct (97.6%). Functional outcome of patients based on Glasgow outcome scale was similar on discharge, however, showed improvement at 6 months during reviewed base on modified Rankin scale (P < 0.001). Conclusion: CTP parameters should be included in the initial evaluation of patients to predict malignant brain infarction and facilitate surgical treatment of large MCA infarctions. Key messages: CT perfusion parameters have an important role in predicting malignant brain infarction and should be included in the initial evaluation of patients to facilitate the early identification and surgical treatment of large middle cerebral artery infarctions, to improve patient’s prognosis.
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Affiliation(s)
- Chun Lin Lee
- Department of Neurosurgery, Hospital Kuala Lumpur, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur
| | - Regunath Kandasamy
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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Whitney E, Mahato D, Odell T, Khan YR, Siddiqi J. The 100-most Cited Articles About Craniectomy and Hemicraniectomy: A Bibliometric Analysis. Cureus 2019; 11:e5524. [PMID: 31687299 PMCID: PMC6819074 DOI: 10.7759/cureus.5524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Craniectomy is a life-saving procedure used in the setting of traumatic brain injury, stroke and increased intracranial pressure. The purpose of this study was to analyze and determine the most influential articles and authors in the field of craniectomy. Our study presents an analysis of the articles that include the word "craniectomy" or "hemicraniectomy" in the title and a detailed analysis of the top 100-cited articles in that selection. This search provided insight into how this procedure was initially documented and how it has been utilized over the years. We used the SCOPUS database to search “craniectomy OR hemicraniectomy” in the article title. We then sorted the top 100 most-cited articles. Bibliometric analysis was performed. An H-index was presented with each author. The citation count ranged from 71 to 5310. The most published author was Werner Hacke, a German researcher (n=6). The highest quantity of influential work was published in 2006 and 2007 (n=9/yr). The United States published the most articles (n=42). The Journal of Neurosurgery published 21 of the top 100 most-cited articles. The chronological timeline shows the evolution of decompression as it related to both stroke and trauma. It demonstrated that well-cited articles acted as turning points to direct further scientific endeavors while highlighting the hard work of certain authors. There is, to the best of our knowledge, a shortage of literature on a bibliometric analysis regarding the term craniectomy. Thus, the current bibliometric study was undertaken to highlight the work of authors who have advanced knowledge about this procedure. It provides an analysis of the top 100-cited articles with craniectomy in the title with dates ranging from 1892 to 2016. A review of its publication history shows how interventions in this field have advanced over the last several decades.
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Affiliation(s)
- Eric Whitney
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | | | - Tiffany Odell
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | - Yasir R Khan
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | - Javed Siddiqi
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
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9
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Pandhi A, Tsivgoulis G, Goyal N, Ishfaq MF, Male S, Boviatsis E, Chang JJ, Zand R, Voumvourakis K, Elijovich L, Alexandrov AW, Malkoff MD, Hoit D, Arthur AS, Alexandrov AV. Hemicraniectomy for Malignant Middle Cerebral Artery Syndrome: A Review of Functional Outcomes in Two High-Volume Stroke Centers. J Stroke Cerebrovasc Dis 2018; 27:2405-2410. [PMID: 29776804 DOI: 10.1016/j.jstrokecerebrovasdis.2018.04.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/11/2018] [Accepted: 04/23/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND AND PURPOSE Despite recent landmark randomized controlled trials showing significant benefits for hemicraniectomy (HCT) compared with medical therapy (MT) in patients with malignant middle cerebral artery infarction (MMCAI), HCT rates have not substantially increased in the United States. We sought to evaluate early outcomes in patients with MMCAI who were treated with HCT (cases) in comparison to patients treated with MT due to the perception of procedural futility by families (controls). METHODS We retrospectively evaluated consecutive patients with acute MMCAI treated in 2 tertiary care centers during a 7-year period. Pretreatment National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 3 months were documented. Functional independence (FI) and survival without severe disability (SWSD) were defined as mRS of 0-2 and 0-4, respectively. RESULTS A total of 66 patients (37 cases and 29 controls) fulfilled the study inclusion criteria (mean age 59 ± 15 years, 52% men, median admission NIHSS score: 19 points [interquartile range {IQR}: 16-22]). Cases were younger (51 ± 11 versus 68 ± 13 years; P < .001) and tended to have lower median admission NIHSS than controls (18 [IQR:16-20] versus 20 [IQR:18-23]; P = .072). The rates of FI and SWSD at 3 months were higher in cases than controls (16% versus 0% [P = .031] and 62% versus 0% [P < .001]), while 3-month mortality was lower (24% versus 77%; P < .001). Multivariable Cox regression analyses adjusting for potential confounders identified HCT as the most important predictor of lower risk of 3-month mortality (hazard ratio: .02, 95% confidence interval: .01-0.10; P < .001). CONCLUSIONS HCT is a critical and effective therapy for patients with MMCAI but cannot provide a guarantee of functional recovery.
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Affiliation(s)
- Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee.
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee; Second Department of Neurology, "Attikon University Hospital", School of Medicine, University of Athens, Athens, Greece
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Muhammad F Ishfaq
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Shailesh Male
- Department of Neurology, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Efstathios Boviatsis
- Second Department of Neurosurgery, "Attikon University Hospital", School of Medicine, University of Athens, Athens, Greece
| | - Jason J Chang
- Neurointensivist, Medstar Washington Hospital Medical Center, Washington, DC
| | - Ramin Zand
- Neurology Director of Clinical Stroke Operations & Northeastern Regional Stroke Director, Geisinger Health System
| | | | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Anne W Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee; Professor and US Principle Investigator, Australian Catholic University, Sydney, Australia
| | - Marc D Malkoff
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Daniel Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
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Cranioplasty following decompressive craniectomy: minor surgical complexity but still high periprocedural complication rates. Neurosurg Rev 2018; 43:217-222. [PMID: 30293162 DOI: 10.1007/s10143-018-1038-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 09/26/2018] [Indexed: 10/28/2022]
Abstract
Cranioplasty following decompressive craniectomy is of low surgical complexity, so much so that it has become the "beginners" cranial case. However, these "simple" procedures may have high complication rates. Identification of specific risk factors would allow targeted intervention to lower the complication rates. The aim of this study was to assess the rate of complications and to evaluate potential risk factors. We conducted a review of all patients who underwent cranioplasty in our center following decompressive craniectomy for stroke or brain trauma between 2009 and 2016. One hundred fifty-two patients were identified. Fifty-three percent were male. Mean age was 48 (range 11-78). Median time from craniectomy until cranioplasty was 102 days (range 14-378). The overall rate of complications, such as postoperative bleeding, seizures, postoperative infection, and hydrocephalus, was 30%. The mortality rate was 1%. None of the following potential risk factors was associated with significantly increased risk of periprocedural complications: gender (p = 0.34), age (p = 0.39), cause of initial surgery (p = 0.08), duration of surgery (p = 0.59), time of surgery (0.24), surgical experience (p = 0.17), and time from craniectomy until cranioplasty (p = 0.27). The 30-day complication rate following cranioplasty is high, but serious permanent deficits from these complications were rare. We found no clear predictor for these 30-day complications, which renders its prevention difficult.
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Elsawaf A, Galhom A. Decompressive Craniotomy for Malignant Middle Cerebral Artery Infarction: Optimal Timing and Literature Review. World Neurosurg 2018; 116:e71-e78. [DOI: 10.1016/j.wneu.2018.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 04/01/2018] [Accepted: 04/02/2018] [Indexed: 10/17/2022]
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Kamal N, Majmundar N, Damadora N, El-Ghanem M, Nuoman R, Keller IA, Schonfeld S, Rybinnik I, Gupta G, Roychowdry S, Al-Mufti F. Mechanical thrombectomy - is time still brain? The DAWN of a new era. Br J Neurosurg 2018; 32:245-249. [PMID: 29417839 DOI: 10.1080/02688697.2018.1426726] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE The purpose of this study is to review the history of treatments for acute ischemic stroke, examine developments in endovascular therapy, and discuss the future of the management of acute ischemic stroke. METHODS A selective review of recent clinical trials for the treatment of acute ischemic stroke was conducted. RESULTS We reviewed completed trials of the management of acute ischemic stroke including intravenous thrombolytics, intraarterial thrombolytics, and thrombectomy. We also assessed the future direction of research by reviewing ongoing clinical trials. CONCLUSIONS The advancement of endovascular treatment for stroke has led to improved morbidity and mortality for patients. Future challenges include delivering these treatments to stroke centers worldwide.
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Affiliation(s)
- Naveed Kamal
- a Department of Neurosurgery , Rutgers University, New Jersey Medical School , Newark , NJ , USA
| | - Neil Majmundar
- a Department of Neurosurgery , Rutgers University, New Jersey Medical School , Newark , NJ , USA
| | - Nitesh Damadora
- a Department of Neurosurgery , Rutgers University, New Jersey Medical School , Newark , NJ , USA
| | - Mohammad El-Ghanem
- a Department of Neurosurgery , Rutgers University, New Jersey Medical School , Newark , NJ , USA
| | - Rolla Nuoman
- b Department of Neurology , Rutgers University, New Jersey Medical School , Newark , NJ , USA
| | - Irwin A Keller
- c Department of Radiology , Rutgers University, Robert Wood Johnson Medical School , New Brunswick , NJ , USA
| | - Steven Schonfeld
- c Department of Radiology , Rutgers University, Robert Wood Johnson Medical School , New Brunswick , NJ , USA
| | - Igor Rybinnik
- d Department of Neurology , Rutgers University, Robert Wood Johnson Medical School , New Brunswick , NJ , USA
| | - Gaurav Gupta
- e Department of Neurosurgery , Rutgers University, Robert Wood Johnson Medical School , New Brunswick , NJ , USA
| | - Sudipta Roychowdry
- c Department of Radiology , Rutgers University, Robert Wood Johnson Medical School , New Brunswick , NJ , USA
| | - Fawaz Al-Mufti
- a Department of Neurosurgery , Rutgers University, New Jersey Medical School , Newark , NJ , USA.,d Department of Neurology , Rutgers University, Robert Wood Johnson Medical School , New Brunswick , NJ , USA
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13
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Managing high blood pressure during acute ischemic stroke and intracerebral hemorrhage. Curr Opin Neurol 2018; 31:8-13. [DOI: 10.1097/wco.0000000000000508] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bilotta F, Robba C, Santoro A, Delfini R, Rosa G, Agati L. Contrast-Enhanced Ultrasound Imaging in Detection of Changes in Cerebral Perfusion. ULTRASOUND IN MEDICINE & BIOLOGY 2016; 42:2708-2716. [PMID: 27475927 DOI: 10.1016/j.ultrasmedbio.2016.06.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 06/02/2016] [Accepted: 06/06/2016] [Indexed: 06/06/2023]
Abstract
Contrast-enhanced ultrasonography (CEU) is a non-invasive imaging technique that provides real-time, bedside information on changes in global and segmental organ perfusion. Currently, there is a lack of data concerning changes in the distribution of segmental brain perfusion in acute ischemic stroke treated by decompressive craniectomy. The aim of our case series was to assess the role of CEU after decompressive craniectomy in patients with acute ischemic stroke. CEU was performed in 12 patients at baseline and after any one of the following interventions was performed as dictated by the patient's clinical condition: vasoactive drug administration (in order to achieve cerebral perfusion pressure ≥70 mm Hg and mean arterial pressure <100 mm Hg for management of arterial blood pressure) and mild hyperventilation (carbon dioxide arterial pressure = 30-35 mm Hg). CEU was able to detect a significant variation in cerebral contrast distribution in both normal and pathologic hemispheres after induced hyperventilation (difference in time to peak [dTTP] = -38.4%), vasodilation (dTTP = -6.6%) and vasoconstriction (dTTP = +31.2%) (p < 0.05). CEU can be useful in assessing real-time cerebral perfusion changes in neurocritical care patients.
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Affiliation(s)
- Federico Bilotta
- Department of Anesthesiology, University of Rome "Sapienza", Rome, Italy
| | - Chiara Robba
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge, United Kingdom.
| | - Antonio Santoro
- Department of Neurosurgery, University of Rome "Sapienza", Rome, Italy
| | - Roberto Delfini
- Department of Neurosurgery, University of Rome "Sapienza", Rome, Italy
| | - Giovanni Rosa
- Department of Anesthesiology, University of Rome "Sapienza", Rome, Italy
| | - Luciano Agati
- Department of Cardiology, University of Rome "Sapienza", Rome, Italy
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Rivkin MJ, Bernard TJ, Dowling MM, Amlie-Lefond C. Guidelines for Urgent Management of Stroke in Children. Pediatr Neurol 2016; 56:8-17. [PMID: 26969237 DOI: 10.1016/j.pediatrneurol.2016.01.016] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 01/18/2016] [Indexed: 01/09/2023]
Abstract
Stroke in children carries lasting morbidity. Once recognized, it is important to evaluate and treat children with acute stroke efficiently and accurately. All children should receive neuroprotective measures. It is reasonable to consider treatment with advanced thrombolytic and endovascular agents. Delivery of such care requires purposeful institutional planning and organization in pediatric acute care centers. Primary stroke centers established for adults provide an example of the multidisciplinary approach that can be applied to the evaluation and treatment of children who present with acute stroke. The organizational infrastructure of these centers can be employed and adapted for treatment of children with acute stroke. It is likely that care for children with acute stroke can best be delivered by regional pediatric primary stroke centers dedicated to the care of children with pediatric stroke.
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Affiliation(s)
- Michael J Rivkin
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts; Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts; Department of Radiology, Boston Children's Hospital, Boston, Massachusetts; Department of Neurology, Harvard Medical School, Boston, Massachusetts.
| | - Timothy J Bernard
- Department of Pediatrics, Hemophilia and Thrombosis Center, Aurora, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Michael M Dowling
- Division of Pediatric Neurology, University of Texas Southwestern Medical Center Dallas, Dallas, Texas; Department of Pediatrics, University of Texas Southwestern Medical Center Dallas, Dallas, Texas; Department of Neurology, University of Texas Southwestern Medical Center Dallas, Dallas, Texas
| | - Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Paredes I, Castaño AM, Cepeda S, Alén JAF, Salvador E, Millán JM, Lagares A. The Effect of Cranioplasty on Cerebral Hemodynamics as Measured by Perfusion Computed Tomography and Doppler Ultrasonography. J Neurotrauma 2016; 33:1586-97. [PMID: 26541365 DOI: 10.1089/neu.2015.4261] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Cranioplasties are performed to protect the brain and correct cosmetic defects, but there is growing evidence that this procedure may result in neurological improvement. We prospectively studied cranioplasties performed at our hospital over a 5-year period. The National Institute of Health Stroke Scale and Barthel index were recorded prior to and within 72 h after the cranioplasty. A perfusion computed tomography (PCT) and transcranial Doppler sonography (TCDS) were performed prior to and 72 h after the surgery. For the PCT, regions irrigated by the anterior cerebral artery, the middle cerebral artery (MCA), the posterior cerebral artery, and the basal ganglia were selected, as well as the mean values for the hemisphere. The sonography was performed in the sitting and the supine position for the MCA and internal carotid. The velocities, pulsatility index, resistance index, and Lindegaard ratio (LR) were obtained, as well as a variation value for the LR (ΔLR = LR sitting - LR supine). Fifty-four patients were included in the study. Of these, 23 (42.6%) patients presented with objective improvement. The mean cerebral blood flow of the defective side (m-CBF-d) increased from 101.86 to 117.17 mL/100 g/min (p = 0.064), and the m-CBF of the healthy side (m-CBF-h) increased from 128.14 to 145.73 mL/100 g/min (p = 0.028). With regard to the TCDS, the ΔLR was greater on the defective side prior the surgery in those patients who showed improvement (1.295 vs. -0.714; p = 0.002). Cranioplasty resulted in clinical improvement in 40% of the patients, with an increase in the post-surgical CBF. The larger variations in the LR when the patient is moved from the sitting to the supine position might predict the clinical improvement.
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Affiliation(s)
- Igor Paredes
- 1 Department of Neurosurgery, University Hospital 12 de Octubre , Madrid, Spain
| | - Ana María Castaño
- 1 Department of Neurosurgery, University Hospital 12 de Octubre , Madrid, Spain
| | - Santiago Cepeda
- 1 Department of Neurosurgery, University Hospital 12 de Octubre , Madrid, Spain
| | | | - Elena Salvador
- 2 Department of Neuroradiology, University Hospital 12 de Octubre , Madrid, Spain
| | - Jose María Millán
- 2 Department of Neuroradiology, University Hospital 12 de Octubre , Madrid, Spain
| | - Alfonso Lagares
- 1 Department of Neurosurgery, University Hospital 12 de Octubre , Madrid, Spain
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Sauvigny T, Göttsche J, Vettorazzi E, Westphal M, Regelsberger J. New Radiologic Parameters Predict Clinical Outcome after Decompressive Craniectomy. World Neurosurg 2015; 88:519-525.e1. [PMID: 26548831 DOI: 10.1016/j.wneu.2015.10.072] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 10/18/2015] [Accepted: 10/19/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Decompressive craniectomy (DC) is an established part of the management of patients with increased intracranial pressure due to malignant middle cerebral artery (MCA) infarction or traumatic brain injury (TBI). The aim of this study was to determine prognostic radiologic parameters regarding the functional outcome of patients with increased intracranial pressure (ICP) undergoing DC. Special focus was put on the potential differences between malignant MCA infarction and TBI. METHODS A total of 113 patients were analyzed for their clinical course where preoperative and postoperative radiologic features in computed tomography (CT) scans were correlated to the clinical outcome assessed by the Glasgow Outcome Scale. The difference between presurgical and postsurgical midline shift (ΔMLS) and the ratio between the diameter of the affected and contralateral hemisphere (HDratio) in presurgical and postsurgical CT scans were calculated. RESULTS ΔMLS (MCA infarction group) and postsurgical HDratio (TBI group) were found to be highly correlating with the clinical outcome on Spearman-correlation testing and underwent further analysis using a binary logistic regression model to evaluate their prognostic value on the outcome, which showed the predictive power of ΔMLS in malignant MCA infarction patients (odds ratio [OR] 0.715; confidence interval [CI] 0.551-0.865). Postsurgical HDratio correlated significantly (OR 0.620; CI 0.384-0.901) with the outcome in the TBI group. CONCLUSION ΔMLS is an objectifiable parameter, predicting outcome in malignant MCA infarction. In contrast, ΔMLS was of no predictive value in TBI patients. Here postsurgical HDratio serves as a strong predictor of clinical outcome. We recommend applying postsurgical HDratio to TBI patients in order to estimate their clinical outcome and adjust treatment.
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Affiliation(s)
- Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Jennifer Göttsche
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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18
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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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19
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Yang MH, Lin HY, Fu J, Roodrajeetsing G, Shi SL, Xiao SW. Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: A systematic review and meta-analysis. Surgeon 2015; 13:230-40. [DOI: 10.1016/j.surge.2014.12.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 12/30/2014] [Indexed: 11/16/2022]
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20
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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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21
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Sundseth J, Sundseth A, Thommessen B, Johnsen LG, Altmann M, Sorteberg W, Lindegaard KF, Berg-Johnsen J. Long-Term Outcome and Quality of Life After Craniectomy in Speech-Dominant Swollen Middle Cerebral Artery Infarction. Neurocrit Care 2014; 22:6-14. [DOI: 10.1007/s12028-014-0056-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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22
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From Incan time to today, the unresolved problem of cranioplasty. World Neurosurg 2013; 82:e439-41. [PMID: 23916493 DOI: 10.1016/j.wneu.2013.07.089] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 07/27/2013] [Indexed: 11/24/2022]
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23
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Moussa WM, Farhoud A. Ventriculosubgaleal shunt in the management of obstructive hydrocephalus caused by cerebellar infarction. ALEXANDRIA JOURNAL OF MEDICINE 2013. [DOI: 10.1016/j.ajme.2012.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Wael M. Moussa
- Department of Neurosurgery, Faculty of Medicine , Alexandria University , Egypt
| | - Ahmed Farhoud
- Department of Neurosurgery, Faculty of Medicine , Alexandria University , Egypt
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24
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El Ahmadieh TY, Adel JG, El Tecle NE, Daou MR, Aoun SG, Nanney AD, Bendok BR. Surgical treatment of elevated intracranial pressure: decompressive craniectomy and intracranial pressure monitoring. Neurosurg Clin N Am 2013; 24:375-91. [PMID: 23809032 DOI: 10.1016/j.nec.2013.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Surgical techniques that address elevated intracranial pressure include (1) intraventricular catheter insertion and cerebrospinal fluid drainage, (2) removal of an intracranial space-occupying lesion, and (3) decompressive craniectomy. This review discusses the role of surgery in the management of elevated intracranial pressure, with special focus on intraventricular catheter placement and decompressive craniectomy. The techniques and potential complications of each procedure are described, and the existing evidence regarding the impact of these procedures on patient outcome is reviewed. Surgical management of mass lesions and ischemic or hemorrhagic stroke occurring in the posterior fossa is not discussed herein.
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Affiliation(s)
- Tarek Y El Ahmadieh
- Department of Neurological Surgery, McGaw Medical Center, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 2210, Chicago, IL 60611, USA
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25
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Lang SS, Kofke WA, Stiefel MF. Monitoring and intraoperative management of elevated intracranial pressure and decompressive craniectomy. Anesthesiol Clin 2012; 30:289-310. [PMID: 22901611 DOI: 10.1016/j.anclin.2012.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Elevated intracranial pressure can be caused by a variety of underlying conditions. Several physiologic and pharmacologic factors have a significant impact on intracranial hypertension, mostly caused by changes on cerebral blood volume, flow, and oxygenation. There are many therapies that can be used to decrease intracranial pressure ranging from pharmacologic to the surgical decompressive removal of the calvarium. Special consideration is made for the anesthetic management of these patients perioperatively.
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Affiliation(s)
- Shih-Shan Lang
- Department of Neurosurgery, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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26
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Yoo SH, Kim TH, Shin JJ, Shin HS, Hwang YS, Park SK. The clinical efficacy of decompressive craniectomy in patients with an internal carotid artery territory infarction. J Korean Neurosurg Soc 2012; 52:293-9. [PMID: 23133715 PMCID: PMC3488635 DOI: 10.3340/jkns.2012.52.4.293] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 08/10/2012] [Accepted: 10/04/2012] [Indexed: 11/27/2022] Open
Abstract
Objective To evaluate the surgical efficacy of and factors associated with decompressive craniectomy in patients with an internal carotid artery (ICA) territory infarction. Methods Seventeen patients (8 men and 9 women, average age 61.53 years, range 53-77 years) were treated by decompressive craniectomy for an ICA territory infarction at our institute. We retrospectively reviewed medical records, radiological findings, and National Institutes of Health Stroke Scale (NIHSS) at presentation and before surgery. Clinical outcomes were assessed using the Glasgow Outcome Scale (GOS). Results Of the 17 patients, 15 (88.24%) achieved a poor outcome (Group A, GOS 1-3) and 2 (11.76%) a good outcome (Group B, GOS 4-5). The mortality rate at one month after surgery was 52.9%. Average preoperative NIHSS was 27.6±10.88% in group A and 10±4.24% in group B. Mean cerebral infarction fraction at the septum pellucidum level before surgery in group A and B were 33.67% and 23.72%, respectively. Mean preoperative NIHSS (p=0.019) and cerebral infarction fraction at the septum pellucidum level (p=0.017) were found to be significantly associated with a better outcome. However, no preexisting prognostic factor was found to be of statistical significance. Conclusion The rate of mortality after ICA territory infarction treatment is relatively high, despite positive evidence for surgical decompression, and most survivors experience severe disabilities. Our findings caution that careful consideration of prognostic factors is required when considering surgical treatment.
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Affiliation(s)
- Seung Ho Yoo
- Department of Neurosurgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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27
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Hempenstall J, Sadek AR, Eynon CA. Decompressive Craniectomy in Acute Brain Injury – Lifting the lid on Neurosurgical Practice. J Intensive Care Soc 2012. [DOI: 10.1177/175114371201300311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Decompressive craniectomy (DC) is an effective method of controlling rising intracranial pressure (ICP) refractory to medical treatment in a range of conditions: traumatic brain injury in both adults and children, malignant middle cerebral artery infarction and following subarachnoid haemorrhage. Herein, we describe its indications, prognosis, current operative methods and postoperative management.
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Affiliation(s)
- Jonathan Hempenstall
- University Hospital Southampton NHS FoundationTrust and Division of Clinical Neurosciences, School of Medicine, University of Southampton
| | - Ahmed-Ramadan Sadek
- Walport Academic Clinical Fellow in Neurosurgery, Jason Brice Fellow in Neurosurgical Research
- University Hospital Southampton NHS FoundationTrust and Division of Clinical Neurosciences, School of Medicine, University of Southampton
| | - C Andrew Eynon
- Director of Major Trauma, Consultant in Neurosciences Intensive Care, Honorary Senior Lecturer
- University Hospital Southampton NHS FoundationTrust and Division of Clinical Neurosciences, School of Medicine, University of Southampton
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28
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Zhao J, Su YY, Zhang Y, Zhang YZ, Zhao R, Wang L, Gao R, Chen W, Gao D. Decompressive hemicraniectomy in malignant middle cerebral artery infarct: a randomized controlled trial enrolling patients up to 80 years old. Neurocrit Care 2012; 17:161-71. [PMID: 22528280 DOI: 10.1007/s12028-012-9703-3] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Decompressive hemicraniectomy (DHC) has proven efficacious for the treatment of malignant middle cerebral artery infarction (mMCAI) only in patients less than 60 years. This study aimed to assess the effectiveness of DHC in patients up to 80. METHODS This is a prospective, randomized, controlled trail comparing the outcomes with or without DHC in patients aged 18-80 with mMCAI (ChiCTR-TRC-11001757). The primary outcome measure was the modified Rankin Scale (mRS) scores at 6 months. The secondary outcome measures included the 6- and 12-month mortality and the mRS scores after 1 year. The prognosis of patients was evaluated independently by two blinded investigators. In addition, subgroup analyses were done for those above 60 years of age. All analyses were by intention-to-treat. RESULTS A significant reduction in the poor outcome (mRS > 4) following DHC was reached after 36 patients had completed the follow-up period of 6 months. The trial was then terminated when 47 participants (24 in the surgical group vs. 23 in the medical group) had been recruited. The final analysis, based on the outcome data of the 47 patients, showed that DHC significantly reduced mortality at 6 and 12 months (12.5 vs. 60.9 %, P = 0.001 and 16.7 vs. 69.6 %, P < 0.001, respectively), and significantly fewer patients had a mRS score >4 after surgery (33.3 vs. 82.6 %, P = 0.001 and 25.0 vs. 87.0 %, P < 0.001, respectively). Similar results were present in the subgroup analyses of elderly participants CONCLUSIONS For patients up to 80 years who suffered mMCAI, DHC within 48 h of stroke onset not only is a life-saving treatment, but also increases the possibility of surviving without severe disability (mRS = 5).
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Affiliation(s)
- Jingwei Zhao
- Division of Neurocritical Care, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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29
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Risk factors for three phases of 12-month mortality in a defined population after subarachnoid hemorrhage. World Neurosurg 2012; 78:579-80. [PMID: 22381322 DOI: 10.1016/j.wneu.2011.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 11/18/2011] [Indexed: 11/20/2022]
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30
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Johnson RD, Maartens NF, Teddy PJ. Decompressive craniectomy for malignant middle cerebral artery infarction: Evidence and controversies. J Clin Neurosci 2011; 18:1018-22. [DOI: 10.1016/j.jocn.2010.12.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Revised: 12/01/2010] [Accepted: 12/07/2010] [Indexed: 10/18/2022]
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31
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Arnaout OM, Aoun SG, Batjer HH, Bendok BR. Decompressive hemicraniectomy after malignant middle cerebral artery infarction: rationale and controversies. Neurosurg Focus 2011; 30:E18. [DOI: 10.3171/2011.3.focus1160] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Malignant middle cerebral artery stroke carries a very poor prognosis. Significant retrospective data support the hypothesis that decompressive hemicraniectomy decreases mortality rates due to this disease entity. Recently, 3 randomized controlled studies have been published and shed light on these issues and enhance the quality of evidence revolving around this procedure. In this review, the rationale, risks, benefits, and unanswered questions related to hemicraniectomy for acute ischemic stroke are reviewed with an emphasis on how 3 randomized trials have influenced knowledge on this life-saving yet controversial procedure. Further randomized studies are needed to clarify lingering questions regarding age indications and impact on quality of life.
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32
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Decompressive hemicraniectomy after aneurysmal subarachnoid hemorrhage. World Neurosurg 2011; 74:465-71. [PMID: 21492596 DOI: 10.1016/j.wneu.2010.08.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Accepted: 07/29/2010] [Indexed: 12/31/2022]
Abstract
BACKGROUND The aim of this study was to document the effects of decompressive hemicraniectomy (DHC) on neurologic outcome in patients treated for aneurysmal subarachnoid hemorrhage (SAH) and developing otherwise uncontrollable intracranial hypertension. METHODS Sixty-six of the 964 patients (6.8%) treated for aneurysmal SAH underwent DHC and were stratified as follows: Group 1, patients undergoing aneurysm clipping and DHC in one surgical sitting (i.e., primary DHC). Group 2, patients receiving aneurysm embolization and thereafter undergoing DHC. Group 3, patients undergoing standard aneurysm surgery and requiring DHC later in the post-SAH period. Group 4, patients with insufficient primary DHC and later requiring surgical enlargement of the craniectomy. RESULTS Outcome was not influenced by the timing of DHC, but depended on the pathology underlying intracranial hypertension (i.e., whether lesions were primary hemorrhagic or secondary ischemic in origin). Patients with large hematomas, undergoing primary, secondary, or repeat DHC (46/66) had significantly better outcomes than the 20 patients treated for edema and delayed ischemic infarctions. There were 16 (34.8%) of the 46 patients in the hematoma group, but only 2 (10.0%) of the 20 patients in the ischemia group had favorable neurologic outcomes, defined as modified Rankin Scale scores 0-3 (P value = 0.038). CONCLUSIONS In the largest series of SAH patients to date who received both microsurgical and endovascular treatment of ruptured aneurysms, and who underwent DHC for otherwise uncontrollable intracranial hypertension. Neurologic outcome was significantly correlated with the pathology underlying intracranial hypertension. DHC beneficially affected neurologic outcomes in patients with space-occupying hematomas, whereas patients suffering delayed ischemic strokes did not benefit to the same extent.
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Lauritzen M, Dreier JP, Fabricius M, Hartings JA, Graf R, Strong AJ. Clinical relevance of cortical spreading depression in neurological disorders: migraine, malignant stroke, subarachnoid and intracranial hemorrhage, and traumatic brain injury. J Cereb Blood Flow Metab 2011; 31:17-35. [PMID: 21045864 PMCID: PMC3049472 DOI: 10.1038/jcbfm.2010.191] [Citation(s) in RCA: 544] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 10/01/2010] [Accepted: 10/01/2010] [Indexed: 01/01/2023]
Abstract
Cortical spreading depression (CSD) and depolarization waves are associated with dramatic failure of brain ion homeostasis, efflux of excitatory amino acids from nerve cells, increased energy metabolism and changes in cerebral blood flow (CBF). There is strong clinical and experimental evidence to suggest that CSD is involved in the mechanism of migraine, stroke, subarachnoid hemorrhage and traumatic brain injury. The implications of these findings are widespread and suggest that intrinsic brain mechanisms have the potential to worsen the outcome of cerebrovascular episodes or brain trauma. The consequences of these intrinsic mechanisms are intimately linked to the composition of the brain extracellular microenvironment and to the level of brain perfusion and in consequence brain energy supply. This paper summarizes the evidence provided by novel invasive techniques, which implicates CSD as a pathophysiological mechanism for this group of acute neurological disorders. The findings have implications for monitoring and treatment of patients with acute brain disorders in the intensive care unit. Drawing on the large body of experimental findings from animal studies of CSD obtained during decades we suggest treatment strategies, which may be used to prevent or attenuate secondary neuronal damage in acutely injured human brain cortex caused by depolarization waves.
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Affiliation(s)
- Martin Lauritzen
- Department of Clinical Neurophysiology, Glostrup Hospital, Glostrup, Denmark.
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Voytek B, Secundo L, Bidet-Caulet A, Scabini D, Stiver SI, Gean AD, Manley GT, Knight RT. Hemicraniectomy: a new model for human electrophysiology with high spatio-temporal resolution. J Cogn Neurosci 2010; 22:2491-502. [PMID: 19925193 DOI: 10.1162/jocn.2009.21384] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Human electrophysiological research is generally restricted to scalp EEG, magneto-encephalography, and intracranial electrophysiology. Here we examine a unique patient cohort that has undergone decompressive hemicraniectomy, a surgical procedure wherein a portion of the calvaria is removed for several months during which time the scalp overlies the brain without intervening bone. We quantify the differences in signals between electrodes over areas with no underlying skull and scalp EEG electrodes over the intact skull in the same subjects. Signals over the hemicraniectomy have enhanced amplitude and greater task-related power at higher frequencies (60-115 Hz) compared with signals over skull. We also provide evidence of a metric for trial-by-trial EMG/EEG coupling that is effective over the hemicraniectomy but not intact skull at frequencies >60 Hz. Taken together, these results provide evidence that the hemicraniectomy model provides a means for studying neural dynamics in humans with enhanced spatial and temporal resolution.
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Affiliation(s)
- Bradley Voytek
- Helen Wills Neuroscience, University of California, Berkeley, Berkeley, CA 94720-3190, USA.
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Abstract
PURPOSE OF REVIEW Space-occupying, malignant hemispheric infarction is one of the most devastating forms of ischemic stroke. Several case series had suggested decompressive hemicraniectomy as a life-saving therapy, but, until recently, there was no proof for this procedure from randomized controlled trials. RECENT FINDINGS In 2007, results from a pooled analysis of three European trials as well as data from two of these trials were published and yield compelling evidence for the benefit of hemicraniectomy. SUMMARY Data from the published trials leave no doubt about the benefit especially the life-saving character of hemicraniectomy for malignant hemispheric infarction. However, some open questions (i.e. timing of surgery, age limit for hemicraniectomy) remain to be answered in the future.
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Pfefferkorn T, Eppinger U, Linn J, Birnbaum T, Herzog J, Straube A, Dichgans M, Grau S. Long-Term Outcome After Suboccipital Decompressive Craniectomy for Malignant Cerebellar Infarction. Stroke 2009; 40:3045-50. [DOI: 10.1161/strokeaha.109.550871] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Suboccipital decompressive craniectomy (SDC) is a life-saving intervention for patients with malignant cerebellar infarction. However, long-term outcome has not been systematically analyzed.
Methods—
In this monocentric retrospective study we analyzed mortality, long-term functional outcome, and quality of life of all consecutive patients that were treated by SDC for malignant cerebellar infarction in our institution between 1995 and 2006.
Results—
A total of 57 patients were identified. All of them were treated by bilateral SDC. An external ventricular drainage was inserted in 82%, necrotic tissue was evacuated in 56% of patients. There were no fatal procedural complications. Five patients were lost for follow-up. In the remaining 52 patients, the mean follow-up interval was 4.7 years (1 to 11 years). Within the first 6 months after surgery 16 of 57 patients (28%) had died. At follow-up, 21 of 52 patients (40%) had died and 4 patients (8%) lived with major disability (mRS 4 or 5). Twenty-one patients (40%) lived functionally independent (mRS 0 to 2). The presence of additional brain stem infarction was associated with poor outcome (mRS ≥4; hazard ratio: 9.1;
P
=0.001). Quality of life in survivors was moderately lower than in healthy controls.
Conclusions—
SDC is a safe procedure in patients with malignant cerebellar infarction. Infarct- but not procedure-related early mortality is substantial. Long-term outcome in survivors is acceptable, particularly in the absence of brain stem infarction.
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Affiliation(s)
- Thomas Pfefferkorn
- From the Departments of Neurology (T.P., U.E., T.B., A.S., M.D.), Neuroradiology (J.L.), and Neurosurgery (S.G.), Klinikum Grosshadern, University of Munich, Germany; and Neurologische Klinik (J.H.), Bad Aibling, Germany
| | - Ursula Eppinger
- From the Departments of Neurology (T.P., U.E., T.B., A.S., M.D.), Neuroradiology (J.L.), and Neurosurgery (S.G.), Klinikum Grosshadern, University of Munich, Germany; and Neurologische Klinik (J.H.), Bad Aibling, Germany
| | - Jennifer Linn
- From the Departments of Neurology (T.P., U.E., T.B., A.S., M.D.), Neuroradiology (J.L.), and Neurosurgery (S.G.), Klinikum Grosshadern, University of Munich, Germany; and Neurologische Klinik (J.H.), Bad Aibling, Germany
| | - Tobias Birnbaum
- From the Departments of Neurology (T.P., U.E., T.B., A.S., M.D.), Neuroradiology (J.L.), and Neurosurgery (S.G.), Klinikum Grosshadern, University of Munich, Germany; and Neurologische Klinik (J.H.), Bad Aibling, Germany
| | - Jürgen Herzog
- From the Departments of Neurology (T.P., U.E., T.B., A.S., M.D.), Neuroradiology (J.L.), and Neurosurgery (S.G.), Klinikum Grosshadern, University of Munich, Germany; and Neurologische Klinik (J.H.), Bad Aibling, Germany
| | - Andreas Straube
- From the Departments of Neurology (T.P., U.E., T.B., A.S., M.D.), Neuroradiology (J.L.), and Neurosurgery (S.G.), Klinikum Grosshadern, University of Munich, Germany; and Neurologische Klinik (J.H.), Bad Aibling, Germany
| | - Martin Dichgans
- From the Departments of Neurology (T.P., U.E., T.B., A.S., M.D.), Neuroradiology (J.L.), and Neurosurgery (S.G.), Klinikum Grosshadern, University of Munich, Germany; and Neurologische Klinik (J.H.), Bad Aibling, Germany
| | - Stefan Grau
- From the Departments of Neurology (T.P., U.E., T.B., A.S., M.D.), Neuroradiology (J.L.), and Neurosurgery (S.G.), Klinikum Grosshadern, University of Munich, Germany; and Neurologische Klinik (J.H.), Bad Aibling, Germany
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Mitchell P, Gregson BA, Crossman J, Gerber C, Jenkins A, Nicholson C, Todd NV, Ross N, Bhattathiri P, Nissen J, Crawford PJ, Wynne-Jones G, Sengupta RP, Graham L, Gani A, Davis M, Gray C, Barer D, Dorman P, Millar D, Williamson J, Durham H, Jones A, Hastie H, Mendelow AD. Reassessment of the HAMLET study. Lancet Neurol 2009; 8:602-3; author reply 603-4. [DOI: 10.1016/s1474-4422(09)70157-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Arac A, Blanchard V, Lee M, Steinberg GK. Assessment of outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 60 years of age. Neurosurg Focus 2009; 26:E3. [DOI: 10.3171/2009.3.focus0958] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Decompressive surgery can be life saving after malignant cerebral infarction. However, severe residual disability occurs in a significant number of surviving patients. Most discussion about the benefits of surgery is based on studies performed in patients who are ≤ 60 years of age. Less is known about the benefits of the procedure in the elderly population. The authors undertook a review of the literature on decompressive craniectomy for malignant cerebral infarction and compared the mortality and outcome data published in patients older and younger than 60 years of age. The authors discuss their analysis, with specific reference to the limitations of the studies analyzed, the outcome measures used, and the special considerations required when discussing stroke recovery in the elderly.
Methods
Studies on decompressive craniectomy for malignant middle cerebral artery infarction reported in the English literature were analyzed. A cutoff point for age of > 60 or ≤ 60 years was set, and the study population was segregated. No studies specifically analyzed patients > 60 years old. A total of 19 studies was identified, 10 of which included patients who were > 60 years of age. A comparison between the 2 age groups was made within the 10 studies and also among all the patients in the 19 studies. Mortality rates and outcome scores were assessed for each study, and a Barthel Index (BI) score of < 60 or a modified Rankin Scale (mRS) score of > 3 was considered to represent a poor outcome. Rates were compared using the Fisher exact test, and p values < 0.05 were considered statistically significant.
Results
Nineteen studies were found, which included 273 patients undergoing decompressive craniectomy for malignant cerebral infarcts. Ten of these studies included 73 patients (26.7%) who were > 60 years of age. The mean follow-up times ranged from 5.75 to 12.3 months in the > 60-years group and 4.2 to 28 months in the ≤ 60-years group. The mortality rate was significantly higher, at 51.3% in the > 60-years group (37 of 72 patients) compared with 20.8% (41 of 197 patients) in the ≤ 60-years group (p < 0.0001). Similarly, patients who survived in the > 60-years group had significantly higher rates of poor outcomes, at 81.8% (27 of 33), compared with 33.1% (47 of 142) in the ≤ 60-year-old group (p < 0.0001). The BI was the most commonly used primary outcome measure (15 out of 19 studies), followed by the mRS score, which was used in 4 studies.
Conclusions
The mortality rate and functional outcome, as measured by the BI and mRS, were significantly worse in patients > 60 years of age following decompressive craniectomy for malignant infarction. Age is an important factor to consider in patient selection for surgery. However, cautious interpretation of the results is required because the outcome scores that were used only measure physical disability, whereas other factors, including psychosocial, financial, and caregiver burden, should be considered in addition to age alone.
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Affiliation(s)
- Ahmet Arac
- 1Department of Neurosurgery, Stanford University Medical Center, Stanford; and
| | - Vanessa Blanchard
- 2Department of Occupational Therapy, Samuel Merritt University, Oakland, California
| | - Marco Lee
- 1Department of Neurosurgery, Stanford University Medical Center, Stanford; and
| | - Gary K. Steinberg
- 1Department of Neurosurgery, Stanford University Medical Center, Stanford; and
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Abstract
Hemicraniectomy and opening underlying dura mater permits the expansion of infarcted, swollen brain outwards, reversing dangerous intracranial pressure elevations and the risk of fatal transtentorial temporal lobe or diencephalic herniation. Recently published randomized controlled trials have proven this procedure a powerful life-saving measure in the setting of malignant middle cerebral artery infarction and allayed concerns that a reduction in mortality is accompanied by an unacceptable increase in patients suffering severe neurological impairments. Appropriate patients are relatively young, in the first five decades of life, suffering infarction of a majority of the middle cerebral artery (MCA) territory in either hemisphere, and decompression should be performed prior to progression to coma or two dilated, fixed pupils. Lethargy combined with midline shift and uncal herniation on neuroimaging is an appropriate trigger to consider and discuss surgical intervention. Families and, when possible, patients themselves, should be informed of the certainty of at least moderate to mild permanent deficits, and the possibility of worse. To be successful decompression must be extensive, targeting a bone flap measuring 14 cm from front to back, and extending 1 to 2 cm lateral to the midline sagittal suture to the floor of the middle cranial fossa at the level of the coronal suture. An augmentation duraplasty is mandatory.
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Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol 2009; 8:326-33. [DOI: 10.1016/s1474-4422(09)70047-x] [Citation(s) in RCA: 649] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Kwon JH. Surgical Management of Acute Stroke. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2009. [DOI: 10.5124/jkma.2009.52.4.375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jee-Hyun Kwon
- Department of Neurology, Ulsan University College of Medicine, Korea.
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Schneck MJ, Origitano TC. Hemicraniectomy and durotomy for malignant middle cerebral artery infarction. Neurosurg Clin N Am 2008; 19:459-68, vi. [PMID: 18790381 DOI: 10.1016/j.nec.2008.07.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Decompressive hemicraniectomy with durotomy is a life-saving procedure for patients who have large middle cerebral artery or carotid terminus strokes at high risk for malignant cerebral edema. Although randomized clinical trial data are not yet available, there are several case series that attempt to address issues of patient selection and timing of the procedure in the context of survival and functional outcomes. Patients who have an increased number of medical comorbidities, especially older age, are less likely to benefit from the procedure, but patients who have even large dominant hemispheric infarctions may do relatively well in certain circumstances.
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Affiliation(s)
- Michael J Schneck
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL 60153, USA.
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Huttner HB, Jüttler E, Schwab S. Hemicraniectomy for middle cerebral artery infarction. Curr Neurol Neurosci Rep 2008; 8:526-33. [PMID: 18957191 DOI: 10.1007/s11910-008-0083-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The space-occupying so-called "malignant" middle cerebral artery infarction is-besides acute basilar artery occlusion-the most devastating form of ischemic stroke. Until recently, there was no proven treatment. In 2007, results from randomized controlled trials provided evidence for the benefit of early hemicraniectomy with respect to mortality after 3 months. This review focuses on current treatment options for malignant ischemic brain infarction, especially hemicraniectomy. Moreover, major unsolved problems and open questions regarding the disease are discussed, and perspective is given on future clinical studies.
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Affiliation(s)
- Hagen B Huttner
- Department of Neurology, University of Erlangen, Erlangen, Germany
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Lindgren A, Malm J. A pressuring issue: hemicraniectomy in patients with malignant middle cerebral artery infarction. Int J Stroke 2008; 2:174-6. [PMID: 18705940 DOI: 10.1111/j.1747-4949.2007.00137.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Arne Lindgren
- Department of Neurology, University Hospital, Lund, Sweden
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47
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Abstract
Decompressive Craniectomy (DC) is used to treat elevated intracranial pressure that is unresponsive to conventional treatment modalities. The underlying cause of intracranial hypertension may vary and consequently there is a broad range of literature on the uses of this procedure. Traumatic brain injury (TBI), middle cerebral artery (MCA) infarction, and aneurysmal subarachnoid hemorrhage (SAH) are three conditions for which DC has been predominantly used in the past. Despite an increasing number of reports supportive of DC, the controversy over the suitability of the procedure and criteria for patient selection remains unresolved. Although the majority of published studies is retrospective, the recent publication of several randomized prospective studies prompts a reevaluation of the utility of DC. We review the literature concerning the use of DC in TBI, MCA infarction, and SAH and address the evidence regarding common questions pertaining to the timing of and laterality of the procedure. We conclude that at the time of this review, there still remains insufficient data to support the routine use of DC in TBI, stroke or SAH. There is evidence that early and aggressive use of DC in good-grade patients may improve outcome, but the notion that DC is indicated in these patients is contentious. At this point, the indication for DC should be individualized and its potential implications on long-term outcomes should be comprehensively discussed with the caregivers.
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Jüttler E, Köhrmann M, Aschoff A, Huttner HB, Hacke W, Schwab S. Hemicraniectomy for space-occupying supratentorial ischemic stroke. FUTURE NEUROLOGY 2008. [DOI: 10.2217/14796708.3.3.251] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Space-occupying, malignant hemispheric infarction is one of the most devastating forms of ischemic stroke. Until recently, there was no proven treatment. In 2007, results from randomized, controlled trials provided evidence for the benefit of early hemicraniectomy. This paper provides an overview on the current treatment options for malignant ischemic brain infarction, with a focus on hemicraniectomy. We also discuss major unsolved problems and open questions regarding the disease. Finally, we give a perspective on future clinical studies in this field of stroke.
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Affiliation(s)
- Eric Jüttler
- University of Heidelberg, Department of Neurology, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany
| | - Martin Köhrmann
- University of Erlangen, Department of Neurology, Schwabachanlage 6, D-91054 Erlangen, Germany
| | - Alfred Aschoff
- University of Heidelberg, Department of Neurosurgery, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany
| | - Hagen B Huttner
- University of Erlangen, Department of Neurology, Schwabachanlage 6, D-91054 Erlangen, Germany
| | - Werner Hacke
- University of Heidelberg, Department of Neurology, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany
| | - Stefan Schwab
- University of Erlangen, Department of Neurology, Schwabachanlage 6, D-91054 Erlangen, Germany
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Kilinçer C, Asil T, Utku U, Balci K, Hamamcioglu MK, Hamacioglu MK. Decompression craniotomy. J Neurosurg 2008; 107:1276-7; author reply 1277-8. [PMID: 18077971 DOI: 10.3171/jns-07/12/1276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Wong GK, Kung J, Ng SC, Zhu XL, Poon WS. Decompressive craniectomy for hemispheric infarction: predictive factors for six month rehabilitation outcome. ACTA NEUROCHIRURGICA. SUPPLEMENT 2008; 102:331-333. [PMID: 19388340 DOI: 10.1007/978-3-211-85578-2_63] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Decompressive craniectomy after hemispheric infarction has been shown to reduce mortality and functional outcome in selected patients. However, the optimal timing for surgery and patient most likely to benefit from this procedures was not known. We aimed to determine possible factors predictive of outcome following decompressive craniectomy for ischemic infarction from review of oneurological outcome in our patients at six months. METHODS We retrospectively reviewed 21 patients who underwent decompressive craniectomy for hemispheric infarction over a three year period in a regional neurosurgical center in Hong Kong. All patients were recruited subsequently for active in-patient rehabilitation, when suitable. FINDINGS The median age was 53 and the male to female ration was 1:3. Four patients (19%) achieved independent activity of daily living at six months after rehabilitation. Neither early surgery, within 24-48 hours after admission, nor side of infarction correlated with six month neurological outcome. All four patients with favourable neurological outcome at six month demonstrated favourable clinical improvement even at one month. CONCLUSIONS Early decompressive hemicraniectomy is not predictive of neurological outcome, determined by Glasgow outcome score, at six months (P = 1.00, NS).
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Affiliation(s)
- G K Wong
- Division of Neurosurgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China.
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