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Kang Y, Yeo M, Derman ID, Ravnic DJ, Singh YP, Alioglu MA, Wu Y, Makkar J, Driskell RR, Ozbolat IT. Intraoperative bioprinting of human adipose-derived stem cells and extra-cellular matrix induces hair follicle-like downgrowths and adipose tissue formation during full-thickness craniomaxillofacial skin reconstruction. Bioact Mater 2024; 33:114-128. [PMID: 38024230 PMCID: PMC10665670 DOI: 10.1016/j.bioactmat.2023.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/31/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023] Open
Abstract
Craniomaxillofacial (CMF) reconstruction is a challenging clinical dilemma. It often necessitates skin replacement in the form of autologous graft or flap surgery, which differ from one another based on hypodermal/dermal content. Unfortunately, both approaches are plagued by scarring, poor cosmesis, inadequate restoration of native anatomy and hair, alopecia, donor site morbidity, and potential for failure. Therefore, new reconstructive approaches are warranted, and tissue engineered skin represents an exciting alternative. In this study, we demonstrated the reconstruction of CMF full-thickness skin defects using intraoperative bioprinting (IOB), which enabled the repair of defects via direct bioprinting of multiple layers of skin on immunodeficient rats in a surgical setting. Using a newly formulated patient-sourced allogenic bioink consisting of both human adipose-derived extracellular matrix (adECM) and stem cells (ADSCs), skin loss was reconstructed by precise deposition of the hypodermal and dermal components under three different sets of animal studies. adECM, even at a very low concentration such as 2 % or less, has shown to be bioprintable via droplet-based bioprinting and exhibited de novo adipogenic capabilities both in vitro and in vivo. Our findings demonstrate that the combinatorial delivery of adECM and ADSCs facilitated the reconstruction of three full-thickness skin defects, accomplishing near-complete wound closure within two weeks. More importantly, both hypodermal adipogenesis and downgrowth of hair follicle-like structures were achieved in this two-week time frame. Our approach illustrates the translational potential of using human-derived materials and IOB technologies for full-thickness skin loss.
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Affiliation(s)
- Youngnam Kang
- Engineering Science and Mechanics Department, Penn State University, University Park, PA, 16802, USA
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA, 16802, USA
| | - Miji Yeo
- Engineering Science and Mechanics Department, Penn State University, University Park, PA, 16802, USA
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA, 16802, USA
| | - Irem Deniz Derman
- Engineering Science and Mechanics Department, Penn State University, University Park, PA, 16802, USA
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA, 16802, USA
| | - Dino J. Ravnic
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA, 16802, USA
- Department of Surgery, College of Medicine, Penn State University, Hershey, PA, 17033, USA
| | - Yogendra Pratap Singh
- Engineering Science and Mechanics Department, Penn State University, University Park, PA, 16802, USA
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA, 16802, USA
| | - Mecit Altan Alioglu
- Engineering Science and Mechanics Department, Penn State University, University Park, PA, 16802, USA
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA, 16802, USA
| | - Yang Wu
- School of Mechanical Engineering and Automation, Harbin Institute of Technology, Shenzhen, 518055, China
| | - Jasson Makkar
- School of Molecular Biosciences, College of Veterinary Medicine, Washington State University, Pullman, WA, 99164, USA
| | - Ryan R. Driskell
- School of Molecular Biosciences, College of Veterinary Medicine, Washington State University, Pullman, WA, 99164, USA
| | - Ibrahim T. Ozbolat
- Engineering Science and Mechanics Department, Penn State University, University Park, PA, 16802, USA
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA, 16802, USA
- Department of Biomedical Engineering, Penn State University, University Park, PA, 16802, USA
- Materials Research Institute, Penn State University, University Park, PA, 16802, USA
- Department of Neurosurgery, Pennsylvania State College of Medicine, Hershey, PA, 17033, USA
- Penn State Cancer Institute, Penn State University, Hershey, PA, 17033, USA
- Department of Medical Oncology, Cukurova University, Adana, 01130, Turkey
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2
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Kang Y, Yeo M, Derman ID, Ravnic DJ, Singh YP, Alioglu MA, Wu Y, Makkar J, Driskell RR, Ozbolat IT. Intraoperative Bioprinting of Human Adipose-derived Stem cells and Extra-cellular Matrix Induces Hair Follicle-Like Downgrowths and Adipose Tissue Formation during Full-thickness Craniomaxillofacial Skin Reconstruction. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.10.03.560695. [PMID: 37873077 PMCID: PMC10592950 DOI: 10.1101/2023.10.03.560695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Craniomaxillofacial (CMF) reconstruction is a challenging clinical dilemma. It often necessitates skin replacement in the form of autologous graft or flap surgery, which differ from one another based on hypodermal/dermal content. Unfortunately, both approaches are plagued by scarring, poor cosmesis, inadequate restoration of native anatomy and hair, alopecia, donor site morbidity, and potential for failure. Therefore, new reconstructive approaches are warranted, and tissue engineered skin represents an exciting alternative. In this study, we demonstrated the reconstruction of CMF full-thickness skin defects using intraoperative bioprinting (IOB), which enabled the repair of defects via direct bioprinting of multiple layers of skin on immunodeficient rats in a surgical setting. Using a newly formulated patient-sourced allogenic bioink consisting of both human adipose-derived extracellular matrix (adECM) and stem cells (ADSCs), skin loss was reconstructed by precise deposition of the hypodermal and dermal components under three different sets of animal studies. adECM, even at a very low concentration such as 2% or less, has shown to be bioprintable via droplet-based bioprinting and exhibited de novo adipogenic capabilities both in vitro and in vivo . Our findings demonstrate that the combinatorial delivery of adECM and ADSCs facilitated the reconstruction of three full-thickness skin defects, accomplishing near-complete wound closure within two weeks. More importantly, both hypodermal adipogenesis and downgrowth of hair follicle-like structures were achieved in this two-week time frame. Our approach illustrates the translational potential of using human-derived materials and IOB technologies for full-thickness skin loss.
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Decompressive Craniectomy for Malignant Ischemic Stroke: An Institutional Experience of 145 Cases in a Brazilian Medical Center. World Neurosurg 2022; 161:e580-e586. [PMID: 35202880 DOI: 10.1016/j.wneu.2022.02.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Malignant ischemic stroke (MIS) occurs in a subgroup of patients with cerebrovascular accident who sustain massive or significant cerebral infarction. It is characterized by neurological deterioration owing to progressive edema, raised intracranial pressure, and cerebral herniation. Decompressive craniectomy (DC) is a surgical technique that can be used to treat select cases of this condition in the presence of medically refractory intracranial hypertension. This study aimed to identify prognostic factors associated with clinical outcome, including timing of the procedure, and postoperative mortality. METHODS We analyzed surgical characteristics associated with prognosis in 145 patients who underwent DC secondary to MIS between 2013 and 2018, assessing clinical outcome at discharge and 6 and 12 months after discharge. Our inclusion criteria were DC secondary to MIS in adult patients with raised intracranial pressure signs. RESULTS Our analysis showed that although patients from cities >100 km from the neurosurgical center had a worse prognosis, only the surgical head side (left vs. right, P = 0.001), hospitalization length (P < 0.001), and earlier timing of procedure (P < 0.001) were statistically relevant in having worse outcomes. CONCLUSIONS Patients in whom more time passed from presentation to the neurosurgical procedure, owing to living in a distant city or taking more time to be seen by a specialist, tended to have a worse prognosis. The timing of procedure, surgical side, and hospitalization length were independent predictors in determining the prognosis of patients who underwent DC after an MIS.
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Sadeh M, Patel S, Souter J, Chiu R, Ansari D, Atwal GS. Clinical and radiographic risk indicators for decompressive hemicraniectomy in patients with ischemic stroke: an institutional and national analysis. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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5
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Oliveira BDD, Lima FO, Homem HDC, Figueirêdo AA, Freire VMB, Maia Carvalho FM. Optic Nerve Sheath Diameter Detects Intracranial Hypertension in Acute Malignant Middle Cerebral Artery Infarction. J Stroke Cerebrovasc Dis 2022; 31:106276. [PMID: 35032755 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106276] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 12/15/2021] [Accepted: 12/17/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES To evaluate optic nerve sheath diameter in the acute phase of patients with malignant ischemic middle cerebral artery stroke submitted or not to decompressive craniectomy surgery. MATERIALS AND METHODS Forty patients participated in the study and were evaluated bilaterally by ultrasound on admission and at 24h, 48h and 72 h after admission. Optic nerve sheath diameter values were correlated with tomographic and/or clinical criteria compatible with severe intracranial hypertension. RESULTS A Receiver Operating Characteristic curve was drawn for each eye, determining a cut-off value for severe intracranial hypertension in the right eye of 5.4 mm (sensitivity: 62%; specificity: 100%; AUC: 0.82) and in the left eye 5.4 mm (sensitivity: 76%; specificity: 84%; AUC: 0.77). In patients undergoing craniectomy, there was a decrease in the mean value of 1.04mm in the right eye (pre: 5.84 ± 0.47 mm; post: 4.80 ± 0.84 mm; p = 0.001), while in the left, it decreased around 0.86mm (pre: 5.59 ± 0.69 mm; post: 4.73 ± 0.74 mm; p = 0.003). Patients with fatal outcome showed a persistent high mean ocular nerve sheath diameter. CONCLUSIONS Monitoring optic nerve sheath by ultrasound can be considered a reliable method for identifying severe intracranial hypertension in patients with large vessel occlusion, as well as for monitoring patients undergoing craniectomy. Additional studies will be necessary to include this parameter in craniectomy indication algorithms in the future.
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Affiliation(s)
- Breno Douglas Dantas Oliveira
- Medical Sciences Postgraduation Program, Universidade de Fortaleza (UNIFOR), Fortaleza, Ceará, 60811-905, Brazil; Medicine Program, Universidade de Fortaleza (UNIFOR), Fortaleza, Ceará, 60811-905, Brazil
| | | | - Hellen do Carm Homem
- Neurology Department, Hospital Geral de Fortaleza, Fortaleza, Ceará, 60150-160, Brazil
| | | | | | - Fernanda Martins Maia Carvalho
- Medical Sciences Postgraduation Program, Universidade de Fortaleza (UNIFOR), Fortaleza, Ceará, 60811-905, Brazil; Neurology Department, Hospital Geral de Fortaleza, Fortaleza, Ceará, 60150-160, Brazil.
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6
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Moncal KK, Gudapati H, Godzik KP, Heo DN, Kang Y, Rizk E, Ravnic DJ, Wee H, Pepley DF, Ozbolat V, Lewis GS, Moore JZ, Driskell RR, Samson TD, Ozbolat IT. Intra-Operative Bioprinting of Hard, Soft, and Hard/Soft Composite Tissues for Craniomaxillofacial Reconstruction. ADVANCED FUNCTIONAL MATERIALS 2021; 31:2010858. [PMID: 34421475 PMCID: PMC8376234 DOI: 10.1002/adfm.202010858] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Indexed: 05/20/2023]
Abstract
Reconstruction of complex craniomaxillofacial (CMF) defects is challenging due to the highly organized layering of multiple tissue types. Such compartmentalization necessitates the precise and effective use of cells and other biologics to recapitulate the native tissue anatomy. In this study, intra-operative bioprinting (IOB) of different CMF tissues, including bone, skin, and composite (hard/soft) tissues, is demonstrated directly on rats in a surgical setting. A novel extrudable osteogenic hard tissue ink is introduced, which induced substantial bone regeneration, with ≈80% bone coverage area of calvarial defects in 6 weeks. Using droplet-based bioprinting, the soft tissue ink accelerated the reconstruction of full-thickness skin defects and facilitated up to 60% wound closure in 6 days. Most importantly, the use of a hybrid IOB approach is unveiled to reconstitute hard/soft composite tissues in a stratified arrangement with controlled spatial bioink deposition conforming the shape of a new composite defect model, which resulted in ≈80% skin wound closure in 10 days and 50% bone coverage area at Week 6. The presented approach will be absolutely unique in the clinical realm of CMF defects and will have a significant impact on translating bioprinting technologies into the clinic in the future.
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Affiliation(s)
- Kazim K Moncal
- Engineering Science and Mechanics, The Pennsylvania State University, University Park, PA 16802, USA
- Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, PA 16802, USA
| | - Hemanth Gudapati
- Engineering Science and Mechanics, The Pennsylvania State University, University Park, PA 16802, USA
- Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, PA 16802, USA
| | - Kevin P Godzik
- Biomedical Engineering, The Pennsylvania State University, University Park, PA 16802, USA
| | - Dong N Heo
- Department of Dental Materials, School of Dentistry, Kyung Hee University, Seoul 02447, Republic of Korea
| | - Youngnam Kang
- Engineering Science and Mechanics, The Pennsylvania State University, University Park, PA 16802, USA
| | - Elias Rizk
- Department of Neurosurgery, The Pennsylvania State University, Hershey, PA 17033, USA
| | - Dino J Ravnic
- Department of Surgery, The Pennsylvania State University, Hershey, PA 17033, USA
| | - Hwabok Wee
- Engineering Science and Mechanics, The Pennsylvania State University, University Park, PA 16802, USA
| | - David F Pepley
- Department of Mechanical Engineering, The Pennsylvania State University, University Park, PA 16802, USA
| | - Veli Ozbolat
- Mechanical Engineering Department, Ceyhan Engineering Faculty, Cukurova University, Adana 01950, Turkey
| | - Gregory S Lewis
- Engineering Science and Mechanics, The Pennsylvania State University, University Park, PA 16802, USA
| | - Jason Z Moore
- Biomedical Engineering, The Pennsylvania State University, University Park, PA 16802, USA
| | - Ryan R Driskell
- School of Molecular Biosciences, Washington State University, Pullman, WA 99164, USA
| | - Thomas D Samson
- Department of Neurosurgery, The Pennsylvania State University, Hershey, PA 17033, USA
| | - Ibrahim T Ozbolat
- Engineering Science and Mechanics, The Pennsylvania State University, University Park, PA 16802, USA
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7
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Sun W, Dong X, Yu G, Shuai L, Yuan Y, Ma C. Transcranial direct current stimulation in patients after decompressive craniectomy: a finite element model to investigate factors affecting the cortical electric field. J Int Med Res 2021; 49:300060520942112. [PMID: 33788619 PMCID: PMC8020252 DOI: 10.1177/0300060520942112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To simulate the process of transcranial direct current stimulation (tDCS) on
patients after decompressive craniectomy (DC), and to model cortical
electric field distributions under different electrode montages, we
constructed a finite element model that represented the human head at high
resolution. Methods Using computed tomography images, we constructed a human head model with high
geometrical similarity. The removed bone flap was simplified to be circular
with a diameter of 12 cm. We then constructed finite element models
according to bioelectrical parameters. Finally, we simulated tDCS on the
finite element models under different electrode montages. Results Inward current had a linear relationship with peak electric field value, but
almost no effect on electric field distribution. If the anode was not over
the skull hole (configuration 2), there was almost no difference in electric
field magnitude and focality between the circular and square electrodes.
However, if the anode was right over the hole (configuration 1), the
circular electrodes led to higher peak electric field values and worse
focality. In addition, configuration 1 significantly decreased focality
compared with configuration 2. Conclusion Our results might serve as guidelines for selecting current and electrode
montage settings when performing tDCS on patients after DC.
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Affiliation(s)
- Weiming Sun
- Institute of Life Science, Nanchang University, Nanchang,
Jiangxi Province, China
- School of Life Science, Nanchang University, Nanchang, Jiangxi
Province, China
- Department of Rehabilitation Medicine, The First Affiliated
Hospital of Nanchang University, Nanchang, Jiangxi Province, China
- Yefeng Yuan, Department of Psychosomatic
Medicine, The First Affiliated Hospital of Nanchang University, No.17,
yongwaizheng street, Donghu District, Nanchang , Jiangxi Province 330006, China.
Chaolin Ma, Institute of Life Science,
Nanchang University, No. 999, xuefu road, Honggutan District, Nanchang, Jiangxi
Province 33003, China.
| | - Xiangli Dong
- Department of Psychosomatic Medicine, The Second Affiliated
Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Guohua Yu
- Department of Rehabilitation Medicine, The First Affiliated
Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Lang Shuai
- Department of Rehabilitation Medicine, The First Affiliated
Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Yefeng Yuan
- Department of Psychosomatic Medicine, The First Affiliated
Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Chaolin Ma
- Institute of Life Science, Nanchang University, Nanchang,
Jiangxi Province, China
- School of Life Science, Nanchang University, Nanchang, Jiangxi
Province, China
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8
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Chen SY, Thompson-Leduc P, Sawyer RN, Fakih I, Cheung HC, Macheca M, Kirson NY, Torbey M. Outcomes and resource use of patients with large hemispheric infarction and cerebral edema: analysis of real-world data. Curr Med Res Opin 2021; 37:781-788. [PMID: 33685308 DOI: 10.1080/03007995.2021.1900090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Large hemispheric infarction (LHI) is associated with a high likelihood of the evolution of life-threatening edema. Few studies have assessed real-world clinical outcomes and management strategies among patients with LHI. The objective of this study was to describe the management, in-hospital outcomes, and direct healthcare resource burden of patients with LHI, as well as those of patients with subsequent cerebral edema. METHODS This observational, retrospective cohort study analyzed de-identified data from US adult patients using the IBM MarketScan Hospital Drug Database (Q4-2015 to Q4-2017). Patients were included in the "Possible LHI" or the "Other Ischemic Strokes" cohorts using ICD-10 diagnosis codes. Patients with possible LHI were further categorized into "LHI with Edema" and "LHI without Edema" subgroups using diagnosis and procedure codes. Select clinical and economic outcomes were compared between cohorts and subgroups using multivariable regressions. RESULTS Of 79,201 eligible encounters with ischemic strokes, 11,772 unique patients were assigned to the Possible LHI cohort while 67,429 were assigned to the Other Ischemic Strokes cohort. Among patients with possible LHI, 869 (7%) were assigned to the LHI with Edema subgroup and 10,903 (93%) were assigned to the LHI without Edema subgroup. Patients in the Possible LHI cohort had longer hospital stays (mean difference [MD] [95%CI] = 2.6 [2.4;2.8] days), higher total facility charges (MD [95%CI] = $28,656 [26,794;30,524]), and higher odds of death (odds ratio [95%CI] = 2.2 [2.0;2.4]) than the Other Ischemic Strokes cohort. Among patients with possible LHI, the incremental clinical and resource burden was further exacerbated in the subgroup of patients with edema (hospital days: MD [95%CI] = 5.0 [3.9;6.2] days; total facility charges: MD [95%CI] = $59,585 [50,816;67,583]; mortality: odds ratio [95%CI] = 10.3 [8.5;12.4]). CONCLUSIONS Among patients with ischemic strokes, LHI was associated with increased clinical management and direct healthcare resource burden in real-world hospital settings. The burden was substantially increased among patients who developed cerebral edema.
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Affiliation(s)
| | | | - Robert N Sawyer
- Department of Neurology, University at Buffalo, Buffalo, NY, USA
| | | | | | | | | | - Michel Torbey
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
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Shepetovsky D, Mezzini G, Magrassi L. Complications of cranioplasty in relationship to traumatic brain injury: a systematic review and meta-analysis. Neurosurg Rev 2021; 44:3125-3142. [PMID: 33686551 PMCID: PMC8592959 DOI: 10.1007/s10143-021-01511-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 11/25/2022]
Abstract
Despite being a common procedure, cranioplasty (CP) is associated with a variety of serious, at times lethal, complications. This study explored the relationship between the initial injury leading to decompressive craniectomy (DC) and the rates and types of complications after subsequent CP. It specifically compared between traumatic brain injury (TBI) patients and patients undergoing CP after DC for other indications.A comprehensive search of PubMed, Scopus, and the Cochrane Library databases using PRISMA guidelines was performed to include case-control studies, cohorts, and clinical trials reporting complication data for CP after DC. Information about the patients' characteristics and the rates of overall and specific complications in TBI and non-TBI patients was extracted, summarized, and analyzed.A total of 59 studies, including the authors' institutional experience, encompassing 9264 patients (4671 TBI vs. 4593 non-TBI) met the inclusion criteria; this total also included 149 cases from our institutional series. The results of the analysis of the published series are shown both with and without our series 23 studies reported overall complications, 40 reported infections, 10 reported new-onset seizures, 13 reported bone flap resorption (BFR), 5 reported post-CP hydrocephalus, 10 reported intracranial hemorrhage (ICH), and 8 reported extra-axial fluid collections (EFC). TBI was associated with increased odds of BFR (odds ratio [OR] 1.76, p < 0.01) and infection (OR 1.38, p = 0.02). No difference was detected in the odds of overall complications, seizures, hydrocephalus, ICH, or EFC.Awareness of increased risks of BFR and infection after CP in TBI patients promotes the implementation of new strategies to prevent these complications especially in this category of patients.
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Affiliation(s)
- David Shepetovsky
- Department of Clinical Surgical Diagnostic and Pediatric Sciences, University of Pavia, Viale Brambilla 74, 27100, Pavia, Italy
| | - Gianluca Mezzini
- Department of Clinical Surgical Diagnostic and Pediatric Sciences, University of Pavia, Viale Brambilla 74, 27100, Pavia, Italy
| | - Lorenzo Magrassi
- Department of Clinical Surgical Diagnostic and Pediatric Sciences, University of Pavia, Viale Brambilla 74, 27100, Pavia, Italy. .,IRCCS Fondazione Policlinico S. Matteo, Pavia, Italy.
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10
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Champeaux C, Weller J. Long-Term Survival After Decompressive Craniectomy for Malignant Brain Infarction: A 10-Year Nationwide Study. Neurocrit Care 2021; 32:522-531. [PMID: 31290068 DOI: 10.1007/s12028-019-00774-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Decompressive craniectomy (DC) has been shown to be an effective treatment for malignant cerebral infarction (MCI). There are limited nationwide studies evaluating outcome after craniectomy for MCI. OBJECTIVE To describe the evolution in DC practices for MCI, long-term survival, and associated prognostic factors. METHODS We searched the French medico-administrative national database to retrieve patients who underwent DC between 2008 and 2017. RESULTS A total of 1841 cases of DC were performed over 10 years in 51 centers. Mean age at procedure was 50.9 years, 18% were above 60 years, and 64.4% were male. There was a significant increase in DC for MCI over the 10 years (p < 0.001), and the annual volume of procedures more than doubled (95/year vs. 243/year). Early survival at one week and one month was 86%, 95%CI (84.5, 87.6) and 79.7%, 95%CI (77.8, 81.5), respectively. Long-term survival at 1 and 5 years were 73.6%, 95%CI (71.6, 75.7) and 68.9%, 95%CI (66.5, 71.4), respectively. Patients below 60 years at the time of DC (HR = 0.5; 95%CI [0.4, 0.7], p < 0.001), DC being performed in a center with a high surgical activity (HR = 0.8; 95%CI [0.6, 0.9], p = 0.002), and the patients having unimpaired consciousness (HR = 0.6; 95%CI [0.5, 0.8], p < 0.001) were associated with increased survival in both univariate and adjusted Cox regressions. 18.7% of the survivors had a cranioplasty inserted within 3 months and 57.8% within 6 months. The probability of having a cranioplasty at one year was 75.6%, 95%CI (77.9, 73.1). CONCLUSION Over the past 10 years in France, DC has been increasingly performed for MCI regardless of age. However, in-hospital mortality remains considerable, as about one quarter of patients died within the first weeks. For those who survive beyond 6 months, the risk of death significantly decreases. Early mortality is especially high for comatose patients above 60 years operated in inexperienced centers. Most of those who remain in good functional status tend to undergo a cranioplasty within the year following DC.
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Affiliation(s)
- Charles Champeaux
- INSERM U1153, Statistic and Epidemiologic Research Centre Sorbonne Paris Cité (CRESS), ECSTRA Team, Université Diderot - Paris 7, USPC, Paris, France. .,Department of Neurosurgery, Lariboisière Hospital, 75010, Paris, France. .,Department of Neurosurgery, Lariboisière Hospital, 2, rue Ambroise Paré, 75475, Paris Cedex 10, France.
| | - Joconde Weller
- Department of Medical Information, Sainte-Anne Hospital, 75014, Paris, France
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11
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Kinsman M, Aljuboori Z, Ball T, Nauta H, Boakye M. Rapid high-fidelity contour shaping of titanium mesh implants for cranioplasty defects using patient-specific molds created with low-cost 3D printing: A case series. Surg Neurol Int 2020; 11:288. [PMID: 33033650 PMCID: PMC7538793 DOI: 10.25259/sni_482_2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 08/28/2020] [Indexed: 11/18/2022] Open
Abstract
Background: Cranioplasty is a neurosurgical procedure to repair skull defects. Sometimes, the patients’ bone flap cannot be used for various reasons. Alternatives include a custom polyether ether ketone (PEEK) implant or titanium mesh; both incur an additional cost. We present a technique that uses a 3D printer to create a patient- specific 3D model used to mold a titanium mesh preoperatively. Case Description: We included three patients whose bone flap could not be used. We collected the patients’ demographics, cost, and time data for implants and the 3D printer. The patients’ computed tomography DICOM images were used for 3D reconstruction of the cranial defect. A 3D printer (Flashforge, CA) was used to print a custom mold of the defect, which was used to shape the titanium mesh. All patients had excellent cosmetic results with no complications. The time required to print a 3D model was ~ 6 h and 45 min for preoperative shaping of the titanium implant. The intraoperative molding (IOM) of a titanium mesh needed an average of 60 min additional operative room time which incurred $4000. The average cost for PEEK and flat titanium mesh is $12,600 and $6750. Our method resulted in $4000 and $5500 cost reduction in comparison to flat mesh with IOM and PEEK implant. Conclusion: 3D printing technology can create a custom model to shape a titanium mesh preoperatively for cranioplasty. It can result in excellent cosmetic results and significant cost reduction in comparison to other cranioplasty options.
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Affiliation(s)
- Michael Kinsman
- Department of Neurosurgery, Kansas University, Kansas City, Missouri
| | - Zaid Aljuboori
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
| | - Tyler Ball
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
| | - Haring Nauta
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
| | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
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12
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Wen X, Li Y, He X, Xu Y, Shu Z, Hu X, Chen J, Jiang H, Gong X. Prediction of Malignant Acute Middle Cerebral Artery Infarction via Computed Tomography Radiomics. Front Neurosci 2020; 14:708. [PMID: 32733197 PMCID: PMC7358521 DOI: 10.3389/fnins.2020.00708] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/11/2020] [Indexed: 12/23/2022] Open
Abstract
Malignant middle cerebral artery infarction (mMCAi) is a serious complication of cerebral infarction usually associated with poor patient prognosis. In this retrospective study, we analyzed clinical information as well as non-contrast computed tomography (NCCT) and computed tomography angiography (CTA) data from patients with cerebral infarction in the middle cerebral artery (MCA) territory acquired within 24 h from symptoms onset. Then, we aimed to develop a model based on the radiomics signature to predict the development of mMCAi in cerebral infarction patients. Patients were divided randomly into training (n = 87) and validation (n = 39) sets. A total of 396 texture features were extracted from each NCCT image from the 126 patients. The least absolute shrinkage and selection operator regression analysis was used to reduce the feature dimension and construct an accurate radiomics signature based on the remaining texture features. Subsequently, we developed a model based on the radiomics signature and Alberta Stroke Program Early CT Score (ASPECTS) based on NCCT to predict mMCAi. Our prediction model showed a good predictive performance with an AUC of 0.917 [95% confidence interval (CI), 0.863-0.972] and 0.913 [95% CI, 0.795-1] in the training and validation sets, respectively. Additionally, the decision curve analysis (DCA) validated the clinical efficacy of the combined risk factors of radiomics signature and ASPECTS based on NCCT in the prediction of mMCAi development in patients with acute stroke across a wide range of threshold probabilities. Our research indicates that radiomics signature can be an instrumental tool to predict the risk of mMCAi.
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Affiliation(s)
- Xuehua Wen
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Yumei Li
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xiaodong He
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Yuyun Xu
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Zhenyu Shu
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xingfei Hu
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Junfa Chen
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Hongyang Jiang
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xiangyang Gong
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China.,Institute of Artificial Intelligence and Remote Imaging, Hangzhou Medical College, Hangzhou, China
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13
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Pelegrini de Almeida L, Casarin MC, Mosser HL, Worm PV. Epileptic Syndrome and Cranioplasty: Implication of Reconstructions in the Electroencephalogram. World Neurosurg 2020; 137:e517-e525. [PMID: 32081819 DOI: 10.1016/j.wneu.2020.02.036] [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: 10/15/2019] [Revised: 02/04/2020] [Accepted: 02/05/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND In the presence of a skull deformity after large decompressive craniectomy (DC), neurologic deterioration manifesting as epileptic syndrome (ES) may occur independently of the primary disease or spontaneous improvement may be unduly impaired, and these unfavorable outcomes have sometimes been reversed by cranioplasty. The objective of this study was to analyze the influence of cranioplasty on the presence of ES in patients who underwent DC. METHODS A prospective study was performed from October 2016 to October 2017 involving patients who underwent DC and subsequent cranioplasty. Electroencephalographic (EEG) status before and after cranioplasty was analyzed in the presence of seizures and was compared with results after DC. RESULTS The sample included 52 patients. Male sex (78.8%) and traumatic brain injury (82.7%) were common indications for DC. ES after DC was verified in 26.9% of patients, and 50% of patients presented with abnormal EEG status. ES after cranioplasty was noted in 21.2% and 36.3% of patients followed by abnormal EEG status. All patients with precranioplasty epileptogenic paroxysms showed better EEG tracings after the procedure. CONCLUSIONS In routine clinical practice, altered amplitudes were observed in the region of bone defects. Although cranioplasty reduced pathologic EEG status (epileptogenic paroxysms), it was not able to produce new EEG tracings that could predict changes in seizure discharge or reduce ES.
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Affiliation(s)
| | | | - Humberto Luiz Mosser
- Department of Neurology, Nossa Senhora da Conceição Hospital, Porto Alegre, Brazil
| | - Paulo Valdeci Worm
- Department of Neurosurgery, Cristo Redentor Hospital, Porto Alegre, Brazil
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14
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Zhong Z, Wu H, Ye M, Yang Y, Luo W, Wu Y, Wu H, Zhong M, Zhao P. Association of APOE Gene Polymorphisms with Cerebral Infarction in the Chinese Population. Med Sci Monit 2018; 24:1171-1177. [PMID: 29479056 PMCID: PMC5841926 DOI: 10.12659/msm.905979] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Apolipoprotein E (ApoE) is a multifunctional protein that plays an important role in lipoprotein metabolism. However, the relationship between APOE gene polymorphisms and cerebral infarction in the Chinese population remains unclear. Therefore, we studied the role of APOE gene polymorphisms in patients with cerebral infarction in a Chinese population. Material/Methods This study involved 906 patients with cerebral infarction and 1,141 individuals without cerebral infarction who served as controls. APOE genotypes were identified in all participants who participated in the study. Factors influencing cerebral infarction were also analyzed. Results Statistically significant variances in the distribution and frequencies of the APOE genotypes in the patients were observed (ɛ2/ɛ3 versus ɛ2/ɛ4 versus ɛ3/ɛ3=22.85% versus 7.62% versus 56.95%) and controls (ɛ2/ɛ3 versus ɛ2/ɛ4 versus ɛ3/ɛ3=17.27% versus 2.72% versus 66.87%; p<0.001). Univariate analysis showed that the APOE ɛ3/ɛ3 genotype [OR, 0.393 (95% CI, 0.237–0.653); p<0.001] and ɛ3/ɛ4 genotype [OR, 0.376 (95% CI 0.221–0.637); p<0.001] played a protective role against cerebral infarction in Chinese men. Conclusions Statistically significant variances in the distribution and frequencies of the APOE genotypes of the patients and controls were observed. The study demonstrated that the APOE ɛ3/ɛ3 and ɛ3/ɛ4 genotypes played a protective role against cerebral infarction in Chinese men, but not women. Additionally, the ɛ2/ɛ4 genotype may be a potential risk factor in men, whereas ɛ3/ɛ4 genotype may play a potential protective role against this disease in women.
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Affiliation(s)
- Zhixiong Zhong
- Center for Cardiovascular Diseases, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, Guangdong, China (mainland).,Center for Precision Medicine, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - Heming Wu
- Center for Precision Medicine, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, Guangdong, China (mainland).,Clinical Core Laboratory, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - Min Ye
- Department of Neurosurgery, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - Yuxian Yang
- Department of Neurology, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - Weixiong Luo
- Surgical Intensive Care Unit, Meizhou People's Hospital, Huangtang Hospital, Meizhou Hospital Affiliated to Sun Yat-sen University, , China (mainland)
| | - Yanli Wu
- Center for Precision Medicine, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, Guangdong, China (mainland).,Clinical Core Laboratory, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - Hesen Wu
- Center for Precision Medicine, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, Guangdong, China (mainland).,Clinical Core Laboratory, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - Miaocai Zhong
- Center for Precision Medicine, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, Guangdong, China (mainland).,Clinical Core Laboratory, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - Pingsen Zhao
- Center for Precision Medicine, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, Guangdong, China (mainland).,Clinical Core Laboratory, Meizhou People's Hospital (Huangtang Hospital), Meizhou Hospital Affiliated to Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
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15
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Lee JC, Volpicelli EJ. Bioinspired Collagen Scaffolds in Cranial Bone Regeneration: From Bedside to Bench. Adv Healthc Mater 2017; 6:10.1002/adhm.201700232. [PMID: 28585295 PMCID: PMC5831258 DOI: 10.1002/adhm.201700232] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/11/2017] [Indexed: 12/24/2022]
Abstract
Calvarial defects are common reconstructive dilemmas secondary to a variety of etiologies including traumatic brain injury, cerebrovascular disease, oncologic resection, and congenital anomalies. Reconstruction of the calvarium is generally undertaken for the purposes of cerebral protection, contour restoration for psychosocial well-being, and normalization of neurological dysfunction frequently found in patients with massive cranial defects. Current methods for reconstruction using autologous grafts, allogeneic grafts, or alloplastic materials have significant drawbacks that are unique to each material. The combination of wide medical relevance and the need for a better clinical solution render defects of the cranial skeleton an ideal target for development of regenerative strategies focused on calvarial bone. With the improved understanding of the instructive properties of tissue-specific extracellular matrices and the advent of precise nanoscale modulation in materials science, strategies in regenerative medicine have shifted in paradigm. Previously considered to be simple carriers of stem cells and growth factors, increasing evidence exists for differential materials directing lineage specific differentiation of progenitor cells and tissue regeneration. In this work, we review the clinical challenges for calvarial reconstruction, the anatomy and physiology of bone, and extracellular matrix-inspired, collagen-based materials that have been tested for in vivo cranial defect healing.
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Affiliation(s)
- Justine C Lee
- Greater Los Angeles Veterans Affairs Research Service, Los Angeles, California
- University of California Los Angeles Division of Plastic and Reconstructive Surgery, Los Angeles, California
| | - Elizabeth J Volpicelli
- Greater Los Angeles Veterans Affairs Research Service, Los Angeles, California
- University of California Los Angeles Division of Plastic and Reconstructive Surgery, Los Angeles, California
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16
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Kamran S, Salam A, Akhtar N, Alboudi A, Ahmad A, Khan R, Nazir R, Nadeem M, Inshasi J, ElSotouhy A, Al Sulaiti G, Shuaib A. Predictors of In-Hospital Mortality after Decompressive Hemicraniectomy for Malignant Ischemic Stroke. J Stroke Cerebrovasc Dis 2017; 26:1941-1947. [PMID: 28694110 DOI: 10.1016/j.jstrokecerebrovasdis.2017.06.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 10/27/2016] [Accepted: 06/11/2017] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The purpose of this retrospective multicenter, pooled-data analysis was to determine the factors associated with in-hospital mortality in decompressive hemicraniectomy (DHC) for malignant middle cerebral artery (MMCA) stroke. PATIENTS AND METHODS The authors reviewed pooled DHC database from 3 countries for patients with MMCA with hospital mortality in spite of DHC to identify factors that predicted in-hospital mortality after DHC. The identified factors were applied to the group of patients who were selected for DHC but either refused surgery and died or stabilized and did not undergo DHC. FINDINGS There were 137 patients who underwent DHC. Multiple logistic regression analysis showed middle cerebral artery (MCA) with additional infarcts (odds ratio [OR], 7.9: 95% confidence interval [CI], 2.4-26; P = .001), preoperative midline shift of septum pellucidum of 1 cm or more (OR, 3.83: 95% CI, 1.13-12.96; P = .031), and patients who remained unconscious on day 7 postoperatively (8.82: 95% CI; OR, 1.08-71.9; P = .042) were significant independent predictors for in-hospital mortality. The identified factors were applied to the group of MMCA patients not operated (n = 19 refused, n = 47 stabilized) single (P < .001), and two predictive factors (P < .001) were significantly more common in patients who died. Whereas two predicative factors were identified in only 9%-18.2% of survivors, the presence of all three predictive factors was seen only in patients who expired (P < .001). The Hosmer-Lemeshow goodness-of-fit statistics (chi-square = 4.65; P value = .589) indicate that the model adequately describes the data. CONCLUSION Direct physical factors, such as MCA with additional territory infarct, extent of midline shift, and postoperative consciousness level, bore a significant relationship to in-hospital mortality in MMCA patients undergoing DHC.
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Affiliation(s)
- Saadat Kamran
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Weill Cornell School of Medicine, Qatar.
| | - Abdul Salam
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Naveed Akhtar
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Weill Cornell School of Medicine, Qatar
| | - Aymen Alboudi
- Department of Neurology, Rashid Hospital, Dubai, United Arab Emirates
| | - Arsalan Ahmad
- Department of Neurology and Neurosurgery, Shifa International Hospital, Islamabad, Pakistan
| | - Rabia Khan
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Rashed Nazir
- Department of Neurology and Neurosurgery, Shifa International Hospital, Islamabad, Pakistan
| | - Muhammad Nadeem
- Department of Neurology and Neurosurgery, Shifa International Hospital, Islamabad, Pakistan
| | - Jihad Inshasi
- Department of Neurology, Rashid Hospital, Dubai, United Arab Emirates
| | - Ahmed ElSotouhy
- Department of Radiology, Hamad General Hospital, Hamad Medical Corporation, Qatar
| | - Ghanim Al Sulaiti
- Department of Neurosurgery, The Neuroscience Institute Hamad General Hospital, Medical Corporation, Doha, Qatar
| | - Ashfaq Shuaib
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Stroke Program, University of Alberta, Canada
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17
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Brown DA, Wijdicks EFM. Decompressive craniectomy in acute brain injury. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:299-318. [PMID: 28187804 DOI: 10.1016/b978-0-444-63600-3.00016-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Decompressive surgery to reduce pressure under the skull varies from a burrhole, bone flap to removal of a large skull segment. Decompressive craniectomy is the removal of a large enough segment of skull to reduce refractory intracranial pressure and to maintain cerebral compliance for the purpose of preventing neurologic deterioration. Decompressive hemicraniectomy and bifrontal craniectomy are the most commonly performed procedures. Bifrontal craniectomy is most often utilized with generalized cerebral edema in the absence of a focal mass lesion and when there are bilateral frontal contusions. Decompressive hemicraniectomy is most commonly considered for malignant middle cerebral artery infarcts. The ethical predicament of deciding to go ahead with a major neurosurgical procedure with the purpose of avoiding brain death from displacement, but resulting in prolonged severe disability in many, are addressed. This chapter describes indications, surgical techniques, and complications. It reviews results of recent clinical trials and provides a reasonable assessment for practice.
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Affiliation(s)
- D A Brown
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - E F M Wijdicks
- Division of Critical Care Neurology, Mayo Clinic and Neurosciences Intensive Care Unit, Mayo Clinic Campus, Saint Marys Hospital, Rochester, MN, USA.
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18
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Sheth KN, Elm JJ, Beslow LA, Sze GK, Kimberly WT. Glyburide Advantage in Malignant Edema and Stroke (GAMES-RP) Trial: Rationale and Design. Neurocrit Care 2016; 24:132-9. [PMID: 26268138 DOI: 10.1007/s12028-015-0189-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with large territory infarction are at high risk of cerebral edema and neurological deterioration, including death. Preclinical studies have shown that a continuous infusion of glyburide blocks edema formation and improves outcome. We hypothesize that treatment with RP-1127 (Glyburide for Injection) reduces formation of brain edema in patients after large anterior circulation infarction. METHODS GAMES-RP is a prospective, randomized, double-blind, multicenter trial designed to evaluate RP-1127 in patients at high risk for the development of malignant cerebral edema. The study population consisted of subjects with a clinical diagnosis of acute severe anterior circulation ischemic stroke with a baseline diffusion-weighted image lesion between 82 and 300 cm(3) who are 18-80 years of age. The target time from symptom onset to start of study infusion was ≤10 h. Subjects were randomized to RP-1127 (glyburide for injection) or placebo and treated with a continuous infusion for 72 h. RESULTS The primary efficacy outcome was a composite of the modified Rankin Scale and the incidence of decompressive craniectomy, assessed at 90 days. Safety outcomes were the frequency and severity of adverse events, with a focus on cardiac- and glucose-related serious adverse events. CONCLUSIONS GAMES-RP was designed to provide critical information regarding glyburide for injection in patients with large hemispheric stroke and will inform the design of future studies.
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Affiliation(s)
- Kevin N Sheth
- Division of Neurocritical Care & Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York Street, LCI 1003, New Haven, CT, 06510, USA.
| | - Jordan J Elm
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, USA
| | - Lauren A Beslow
- Division of Neurocritical Care & Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York Street, LCI 1003, New Haven, CT, 06510, USA.,Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Gordon K Sze
- Department of Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - W Taylor Kimberly
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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Abstract
Malignant cerebral edema is a potential consequence of large territory cerebral infarction, as the resultant elevation in intracranial pressure may progress to transtentorial herniation, brainstem compression, and death. In appropriate patients, decompressive hemicraniectomy (DHC) reduces mortality without increasing the risk of severe disability. However, as the foundational DHC randomized, controlled trials excluded patients greater than 60 years of age, the appropriateness of DHC in older adults remains controversial. Recent clinical trials among elderly participants, including DESTINY II, reported that DHC reduces mortality, but may leave patients with substantial morbidity. Nationwide analyses have demonstrated generalizability of such data. However, what constitutes an acceptable outcome - the perspective on quality of life after survival with substantial disability - varies between clinicians, patients, and caregivers. Consequently, quality of life measures are being increasingly incorporated into stroke research. This review summarizes the impact of DHC in space-occupying cerebral infarction, and the influence of patient age on postoperative survival, functional capacity, and quality of life-all key factors in the clinical decision process. Ultimately, these data underscore the inherent complexity in balancing scientific evidence, clinical expertise, and patient and family preference when pursuing hemicraniectomy among the elderly.
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Affiliation(s)
- Faith C Robertson
- Harvard Medical School, Boston, Massachusetts, United States of America.,Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Hormuzdiyar H Dasenbrock
- Harvard Medical School, Boston, Massachusetts, United States of America.,Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.,Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - William B Gormley
- Harvard Medical School, Boston, Massachusetts, United States of America.,Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.,Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
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20
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Patient Age and the Outcomes after Decompressive Hemicraniectomy for Stroke: A Nationwide Inpatient Sample Analysis. Neurocrit Care 2016; 25:371-383. [DOI: 10.1007/s12028-016-0287-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Decompressive craniectomy (DC) has been used for many years in the management of patients with elevated intracranial pressure and cerebral edema. Ongoing clinical trials are investigating the clinical and cost effectiveness of DC in trauma and stroke. While DC has demonstrable efficacy in saving life, it is accompanied by a myriad of non-trivial complications that have been inadequately highlighted in prospective clinical trials. Missing from our current understanding is a comprehensive analysis of all potential complications associated with DC. Here, we review the available literature, we tabulate all reported complications, and we calculate their frequency for specific indications. Of over 1500 records initially identified, a final total of 142 eligible records were included in our comprehensive analysis. We identified numerous complications related to DC that have not been systematically reviewed. Complications were of three major types: (1) Hemorrhagic (2) Infectious/Inflammatory, and (3) Disturbances of the CSF compartment. Complications associated with cranioplasty fell under similar major types, with additional complications relating to the bone flap. Overall, one of every ten patients undergoing DC may suffer a complication necessitating additional medical and/or neurosurgical intervention. While DC has received increased attention as a potential therapeutic option in a variety of situations, like any surgical procedure, DC is not without risk. Neurologists and neurosurgeons must be aware of all the potential complications of DC in order to properly advise their patients.
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22
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Association between total antioxidant capacity and mortality in ischemic stroke patients. Ann Intensive Care 2016; 6:39. [PMID: 27107565 PMCID: PMC4842192 DOI: 10.1186/s13613-016-0143-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 04/11/2016] [Indexed: 11/10/2022] Open
Abstract
Objective Data on circulating total antioxidant capacity (TAC) levels in ischemic stroke patients compared with healthy controls are limited and provided conflicting findings. There are not data about the association between circulating TAC levels, peroxidation state and outcome in patients with severe ischemic stroke. The objective of this study was to examine the relationship of TAC with 30-day mortality after severe ischemic stroke. Methods This multicenter study included 58 patients with coma (Glasgow Coma Scale < 9) following severe malignant middle cerebral artery infarction (MMCAI). We measured circulating levels of TAC and malondialdehyde (MDA, a biomarker of lipid peroxidation) on day 1 of severe MMCAI diagnosis. The study endpoint was 30-day mortality. Results Non-survivors (n = 29) showed higher serum TAC levels (p < 0.001) and higher serum MDA levels (p = 0.004) than survivors (n = 29). Multiple binomial logistic regression analysis showed that serum TAC levels were associated with 30-day mortality, after controlling for Glasgow Coma Scale and age (odds ratio 1.92; 95 % confidence interval 1.201–3.072; p = 0.006). There was a correlation between serum TAC and MDA levels (rho = 0.35; p = 0.008). Conclusions This single-center study in severe MMCAI patients found an association between higher serum TAC levels and 30-day mortality and further identified a relationship between serum TAC levels, lipid peroxidation state and mortality after severe ischemic stroke.
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Santana-Cabrera L, Ocampo-Pérez J, Rodríguez-Escot C, Granados-Rodríguez M, Rodríguez-Pérez H. Safety and outcomes of decompressive craniectomy after intravenous tissue plasminogen activator administration for malignant cerebral infarction. Br J Neurosurg 2016; 30:274-6. [DOI: 10.3109/02688697.2016.1161177] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
PURPOSE OF REVIEW Large hemispheric infarction is a devastating disease that continues to be associated with significant mortality and morbidity. Most often these patients are admitted to the ICU requiring significant physician and nursing resources. This review will address some of the ICU management issues and review the evidence supporting medical and surgical management of malignant cerebral edema. RECENT FINDINGS The most recent changes in management of large hemispheric infarct include the American Heart Association and Neurocritical Care Guidelines. These guidelines address airway management and mechanical ventilation, blood pressure control, fluid management, and glucose and temperature control. In addition, they addressed the indication for surgical management of cerebral edema. We review the recent guidelines updates and trials of surgical management of large hemispheric infarcts. SUMMARY Large hemispheric infarcts continue to have significant morbidity and mortality. Recent guidelines have provided an excellent framework to help intensivists manage these complicated patients. Recent surgical data continue to support early hemicraniectomy even in elderly patients.
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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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26
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Pushkov D, Nicholson JD, Michowiz S, Novitzky I, Weiss S, Ben Hemou M, Hochhauser E, Goldenberg-Cohen N. Relative neuroprotective effects hyperbaric oxygen treatment and TLR4 knockout in a mouse model of temporary middle cerebral artery occlusion. Int J Neurosci 2015; 126:174-81. [PMID: 25562174 DOI: 10.3109/00207454.2014.1002609] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To examine the effects of hyperbaric oxygen (HBO) therapy and knockout of toll-like receptor 4 (TLR4) on the outcome of temporary middle cerebral artery occlusion (MCAO) in a mouse model. MATERIALS AND METHODS MCAO was induced in anesthetized male C57Bl/6 mice (WT) and TLR4 knockout mice (TLR4(-/-)) using an intra-arterial filament method. After 30 or 90 min, the filament was removed, and the mice were given either no treatment (WT and TLR4(-/-) groups) or HBO (WT only). Mice were euthanized 24 h after MCAO, and the brain infarct area was examined using 2,3,5-triphenyltetrazolium chloride (TTC) staining. RESULTS In the WT group, without treatment, lesion volume was 120 ± 13 mm(3) in the mice subjected to 30 min' MCAO and 173 ± 23 mm(3) in the mice subjected to 90 min' MCAO. Respective values with HBO treatment were 66.5 ± 36.7 mm(3) and 53.2 ± 17.2 mm(3). The difference was significant only for 90-minute MCAO (p < 0.01, nonparametric test). In the TLR4(-/-) group (all untreated), lesion volume was 95.9 ± 17.9 after 90 min of MCAO, which was significantly lower than in the untreated WT animals (p < 0.05, nonparametric test). CONCLUSIONS A single treatment of HBO immediately after MCAO followed by 24 h' reperfusion significantly reduces edema and may improve perfusion. TLR4 knockout protects mice from MCAO damage, but to a lesser extent than HBO treatment.
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Affiliation(s)
- Dennis Pushkov
- a Department of Neurosurgery, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel
| | - James D Nicholson
- c Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,d The Krieger Eye Research Laboratory, Felsenstein Medical Research Center, Petach Tikva, Israel
| | - Shalom Michowiz
- a Department of Neurosurgery, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel.,c Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ivan Novitzky
- a Department of Neurosurgery, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel
| | - Shirel Weiss
- c Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,d The Krieger Eye Research Laboratory, Felsenstein Medical Research Center, Petach Tikva, Israel
| | - Moshe Ben Hemou
- c Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,d The Krieger Eye Research Laboratory, Felsenstein Medical Research Center, Petach Tikva, Israel
| | - Edith Hochhauser
- c Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,e Laboratory of Cardiac Research, Felsenstein Medical Research Center, Petach Tikva, Israel
| | - Nitza Goldenberg-Cohen
- b Pediatric Ophthalmology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,c Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,d The Krieger Eye Research Laboratory, Felsenstein Medical Research Center, Petach Tikva, Israel
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Glibenclamide for the treatment of ischemic and hemorrhagic stroke. Int J Mol Sci 2015; 16:4973-84. [PMID: 25749474 PMCID: PMC4394459 DOI: 10.3390/ijms16034973] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 02/17/2015] [Accepted: 02/26/2015] [Indexed: 11/16/2022] Open
Abstract
Ischemic and hemorrhagic strokes are associated with severe functional disability and high mortality. Except for recombinant tissue plasminogen activator, therapies targeting the underlying pathophysiology of central nervous system (CNS) ischemia and hemorrhage are strikingly lacking. Sur1-regulated channels play essential roles in necrotic cell death and cerebral edema following ischemic insults, and in neuroinflammation after hemorrhagic injuries. Inhibiting endothelial, neuronal, astrocytic and oligodendroglial sulfonylurea receptor 1-transient receptor potential melastatin 4 (Sur1-Trpm4) channels and, in some cases, microglial KATP (Sur1-Kir6.2) channels, with glibenclamide is protective in a variety of contexts. Robust preclinical studies have shown that glibenclamide and other sulfonylurea agents reduce infarct volumes, edema and hemorrhagic conversion, and improve outcomes in rodent models of ischemic stroke. Retrospective studies suggest that diabetic patients on sulfonylurea drugs at stroke presentation fare better if they continue on drug. Additional laboratory investigations have implicated Sur1 in the pathophysiology of hemorrhagic CNS insults. In clinically relevant models of subarachnoid hemorrhage, glibenclamide reduces adverse neuroinflammatory and behavioral outcomes. Here, we provide an overview of the preclinical studies of glibenclamide therapy for CNS ischemia and hemorrhage, discuss the available data from clinical investigations, and conclude with promising preclinical results that suggest glibenclamide may be an effective therapeutic option for ischemic and hemorrhagic stroke.
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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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Macdonald RL. When you are old. Stroke 2014; 45:2830-2. [PMID: 25116871 DOI: 10.1161/strokeaha.114.006666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- R Loch Macdonald
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St Michael's Hospital, Department of Surgery, University of Toronto, Ontario, Canada.
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Walcott BP, Miller JC, Kwon CS, Sheth SA, Hiller M, Cronin CA, Schwamm LH, Simard JM, Kahle KT, Kimberly WT, Sheth KN. Outcomes in severe middle cerebral artery ischemic stroke. Neurocrit Care 2014; 21:20-6. [PMID: 23839704 PMCID: PMC3880600 DOI: 10.1007/s12028-013-9838-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Severe middle cerebral artery stroke (MCA) is associated with a high rate of morbidity and mortality. We assessed the hypothesis that patient-specific variables may be associated with outcomes. We also sought to describe under-recognized patient-centered outcomes. METHODS A consecutive, multi-institution, retrospective cohort of adult patients (≤70 years) was established from 2009 to 2011. We included patients with NIHSS score ≥15 and infarct volume ≥60 mL measured within 48 h of symptom onset. Malignant edema was defined as the development of midline brain shift of ≥5 mm in the first 5 days. Exclusion criterion was enrollment in any experimental trial. A univariate and multivariate logistic regression analysis was performed to model and predict the factors related to outcomes. RESULTS 46 patients (29 female, 17 male; mean age 57.3 ± 1.5 years) met study criteria. The mortality rate was 28% (n = 13). In a multivariate analysis, only concurrent anterior cerebral artery (ACA) involvement was associated with mortality (OR 9.78, 95% CI 1.15, 82.8, p = 0.04). In the malignant edema subgroup (n = 23, 58%), 4 died (17%), 7 underwent decompressive craniectomy (30%), 7 underwent tracheostomy (30%), and 15 underwent gastrostomy (65%). CONCLUSIONS Adverse outcomes after severe stroke are common. Concurrent ACA involvement predicts mortality in severe MCA stroke. It is useful to understand the incidence of life-sustaining procedures, such as tracheostomy and gastrostomy, as well as factors that contribute to their necessity.
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Yang TW, Son S, Choi DS, Oh MK, Lee CH, Kim SK, Kang H, Park KJ, Choi NC, Kwon OY, Lim BH. Factors Affecting Acceptable Behavior Toward Decompressive Craniectomy For Malignant Middle Cerebral Artery Infarction. JOURNAL OF NEUROCRITICAL CARE 2014. [DOI: 10.18700/jnc.2014.7.1.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Walcott BP, Kamel H, Castro B, Kimberly WT, Sheth KN. Tracheostomy after severe ischemic stroke: a population-based study. J Stroke Cerebrovasc Dis 2014; 23:1024-9. [PMID: 24103666 PMCID: PMC3976897 DOI: 10.1016/j.jstrokecerebrovasdis.2013.08.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 08/03/2013] [Accepted: 08/23/2013] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Stroke can result in varying degrees of respiratory failure. Some patients require tracheostomy in order to facilitate weaning from mechanical ventilation, long-term airway protection, or a combination of the two. Little is known about the rate and predictors of this outcome in patients with severe stroke. We aim to determine the rate of tracheostomy after severe ischemic stroke. METHODS Using the Nationwide Inpatient Sample database from 2007 to 2009, patients hospitalized with ischemic stroke were identified based on validated International Classification of Diseases, 9th revision, Clinical Modification codes. Next, patients with stroke were stratified based on whether they were treated with or without decompressive craniectomy, and the rate of tracheostomy for each group was determined. A logistic regression analysis was used to identify predictors of tracheostomy after decompressive craniectomy. Survey weights were used to obtain nationally representative estimates. RESULTS In 1,550,000 patients discharged with ischemic stroke nationwide, the rate of tracheostomy was 1.3% (95% confidence interval [CI], 1.2-1.4%), with a 1.3% (95% CI, 1.1-1.4%) rate in patients without decompressive craniectomy and a 33% (95% CI, 26-39%) rate in the surgical treatment group. Logistic regression analysis identified pneumonia as being significantly associated with tracheostomy after decompressive craniectomy (odds ratio, 3.95; 95% CI, 1.95-6.91). CONCLUSIONS Tracheostomy is common after decompressive craniectomy and is strongly associated with the development of pneumonia. Given its impact on patient function and potentially modifiable associated factors, tracheostomy may warrant further study as an important patient-centered outcome among patients with stroke.
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Affiliation(s)
- Brian P Walcott
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Brandyn Castro
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Boston University School of Medicine, Boston, Massachusetts
| | - W Taylor Kimberly
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
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Rahmanian A, Seifzadeh B, Razmkon A, Petramfar P, Kivelev J, Alibai EA, Hernesniemi J. Outcome of decompressive craniectomy in comparison to nonsurgical treatment in patients with malignant MCA infarction. SPRINGERPLUS 2014; 3:115. [PMID: 24711983 PMCID: PMC3977016 DOI: 10.1186/2193-1801-3-115] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 01/13/2014] [Indexed: 11/17/2022]
Abstract
Background Malignant cerebral infarction is a well-recognized disease, comprising 10-15% of all cases with cerebral infarction and causing herniation and death in 80% of cases. In this study, we compare the effects of decompressive craniectomy versus conventional medical treatment on mortality rate and functional and neurological outcome in patients with malignant MCA infarction. Methods We performed a prospective case–control study on 60 patients younger than 80years of age suffering malignant MCA cerebral infarction. The case group underwent decompressive craniectomy in addition to routine aggressive medical care; while the control group received routine medical treatment. Patient outcome was assessed using Glasgow outcome scale and modified Rankin scale within three months of follow-up. The data were analyzed by SPSS version 16.0 software using Chi Square, One-way ANOVA and Mann–Whitney tests. Results There were 27 male and 33 female patients with a mean age of 60.6 years (SD = 12.3). Glasgow outcome scale score averaged 2.93 in the surgical versus 1.53 in the medical group; this difference was significant (p = 0.001). Outcome in modified Rankin scale was also significantly lower in the surgical (3.27) versus medical (5.27) group (p < 0.001). Surgery could decrease the mortality rate about 47%. Conclusion In this study, decompressive craniectomy could decrease mortality rate, and improve neurological and functional outcome, and decrease long-term disability in patients with malignant MCA infarction.
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Affiliation(s)
- Abdolkarim Rahmanian
- Department of Neurosurgery, Shiraz University of Medical Sciences, Nemazee Hospital, P.O. Box: 71937-11351, Shiraz, Iran
| | - Babak Seifzadeh
- Department of Neurosurgery, Shiraz University of Medical Sciences, Nemazee Hospital, P.O. Box: 71937-11351, Shiraz, Iran
| | - Ali Razmkon
- Department of Neurosurgery, Shiraz University of Medical Sciences, Nemazee Hospital, P.O. Box: 71937-11351, Shiraz, Iran ; Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Peyman Petramfar
- Department of Neurology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Juri Kivelev
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260 Helsinki, Finland
| | - Ehsan-Ali Alibai
- Department of Neurosurgery, Shiraz University of Medical Sciences, Nemazee Hospital, P.O. Box: 71937-11351, Shiraz, Iran
| | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260 Helsinki, Finland
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Wijdicks EFM, Sheth KN, Carter BS, Greer DM, Kasner SE, Kimberly WT, Schwab S, Smith EE, Tamargo RJ, Wintermark M. Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:1222-38. [PMID: 24481970 DOI: 10.1161/01.str.0000441965.15164.d6] [Citation(s) in RCA: 311] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE There are uncertainties surrounding the optimal management of patients with brain swelling after an ischemic stroke. Guidelines are needed on how to manage this major complication, how to provide the best comprehensive neurological and medical care, and how to best inform families facing complex decisions on surgical intervention in deteriorating patients. This scientific statement addresses the early approach to the patient with a swollen ischemic stroke in a cerebral or cerebellar hemisphere. METHODS The writing group used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. The panel reviewed the most relevant articles on adults through computerized searches of the medical literature using MEDLINE, EMBASE, and Web of Science through March 2013. The evidence is organized within the context of the American Heart Association framework and is classified according to the joint American Heart Association/American College of Cardiology Foundation and supplementary American Heart Association Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive American Heart Association internal peer review. RESULTS Clinical criteria are available for hemispheric (involving the entire middle cerebral artery territory or more) and cerebellar (involving the posterior inferior cerebellar artery or superior cerebellar artery) swelling caused by ischemic infarction. Clinical signs that signify deterioration in swollen supratentorial hemispheric ischemic stroke include new or further impairment of consciousness, cerebral ptosis, and changes in pupillary size. In swollen cerebellar infarction, a decrease in level of consciousness occurs as a result of brainstem compression and therefore may include early loss of corneal reflexes and the development of miosis. Standardized definitions should be established to facilitate multicenter and population-based studies of incidence, prevalence, risk factors, and outcomes. Identification of patients at high risk for brain swelling should include clinical and neuroimaging data. If a full resuscitative status is warranted in a patient with a large territorial stroke, admission to a unit with neurological monitoring capabilities is needed. These patients are best admitted to intensive care or stroke units attended by skilled and experienced physicians such as neurointensivists or vascular neurologists. Complex medical care includes airway management and mechanical ventilation, blood pressure control, fluid management, and glucose and temperature control. In swollen supratentorial hemispheric ischemic stroke, routine intracranial pressure monitoring or cerebrospinal fluid diversion is not indicated, but decompressive craniectomy with dural expansion should be considered in patients who continue to deteriorate neurologically. There is uncertainty about the efficacy of decompressive craniectomy in patients ≥60 years of age. In swollen cerebellar stroke, suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically. Ventriculostomy to relieve obstructive hydrocephalus after a cerebellar infarct should be accompanied by decompressive suboccipital craniectomy to avoid deterioration from upward cerebellar displacement. In swollen hemispheric supratentorial infarcts, outcome can be satisfactory, but one should anticipate that one third of patients will be severely disabled and fully dependent on care even after decompressive craniectomy. Surgery after a cerebellar infarct leads to acceptable functional outcome in most patients. CONCLUSIONS Swollen cerebral and cerebellar infarcts are critical conditions that warrant immediate, specialized neurointensive care and often neurosurgical intervention. Decompressive craniectomy is a necessary option in many patients. Selected patients may benefit greatly from such an approach, and although disabled, they may be functionally independent.
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Malignant Cerebral Edema After Large Anterior Circulation Infarction: A Review. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:275. [DOI: 10.1007/s11936-013-0275-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Ney JP, van der Goes DN, Nuwer MR, Nelson L, Eccher MA. Continuous and routine EEG in intensive care: utilization and outcomes, United States 2005-2009. Neurology 2013; 81:2002-8. [PMID: 24186910 DOI: 10.1212/01.wnl.0000436948.93399.2a] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To evaluate the effect of intensive care unit continuous EEG (cEEG) monitoring on inpatient mortality, hospital charges, and length of stay. METHODS A retrospective cross-sectional study was conducted using the Nationwide Inpatient Sample, a dataset representing 20% of inpatient discharges in nonfederal US hospitals. Adult discharge records reporting mechanical ventilation and EEG (routine EEG or cEEG) were included. cEEG was compared with routine EEG alone in association with the primary outcome of in-hospital mortality and secondary outcomes of total hospital charges and length of stay. Demographics, hospital characteristics, and medical comorbidity were used for multivariate adjustments of the primary and secondary outcomes. RESULTS A total of 40,945 patient discharges in the weighted sample met inclusion criteria, of which 5,949 had reported cEEG. Mechanically ventilated patients receiving cEEG were younger than routine EEG patients (56 vs 61 years; p < 0.001). There was no difference in the 2 groups in income or medical comorbidities. cEEG was significantly associated with lower in-hospital mortality in both univariate (odds ratio = 0.54, 95% confidence interval 0.45-0.64; p < 0.001) and multivariate (odds ratio = 0.63, 95% confidence interval 0.51-0.76; p < 0.001) analyses. There was no significant difference in costs or length of stay for patients who received cEEG relative to those receiving only routine EEG. Sensitivity analysis showed that adjusting for diagnosis-related groups (DRGs) for any neurologic diagnoses, DRGs for neurologic procedures, and specific DRGs for epilepsy/convulsions did not substantially alter the association of cEEG with reduced inpatient mortality. CONCLUSIONS cEEG is favorably associated with inpatient survival in mechanically ventilated patients, without adding significant charges to the hospital stay.
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Affiliation(s)
- John P Ney
- From the Departments of Neurology (J.P.N.) and Health Services (L.N.), University of Washington, Seattle; Department of Economics & Robert Wood Johnson Foundation (D.N.v.d.G), University of New Mexico, Albuquerque; Reed Neurological Research Center (M.R.N.), University of California, Los Angeles; and Department of Neurology (M.A.E.), Case Western Reserve University, Cleveland, OH
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Kurland DB, Tosun C, Pampori A, Karimy JK, Caffes NM, Gerzanich V, Simard JM. Glibenclamide for the treatment of acute CNS injury. Pharmaceuticals (Basel) 2013; 6:1287-303. [PMID: 24275850 PMCID: PMC3817601 DOI: 10.3390/ph6101287] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 09/17/2013] [Accepted: 09/23/2013] [Indexed: 12/22/2022] Open
Abstract
First introduced into clinical practice in 1969, glibenclamide (US adopted name, glyburide) is known best for its use in the treatment of diabetes mellitus type 2, where it is used to promote the release of insulin by blocking pancreatic KATP [sulfonylurea receptor 1 (Sur1)-Kir6.2] channels. During the last decade, glibenclamide has received renewed attention due to its pleiotropic protective effects in acute CNS injury. Acting via inhibition of the recently characterized Sur1-Trpm4 channel (formerly, the Sur1-regulated NCCa-ATP channel) and, in some cases, via brain KATP channels, glibenclamide has been shown to be beneficial in several clinically relevant rodent models of ischemic and hemorrhagic stroke, traumatic brain injury, spinal cord injury, neonatal encephalopathy of prematurity, and metastatic brain tumor. Glibenclamide acts on microvessels to reduce edema formation and secondary hemorrhage, it inhibits necrotic cell death, it exerts potent anti-inflammatory effects and it promotes neurogenesis—all via inhibition of Sur1. Two clinical trials, one in TBI and one in stroke, currently are underway. These recent findings, which implicate Sur1 in a number of acute pathological conditions involving the CNS, present new opportunities to use glibenclamide, a well-known, safe pharmaceutical agent, for medical conditions that heretofore had few or no treatment options.
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Affiliation(s)
- David B. Kurland
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
| | - Cigdem Tosun
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
| | - Adam Pampori
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
| | - Jason K. Karimy
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
| | - Nicholas M. Caffes
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +1-410-328-0850; Fax: +1-410-328-0124
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Walcott BP, Kwon CS, Sheth SA, Fehnel CR, Koffie RM, Asaad WF, Nahed BV, Coumans JV. Predictors of cranioplasty complications in stroke and trauma patients. J Neurosurg 2013; 118:757-62. [DOI: 10.3171/2013.1.jns121626] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Decompressive craniectomy mandates subsequent cranioplasty. Complications of cranioplasty may be independent of the initial craniectomy, or they may be contingent upon the craniectomy. Authors of this study aimed to identify surgery- and patient-specific risk factors related to the development of surgical site infection and other complications following cranioplasty.
Methods
A consecutive cohort of patients of all ages and both sexes who had undergone cranioplasty following craniectomy for stroke or trauma at a single institution in the period from May 2004 to May 2012 was retrospectively established. Patients who had undergone craniectomy for infectious lesions or neoplasia were excluded. A logistic regression analysis was performed to model and predict determinants related to infection following cranioplasty.
Results
Two hundred thirty-nine patients met the study criteria. The overall rate of complication following cranioplasty was 23.85% (57 patients). Complications included, predominantly, surgical site infection, hydrocephalus, and new-onset seizures. Logistic regression analysis identified previous reoperation (OR 3.25, 95% CI 1.30–8.11, p = 0.01) and therapeutic indication for stroke (OR 2.45, 95% CI 1.11–5.39, p = 0.03) as significantly associated with the development of cranioplasty infection. Patient age, location of cranioplasty, presence of an intracranial device, bone flap preservation method, cranioplasty material, booking method, and time interval > 90 days between initial craniectomy and cranioplasty were not predictive of the development of cranioplasty infection.
Conclusions
Cranioplasty complications are common. Cranioplasty infection rates are predicted by reoperation following craniectomy and therapeutic indication (stroke). These variables may be associated with patient-centered risk factors that increase cranioplasty infection risk.
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Affiliation(s)
- Brian P. Walcott
- 1Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Churl-Su Kwon
- 1Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sameer A. Sheth
- 1Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Corey R. Fehnel
- 2Department of Neurology, Brown University Alpert Medical School and Rhode Island Hospital; and
| | - Robert M. Koffie
- 1Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Wael F. Asaad
- 3Department of Neurosurgery and Brown Institute for Brain Science, Providence, Rhode Island
| | - Brian V. Nahed
- 1Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jean-Valery Coumans
- 1Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Bashinskaya B, Zimmerman RM, Walcott BP, Antoci V. Arthroplasty Utilization in the United States is Predicted by Age-Specific Population Groups. ISRN ORTHOPEDICS 2012; 2012. [PMID: 23505612 PMCID: PMC3597125 DOI: 10.5402/2012/185938] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Osteoarthritis is a common indication for hip and knee arthroplasty. An accurate assessment of current trends in healthcare utilization as they relate to arthroplasty may predict the needs of a growing elderly population in the United States. First, incidence data was queried from the United States Nationwide Inpatient Sample from 1993 to 2009. Patients undergoing total knee and hip arthroplasty were identified. Then, the United States Census Bureau was queried for population data from the same study period as well as to provide future projections. Arthroplasty followed linear regression models with the population group >64 years in both hip and knee groups. Projections for procedure incidence in the year 2050 based on these models were calculated to be 1,859,553 cases (hip) and 4,174,554 cases (knee). The need for hip and knee arthroplasty is expected to grow significantly in the upcoming years, given population growth predictions.
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Affiliation(s)
- Bronislava Bashinskaya
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA ; Boston University, Boston, MA 02215, USA
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40
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Bashinskaya B, Nahed BV, Walcott BP, Coumans JVCE, Onuma OK. Socioeconomic status correlates with the prevalence of advanced coronary artery disease in the United States. PLoS One 2012; 7:e46314. [PMID: 23050011 PMCID: PMC3457990 DOI: 10.1371/journal.pone.0046314] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Accepted: 08/31/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Increasingly studies have identified socioeconomic factors adversely affecting healthcare outcomes for a multitude of diseases. To date, however, there has not been a study correlating socioeconomic details from nationwide databases on the prevalence of advanced coronary artery disease. We seek to identify whether socioeconomic factors contribute to advanced coronary artery disease prevalence in the United States. METHODS AND FINDINGS State specific prevalence data was queried form the United States Nationwide Inpatient Sample for 2009. Patients undergoing percutaneous coronary angioplasty and coronary artery bypass graft were identified as principal procedures. Non-cardiac related procedures, lung lobectomy and hip replacement (partial and total) were identified and used as control groups. Information regarding prevalence was then merged with data from the Behavioral Risk Factor Surveillance System, the largest, on-going telephone health survey system tracking health conditions and risk behaviors in the United States. Pearson's correlation coefficient was calculated for individual socioeconomic variables including employment status, level of education, and household income. Household income and education level were inversely correlated with the prevalence of percutaneous coronary angioplasty (-0.717; -0.787) and coronary artery bypass graft surgery (-0.541; -0.618). This phenomenon was not seen in the non-cardiac procedure control groups. In multiple linear regression analysis, socioeconomic factors were significant predictors of coronary artery bypass graft and percutaneous transluminal coronary angioplasty (p<0.001 and p=0.005, respectively). CONCLUSIONS Socioeconomic status is related to the prevalence of advanced coronary artery disease as measured by the prevalence of percutaneous coronary angioplasty and coronary artery bypass graft surgery.
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Affiliation(s)
- Bronislava Bashinskaya
- Massachusetts General Hospital and Department of Medicine (Cardiology Division), Harvard Medical School, Boston, Massachusetts, United States of America
- Boston University, Boston, Massachusetts, United States of America
| | - Brian V. Nahed
- Massachusetts General Hospital and Department of Surgery (Neurosurgery Division), Harvard Medical School, Boston, Massachusetts, United States of America
| | - Brian P. Walcott
- Massachusetts General Hospital and Department of Surgery (Neurosurgery Division), Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Jean-Valery C. E. Coumans
- Massachusetts General Hospital and Department of Surgery (Neurosurgery Division), Harvard Medical School, Boston, Massachusetts, United States of America
| | - Oyere K. Onuma
- Massachusetts General Hospital and Department of Medicine (Cardiology Division), Harvard Medical School, Boston, Massachusetts, United States of America
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