Outcome after external decompression for massive cerebral infarction

Radiologic and Blood Markers Predicting Long-Term Neurologic Outcome Following Decompressive Craniectomy for Malignant Ischemic Stroke: A Preliminary Single-Center Study

BACKGROUND

 Malignant ischemic stroke (MIS) is defined by progressive cerebral edema leading to increased intracranial pressure (ICP), compression of neural structures, and, eventually, death. Decompressive craniectomy (DC) has been advocated as a lifesaving procedure in the management of patients with MIS. This study aims to identify pre- and postoperative predictive variables of neurologic outcomes in patients undergoing DC for MIS.

METHODS

 We conducted a retrospective study of patients undergoing DC in a single center from April 2016 to April 2020. Preoperative workup included baseline clinical status, laboratory data, and brain computed tomography (CT). The primary outcome was the 6-month modified Rankin score (mRS). The secondary outcome was the 30-day mortality.

RESULTS

 During data capture, a total of 58 patients fulfilled the criteria for MIS, of which 22 underwent DC for medically refractory increased ICP and were included in the present analysis. The overall median age was 58.5 years. An immediate (24 hour) postoperative extended Glasgow Outcome Scale (GOSE) score ≥5 was associated with a good 6-month mRS (1-3; p = 0.004). Similarly, low postoperative neutrophils (p = 0.002), low lymphocytes (p = 0.004), decreased neutrophil-to-lymphocyte ratio (NLR; p = 0.02), and decreased platelet-to-lymphocytes ratio (PLR; p = 0.03) were associated with good neurologic outcomes. Preoperative variables independently associated with worsened 6-month mRS were the following: increased age (odds ratio [OR]: 1.10; 95% confidence interval [CI]: 1.01-1.20; p = 0.02), increased National Institutes of Health Stroke Scale (NIHSS) score (OR: 7.8; 95% CI: 2.5-12.5; p = 0.035), Glasgow Coma Scale (GCS) score less than 8 at the time of neurosurgical referral (OR: 21.63; 95% CI: 1.42-328; p = 0.02), and increased partial thromboplastin time (PTT) before surgery (OR: 2.11; 95% CI: 1.11-4; p = 0.02). Decreased postoperative lymphocytes confirmed a protective role against worsened functional outcomes (OR: 0.01; 95% CI: 0.01-0.4; p = 0.02). Decreased postoperative lymphocyte count was associated with a protective role against increased mRS (OR: 0.01; 95% CI: 0.01-0.4; p = 0.02). The occurrence of hydrocephalus at the postoperative CT scan was associated with 30-day mortality (p = 0.005), while the persistence of postoperative compression of the ambient and crural cistern showed a trend towards higher mortality (p = 0.07).

CONCLUSIONS

 This study reports that patients undergoing DC for MIS showing decreased postoperative blood inflammatory markers achieved better 6-month neurologic outcomes than patients with increased inflammatory markers. Similarly, poor NIHSS score, poor GCS score, increased age, and larger PTT values at the time of surgery were independent predictors of poor outcomes. Moreover, the persistence of postoperative compression of basal cisterns and the occurrence of hydrocephalus are associated with 30-day mortality.

Net water uptake within the ischemic penumbra predicts the presence of the midline shift in patients with acute ischemic stroke

Objective

The study aimed to explore the association between midline shift (MLS) and net water uptake (NWU) within the ischemic penumbra in acute ischemic stroke patients.

Methods

This was a retrospective cohort study that examined patients with anterior circulation stroke. Net water uptake within the acute ischemic core and penumbra was calculated using data from admission multimodal CT scans. The primary outcome was severe cerebral edema measured by the presence of MLS on 24 to 48 h follow-up CT scans. The presence of a significant MLS was defined by a deviation of the septum pellucidum from the midline on follow-up CT scans of at least 3 mm or greater due to the mass effect of ischemic edema. The net water uptake was compared between patients with and without MLS, followed by logistic regression analyses and receiver operating characteristics (ROCs) to assess the predictive power of net water uptake in MLS.

Results

A total of 133 patients were analyzed: 50 patients (37.6%) with MLS and 83 patients (62.4%) without. Compared to patients without MLS, patients with MLS had higher net water uptake within the core [6.8 (3.2-10.4) vs. 4.9 (2.2-8.1), P = 0.048] and higher net water uptake within the ischemic penumbra [2.9 (1.8-4.3) vs. 0.2 (-2.5-2.7), P < 0.001]. Penumbral net water uptake had higher predictive performance than net water uptake of the core in MLS [area under the curve: 0.708 vs. 0.603, p < 0.001]. Moreover, the penumbral net water uptake predicted MLS in the multivariate regression model, adjusting for age, sex, admission National Institutes of Health Stroke Scale (NIHSS), diabetes mellitus, atrial fibrillation, ischemic core volume, and poor collateral vessel status (OR = 1.165; 95% CI = 1.002-1.356; P = 0.047). No significant prediction was found for the net water uptake of the core in the multivariate regression model.

Conclusion

Net water uptake measured acutely within the ischemic penumbra could predict severe cerebral edema at 24-48 h.

Clinical Evaluation of Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarction using 3D Area and Volume Calculations

Objective:

We aimed to measure the craniectomy area using three-dimensional (3D) anatomic area and volume calculations to demonstrate that it can be an effective criterion for evaluating survival and functional outcomes of patients with malignant middle cerebral artery (MCA) infarction.

Material and Methods:

The patients diagnosed with malignant ischemic stroke between 2013 and 2018, for which they underwent surgery due to deterioration in their neurological function, were retrospectively reviewed. Radiological images of all patients were evaluated; total brain tissue volume, ischemic brain tissue volume, total calvarial bone area, and decompression bone area were measured using 3D anatomical area and volume calculations.

Results:

In total, 45 patients (27 males and 18 females) had been treated with decompressive craniectomy (DC). The removed bone area was found to be significantly related to the outcome in patients with MCA infarction. The average decompression bone area and mean bone removal rate for patients who died after DC were 112 ± 27 cm² and 20%, whereas these values for surviving patients were 149 ± 29 cm² and 26% (P = 0.001), respectively. At the 6-month follow-up, the average decompression bone area and mean bone removal rate for patients with severe disability were 126 ± 30 cm² and 22.2%, whereas these values for patients without severe disability were 159 cm² ± 26 and 28.4% (P = 0.001), respectively.

Conclusion:

In patients with malignant MCA infarction, the decompression area is associated with favorable functional outcomes, first, survival and second, 6-month modified Rankin scale score distribution after craniectomy.

Hemicraniectomy for Dominant vs Nondominant Middle Cerebral Artery Infarction: A Systematic Review and Meta-Analysis

OBJECTIVES

Decompressive hemicraniectomy decreases mortality and severe disability from space-occupying middle cerebral artery infarction in selected patients. However, attitudes towards hemicraniectomy for dominant-hemispheric stroke have been hesitant. This systematic review and meta-analysis examines the association of stroke laterality with outcome after hemicraniectomy.

MATERIALS AND METHODS

We performed a systematic literature search up to 6th February 2020 to retrieve original articles about hemicraniectomy for space-occupying middle cerebral artery infarction that reported outcome in relation to laterality. The primary outcome was severe disability (modified Rankin Scale 4‒6 or 5‒6 or Glasgow Outcome Scale 1‒3) or death. A two-stage combined individual patient and aggregate data meta-analysis evaluated the association between dominant-lateralized stroke and (a) short-term (≤ 3 months) and (b) long-term (> 3 months) outcome. We performed sensitivity analyses excluding studies with sheer mortality outcome, second-look strokectomy, low quality, or small sample size, and comparing populations from North America/Europe vs Asia/South America.

RESULTS

The analysis included 51 studies (46 observational studies, one nonrandomized trial, and four randomized controlled trials) comprising 2361 patients. We found no association between dominant laterality and unfavorable short-term (OR 1.00, 95% CI 0.69‒1.45) or long-term (OR 1.01, 95% CI 0.76‒1.33) outcome. The results were unchanged in all sensitivity analyses. The grade of evidence was very low for short-term and low for long-term outcome.

CONCLUSIONS

This meta-analysis suggests that patients with dominant-hemispheric stroke have equal outcome after hemicraniectomy compared to patients with nondominant stroke. Despite the shortcomings of the available evidence, our results do not support withholding hemicraniectomy based on stroke laterality.

Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature

(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, a decision that often decides life and death for the patient. To assist in this process in coming to a good evidence-based decision, we reviewed the available literature. (2) Methods: We performed a systematic review through a literature search of the MEDLINE database of former and current absolute and relative contraindications to the initiation of ECMO treatment. (3) Results: The following relative and absolute contraindications were identified in the literature: absolute-refusal of the use of extracorporeal techniques by the patient, advanced stage of cancer, fatal intracerebral hemorrhage/cerebral herniation/intractable intracranial hypertension, irreversible destruction of the lung parenchyma without the possibility of transplantation, and contraindications to lung transplantation; relative-advanced age, immunosuppressed patients/pharmacological immunosuppression, injurious ventilator settings > 7 days, right-heart failure, hematologic malignancies, especially bone marrow transplantation and graft-versus-host disease, SAPS II score ≥ 60 points, SOFA score > 12 points, PRESERVE score ≥ 5 points, RESP score ≤ -2 points, PRESET score ≥ 6 points, and "do not attempt resuscitation" order (DN(A)R status). (4) Conclusions: We provide a simple-to-follow algorithm that incorporates absolute and relative contraindications to the initiation of ECMO treatment. This algorithm attempts to weigh pros and cons regarding the benefit for an individual patient and hopefully assists caregivers to make better, informed decisions.

Association of Japan Coma Scale score on hospital arrival with in-hospital mortality among trauma patients

Background

The Japan Coma Scale (JCS) score has been widely used to assess patients’ consciousness level in Japan. JCS scores are divided into four main categories: alert (0) and one-, two-, and three-digit codes based on an eye response test, each of which has three subcategories. The purpose of this study was to investigate the utility of the JCS score on hospital arrival in predicting outcomes among adult trauma patients.

Methods

Using the Japan Trauma Data Bank, we conducted a nationwide registry-based retrospective cohort study. Patients 16 years old or older directly transported from the trauma scene between January 2004 and December 2017 were included. Our primary outcome was in-hospital mortality. We examined outcome prediction accuracy based on area under the receiver operating characteristic curve (AUROC) and multiple logistic regression analysis with multiple imputation.

Results

A total of 222,540 subjects were included; their in-hospital mortality rate was 7.1% (n = 15,860). The 10-point scale JCS and the total sum of Glasgow Coma Scale (GCS) scores demonstrated similar performance, in which the AUROC (95% CIs) showed 0.874 (0.871–0.878) and 0.878 (0.874–0.881), respectively. Multiple logistic regression analysis revealed that the higher the JCS score, the higher the predictability of in-hospital death. When we focused on the simple four-point scale JCS score, the adjusted odds ratio (95% confidence intervals [CIs]) were 2.31 (2.12–2.45), 4.81 (4.42–5.24), and 27.88 (25.74–30.20) in the groups with one-digit, two-digit, and three-digit scores, respectively, with JCS of 0 as a reference category.

Conclusions

JCS score on hospital arrival after trauma would be useful for predicting in-hospital mortality, similar to the GCS score.

Predictors of early in-hospital death after decompressive craniectomy in swollen middle cerebral artery infarction

BACKGROUND

Swollen middle cerebral artery infarction is a life-threatening disease and decompressive craniectomy is improving survival significantly. Despite decompressive surgery, however, many patients are not discharged from the hospital alive. We therefore wanted to search for predictors of early in-hospital death after craniectomy in swollen middle cerebral artery infarction.

METHODS

All patients operated with decompressive craniectomy due to swollen middle cerebral artery infarction at the Department of Neurosurgery, Oslo University Hospital Rikshospitalet, Oslo, Norway, between May 1998 and October 2010, were included. Binary logistic regression analyses were performed and candidate variables were age, sex, time from stroke onset to decompressive craniectomy, NIHSS on admission, infarction territory, pineal gland displacement, reduction of pineal gland displacement after surgery, and craniectomy size.

RESULTS

Fourteen out of 45 patients (31%) died during the primary hospitalization (range, 3-44 days). In the multivariate logistic regression model, middle cerebral artery infarction with additional anterior and/or posterior cerebral artery territory involvement was found as the only significant predictor of early in-hospital death (OR, 12.7; 95% CI, 0.01-0.77; p = 0.029).

CONCLUSIONS

The present study identified additional territory infarction as a significant predictor of early in-hospital death. The relatively small sample size precludes firm conclusions.

Initial research on the relationship between let-7 family members in the serum and massive cerebral infarction

Eighty-eight ischemic stroke patients with massive cerebral infarction (MCI) who met our selection criteria were included in this study. MCI was assessed using the Glasgow Coma Scale (GCS) at hospital admission and at 2 weeks. The sera of all patients and controls were sampled at 48 h after the patients' attacks, and the sera of patients with MCI who had no severe cardiopulmonary complications, including those with hemorrhagic transformation (HT), were sampled again at 2 weeks. The relative expression of let-7 miRNA in the serum was determined by real-time qRT-PCR, and the blood levels of lipids, glucose, high-sensitivity C-reactive protein (hs-CRP), homocysteine and blood pressure were measured at admission. Interleukin-6 (IL-6) levels were detected by ELISA, and a luciferase assay was performed to confirm that IL-6 was a gene target of let-7. The relative expression of let-7f was significantly down-regulated in MCI without HT patients compared with controls (P<0.001), and it was positively correlated with GCS (P<0.01) and negatively correlated with hs-CRP (P<0.01). The relative expression of let-7f was significantly up-regulated in MCI patients with HT (P<0.01). IL-6 is a direct target gene for let-7f, and IL-6 expression was increased in MCI without HT patients compared to controls (P<0.01). The expression of let-7f in serum is associated with MCI without HT, which specifically inhibits IL-6. This suggests that let-7f may control inflammation in patients with MCI without HT.

Hemispheric differences in malignant middle cerebral artery stroke

BACKGROUND

We recently reported that left versus right hemisphere cerebral infarctions patients more frequently have worse outcomes. However our clinical experience led us to suspect that the incidence of malignant middle cerebral artery infarctions (MMCA) was higher in the right compared to the left hemispheric strokes.

OBJECTIVE

To determine whether laterality in MMCA stroke is an important determinant of stroke sequelae.

METHODS

A systematic search was performed for publications in PubMed using "malignant middle cerebral artery and infarction". A total of 73 relevant studies were abstracted.

RESULTS

MMCA laterality data were available for 2673 patients, with 1687 (63%) right hemispheric involvement, thus right being more commonly associated with MMCA (binomial test, p<0.05). While mortality rates were similar, right hemispheric MMCA (n=271) had mortality of 31% (n=85) whereas left hemispheric MMCA (n=144) had mortality of 36% (n=53), morbidity rates were worse on the right.

CONCLUSION

MMCA stroke appears to be more common on the right, and this laterality is also associated with significantly higher morbidity. Further prospective studies are needed to more completely understand the nature of this laterality as well as test possible new treatments to reduce mortality and morbidity associated with MMCA.

Craniectomy in Acute Ischemic Stroke

Anterior and posterior circulation acute ischemic stroke carries significant morbidity and mortality as a result of malignant cerebral edema. Decompressive craniectomy has evolved as a viable neurosurgical intervention in the armamentarium of treatment options for this life-threatening edema. In this review, we highlight the history of craniectomy for stroke and discuss recent data relevant to its efficacy in modern neurosurgical practice.

Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association

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.

Outcome after decompressive craniectomy in patients with dominant middle cerebral artery infarction: A preliminary report

Introduction:

Life-threatening, space occupying, infarction develops in 10-15% of patients after middle cerebral artery infarction (MCAI). Though decompressive craniectomy (DC) is now standard of care in patients with non-dominant stroke, its role in dominant MCAI (DMCAI) is largely undefined. This may reflect the ethical dilemma of saving life of a patient who may then remain hemiplegic and dysphasic. This study specifically addresses this issue.

Materials and Methods:

This retrospective analysis studied patients with DMCAI undergoing DC. Patient records, operation notes, radiology, and out-patient files were scrutinized to collate data. Glasgow outcome scale (GOS), Barthel index (BI) and improvement in language and motor function were evaluated to determine functional outcome.

Results:

Eighteen patients between 22 years and 72 years of age were included. 6 week, 3 month, 6 month and overall survival rates were 66.6% (12/18), 64% (11/17), 62.5% (10/16) and 62.5% (10/16) respectively. Amongst ten surviving patients with long-term follow-up, 60% showed improvement in GOS, 70% achieved BI score >60 while 30% achieved full functional independence. In this group, motor power and language function improved in 9 and 8 patients respectively. At last follow-up, 8 of 10 surviving patients were ambulatory with (3/8) or without (5/8) support. Age <50 years corresponded with better functional outcome amongst survivors (P value –0.0068).

Conclusion:

Language and motor outcomes after DC in patients with DMCAI are not as dismal as commonly perceived. Perhaps young patients (<50 years) with DMCAI should be treated with the same aggressiveness that non-DMCAI is currently dealt with.

Retrospective analysis of hinge technique for head trauma or stroke

Hinge technique is a new method for cerebral decompression that allows the bone flap to move outward in response to brain swelling and essentially allows reconstruction of the cranial vault as a minor procedure under local anesthesia. This retrospective study assessed outcomes following the use of this new decompressive technique. During an approximately 7-year period (June 2004 to March 2011), 58 patients who had suffered head trauma or stroke underwent cerebral decompression using the hinge technique or conventional decompressive craniectomy. Patients were assessed with the Glasgow Coma Scale (GCS), the Glasgow Outcome Scale (GOS), and the modified Rankin scale (mRS). Twenty-one patients (16 males, 5 females; age range, 21-78 yrs; mean age, 57.4 ± 15.5 yrs) underwent cerebral decompression using the hinge technique, and 37 patients (18 males, 19 females; age range, 5-83 yrs; mean age, 54.1 ± 20.9 yrs) underwent conventional decompressive craniectomy. There was no significant difference in preoperative GCS or postoperative GOS or mRS between the two groups. Six patients in the decompressive craniectomy group and none of the patients in the hinge technique group developed bone flap infection (p = 0.02). The bone flap was removed in two cases in the hinge technique group due to low cerebral perfusion pressure as well as elevated intracranial pressure (ICP). The hinge technique with ICP monitoring was effective and safe for management for head trauma or stroke and was not associated with bone flap infection.

Outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 70 years old

Objective

Malignant middle cerebral artery (MCA) infarction occurs in 10% of all ischemic strokes and these severe strokes are associated with high mortality rates. Recent clinical trials demonstrated that early decompressive craniectomy reduce mortality rates and improves functional outcomes in healthy young patients (less than 61 years of age) with a malignant infarction. The purpose of this study was to assess the efficacy of decompressive craniectomy in elderly patients (older than 70 years of age) with a malignant MCA infarction.

Methods

Between February 2008 and October 2011, 131 patients were diagnosed with malignant MCA infarctions. We divided these patients into two groups: patients who underwent decompressive craniectomy (n = 58) and those who underwent conservative care (n = 73). A cut-off point of 70 years of age was set, and the study population was segregated into those who fell above or below this point. Mortality rates and functional outcome scores were assessed, and a modified Rankin Scale (mRS) score of > 3 was considered to represent a poor outcome.

Results

Mortality rates were significantly lower at 29.3% (one-month mortality rate) and 48.3% (six-month mortality rate) in the craniectomy group as compared to 58.9% and 71.2%, respectively, in the conservative care group (p < 0.001, p = 0.007). Age (≥70 years vs. < 70 years) did not statistically differ between groups for the six-month mortality rate (p = 0.137). However, the pre-operative National Institutes of Health Stroke Scale (NIHSS) score did contribute to the six-month mortality rate (p = 0.047).

Conclusion

Decompressive craniectomy is effective for patients with a malignant MCA infarction regardless of their age. Therefore, factors other than age should be considered and the treatment should be individualized in elderly patients with malignant infarctions.

Surgical decompression for cerebral oedema in acute ischaemic stroke

BACKGROUND

Large cerebral infarction has a high case fatality. Despite the use of conventional medical treatments such as hyperventilation, mannitol, diuretics, corticosteroids and barbiturates, the outcome of this condition remains poor. Decompressive surgery to relieve intracranial pressure is performed in some cases, although evidence of any clinical benefits has not been available until recently. This is an update of a Cochrane review first published in 2002.

OBJECTIVES

To examine the effects of decompressive surgery in patients with massive acute ischaemic stroke complicated with cerebral oedema, and to judge whether decompressive surgery is effective in improving survival or survival free of severe disability.

SEARCH METHODS

We searched the Cochrane Stroke Group's Trials Register (last searched October 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 7), MEDLINE (1966 to October 2010), EMBASE (1980 to October 2010) and Science Citation Index (October 2010). We also searched the reference lists of all relevant articles.

SELECTION CRITERIA

Randomised controlled studies of decompressive surgery plus medical treatment versus medical treatment alone in patients with clinically and radiologically confirmed cerebral infarcts complicated with cerebral oedema.

DATA COLLECTION AND ANALYSIS

One author assessed the titles and retrieved the relevant studies. The same author extracted data, with discussion among all authors for clarification. Outcomes were death at the end of follow-up, death or disability defined as the modified Rankin Scale (mRS) > 3 at the end of follow-up, death or severe disability defined as mRS > 4 at 12 months and disability defined as mRS 4 or 5 at 12 months. The results are given using the Peto odds ratio (Peto OR) with 95% confidence intervals (CIs).

MAIN RESULTS

We included three trials in this review, involving 134 patients who were 60 years of age or younger. The time window for the intervention was 30 hours from stroke onset in two studies and 96 hours in one study. All trials were stopped early. Surgical decompression reduced the risk of death at the end of follow-up (OR 0.19, 95% CI 0.09 to 0.37) and the risk of death or disability defined as mRS > 4 at 12 months (OR 0.26, 95% CI 0.13 to 0.51). Death or disability defined as mRS > 3 at the end of follow-up was no different between the treatment arms (OR 0.56, 95% CI 0.27 to 1.15).

AUTHORS' CONCLUSIONS

Surgical decompression lowers the risk of death and death or severe disability defined as mRS > 4 in selected patients 60 years of age or younger with a massive hemispheric infarction and oedema. Optimum criteria for patient selection and for timing of decompressive surgery are yet to be defined. Since survival may be at the expense of substantial disability, surgery should be the treatment of choice only when it can be assumed, based on their preferences, that it is in the best interest of patients. Since all the trials were stopped early, an overestimation of the effect size cannot be excluded.

Coma scales: a historical review

OBJECTIVE

To describe the most important coma scales developed in the last fifty years.

METHOD

A review of the literature between 1969 and 2009 in the Medline and Scielo databases was carried out using the following keywords: coma scales, coma, disorders of consciousness, coma score and levels of coma.

RESULTS

Five main scales were found in chronological order: the Jouvet coma scale, the Moscow coma scale, the Glasgow coma scale (GCS), the Bozza-Marrubini scale and the FOUR score (Full Outline of UnResponsiveness), as well as other scales that have had less impact and are rarely used outside their country of origin.

DISCUSSION

Of the five main scales, the GCS is by far the most widely used. It is easy to apply and very suitable for cases of traumatic brain injury (TBI). However, it has shortcomings, such as the fact that the speech component in intubated patients cannot be tested. While the Jouvet scale is quite sensitive, particularly for levels of consciousness closer to normal levels, it is difficult to use. The Moscow scale has good predictive value but is little used by the medical community. The FOUR score is easy to apply and provides more neurological details than the Glasgow scale.

Comparison of the effect of decompressive craniectomy on different neurosurgical diseases

BACKGROUND

Many previous studies have reported that decompressive craniectomy has improved clinical outcomes in patients with intractable increased intracranial pressure (ICP) caused by various neurosurgical diseases. However there is no report that compares the effectiveness of the procedure in the different conditions. The authors performed decompressive craniectomy following a constant surgical indication and compared the clinical outcomes in different neurosurgical diseases.

MATERIALS AND METHODS

Seventy five patients who underwent decompressive craniectomy were analysed retrospectively. There were 28 with severe traumatic brain injury (TBI), 24 cases with massive intracerebral haemorrhage (ICH), and 23 cases with major infarction (MI). The surgical indications were GCS score less than 8 and/or a midline shift more than 6 mm on CT. The clinical outcomes were assessed on the basis of mortality and Glasgow Outcome Scale (GOS) scores. The changes of ventricular pressure related to the surgical intervention were also compared between the different disease groups.

FINDINGS

Clinical outcomes were evaluated 6 months after decompressive craniectomy. The mortality was 21.4% in patients with TBI, 25% in those with ICH and 60.9% in MI. A favourable outcome, i.e. GOS 4-5 (moderate disability or better) was observed in 16 (57.1%) patients with TBI, 12 (50%) with ICH and 7 (30.4%) with MI. The change of ventricular pressure after craniectomy and was 53.2 (reductions of 17.4%) and further reduced by 14.9% (with dural opening) and (24.8%) after returning to its recovery room, regardless of the diseases group.

CONCLUSIONS

According to the mortality and GOS scores, decompressive craniectomy with dural expansion was found to be more effective in patients with ICH or TBI than in the MI group. However, the ventricular pressure change during the decompressive craniectomy was similar in the different disease groups. The authors thought that decompressive craniectomy should be performed earlier for the major infarction patients.

Aggravation of infarct formation by brain swelling in a large territorial stroke: a target for neuroprotection?

OBJECT

In territorial stroke vasogenic edema formation leads to elevated intracranial pressure (ICP) and can cause herniation and death. Brain swelling further impairs collateral blood flow to the ischemic penumbra and causes mechanical damage to adjacent brain structures. In the present study the authors sought to quantify the impact of this space-occupying effect on ischemic lesion formation.

METHODS

Wistar rats were assigned to undergo bilateral craniectomy or a sham operation and then were subjected to temporary middle cerebral artery occlusion (MCAO) for 90 minutes. A clinical evaluation and 7-T MR imaging studies were performed 5 and 24 hours after MCAO. The absolute brain water content was determined at 24 hours by using the wet/dry method.

RESULTS

Bilateral craniectomy before MCAO led to a drastic reduction in lesion volume at both imaging time points (p < 0.0001). Ischemic lesion volume was 2.7- and 2.3-fold larger in sham-operated animals after 5 and 24 hours, respectively. Clinical scores were likewise better in rats that had undergone craniectomy (p < 0.05). After 24 hours the midline shift differed significantly between the 2 groups (p < 0.001), but not after 5 hours. The relation between brain water content and ischemic lesion volume as well as the T2 relaxation time within the infarcted area was not different between the groups (p > 0.05).

CONCLUSIONS

The data indicated that collateral damage caused by the space-occupying effect of a large MCA territory stroke contributes seriously to ischemic lesion formation. The elimination of increased ICP thus must be regarded as a highly neuroprotective measure, rather than only a life-saving procedure to prevent cerebral herniation. Further clinical trials should reveal the neuroprotective potential of surgical and pharmacological ICP-lowering therapeutic approaches.

Guidelines for the Early Management of Adults With Ischemic Stroke

Purpose— Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included.

Methods— Members of the panel were appointed by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council’s Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years.

Results— Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.

The role of surgery in ischemic stroke: decompressive surgery

PURPOSE OF REVIEW

This review gives an integrated view on the current status of decompressive surgery in space-occupying hemispheric brain infarction with a focus on new developments based on the available data of recent clinical trials, also including preliminary data from randomized trials reported at international stroke conferences in 2006.

RECENT FINDINGS

The treatment of ischemic brain infarction with life-threatening space-occupying edema is, because of a lack of prospective studies, one of the major controversial issues within neurocritical care medicine today. Only a few years ago, massive cerebral infarctions were regarded an untreatable disease with fatal outcome. The introduction of decompressive surgery (hemicraniectomy) has completely changed this point of view. Most of the reports, however, are retrospective with low numbers of patients. There are only few prospective trials that suggest a substantial benefit of decompressive surgery to significantly reduce mortality as compared to maximal conservative treatment alone. The control groups in these studies, however, consist of patients with higher age and higher rates of co-morbidities. Also, in most studies information on long-term outcome is insufficient. In 2006 long expected preliminary data from randomized trials of hemicraniectomy have been reported at international stroke conferences. They yield very positive results.

SUMMARY

Decompressive surgery appears to be a promising treatment option for patients with space-occupying hemispheric brain infarction.

Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists

PURPOSE

Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included.

METHODS

Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council's Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years.

RESULTS

Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.

Physical characteristics of patients with developmental cervical spinal canal stenosis

There has been only one report on the physical characteristics of patients with developmental cervical spinal canal stenosis. The objective of this consecutive clinical study was to identify the physical characteristics of patients with developmental cervical spinal canal stenosis. The subjects were 243 patients with cervical spine disease who received treatment in our department between April 2001 and March 2002. These patients were divided into two groups (the groups of patients with and without spinal canal stenosis) on the basis of their lateral cervical spine radiographs. The six items examined were height, weight, sitting height, inter inner canthal distance, upper arm length, and head circumference in each patient, and then their values were compared between the two groups. The mean inter inner canthal distance was 2.7 cm in the group of patients with spinal canal stenosis and 3.5 cm in the group of patients without spinal canal stenosis; a significant difference (P < 0.01) was observed. Regarding height, weight, sitting height, upper arm length, and head circumference, no significant difference was found while comparing the two groups. In conclusion, developmental cervical spinal canal stenosis seems to be highly likely in patients with smaller inter inner canthal distance.

Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials

BACKGROUND

Malignant infarction of the middle cerebral artery (MCA) is associated with an 80% mortality rate. Non-randomised studies have suggested that decompressive surgery reduces this mortality without increasing the number of severely disabled survivors. To obtain sufficient data as soon as possible to reliably estimate the effects of decompressive surgery, results from three European randomised controlled trials (DECIMAL, DESTINY, HAMLET) were pooled. The trials were ongoing when the pooled analysis was planned.

METHODS

Individual data for patients aged between 18 years and 60 years, with space-occupying MCA infarction, included in one of the three trials, and treated within 48 h after stroke onset were pooled for analysis. The protocol was designed prospectively when the trials were still recruiting patients and outcomes were defined without knowledge of the results of the individual trials. The primary outcome measure was the score on the modified Rankin scale (mRS) at 1 year dichotomised between favourable (0-4) and unfavourable (5 and death) outcome. Secondary outcome measures included case fatality rate at 1 year and a dichotomisation of the mRS between 0-3 and 4 to death. Data analysis was done by an independent data monitoring committee.

FINDINGS

93 patients were included in the pooled analysis. More patients in the decompressive-surgery group than in the control group had an mRS<or=4 (75%vs 24%; pooled absolute risk reduction 51% [95% CI 34-69]), an mRS<or=3 (43%vs 21%; 23% [5-41]), and survived (78%vs 29%; 50% [33-67]), indicating numbers needed to treat of two for survival with mRS<or=4, four for survival with mRS<or=3, and two for survival irrespective of functional outcome. The effect of surgery was highly consistent across the three trials.

INTERPRETATION

In patients with malignant MCA infarction, decompressive surgery undertaken within 48 h of stroke onset reduces mortality and increases the number of patients with a favourable functional outcome. The decision to perform decompressive surgery should, however, be made on an individual basis in every patient.

Established treatments for acute ischaemic stroke

This article reviews the recommended management of patients presenting to accident and emergency departments with acute ischaemic stroke, and focuses on thrombolysis. The review includes initial management, recommended clinical, laboratory, and radiographic examinations. Appropriate general medical care, consisting of monitoring of oxygenation, fever, blood pressure, and blood glucose concentrations are examined. Criteria for thrombolysis with intravenous recombinant tissue plasminogen activator (rt-PA) are discussed. Complications of rt-PA therapy, such as haemorrhagic transformation and angio-oedema, are reviewed. An approach to management of rt-PA complications is outlined. Only a small percentage of acute ischaemic stroke patients meet criteria for rt-PA; therefore, alternative acute treatment strategies are also discussed. Acute medical and neurological complications in stroke patients are analysed, along with recommendations for treatment.

Clinical review: Therapy for refractory intracranial hypertension in ischaemic stroke

The treatment of patients with large hemispheric ischaemic stroke accompanied by massive space-occupying oedema represents one of the major unsolved problems in neurocritical care medicine. Despite maximum intensive care, the prognosis of these patients is poor, with case fatality rates as high as 80%. Therefore, the term 'malignant brain infarction' was coined. Because conservative treatment strategies to limit brain tissue shift almost consistently fail, these massive infarctions often are regarded as an untreatable disease. The introduction of decompressive surgery (hemicraniectomy) has completely changed this point of view, suggesting that mortality rates may be reduced to approximately 20%. However, critics have always argued that the reduction in mortality may be outweighed by an accompanying increase in severe disability. Due to the lack of conclusive evidence of efficacy from randomised trials, controversy over the benefit of these treatment strategies remained, leading to large regional differences in the application of this procedure. Meanwhile, data from randomised trials confirm the results of former observational studies, demonstrating that hemicraniectomy not only significantly reduces mortality but also significantly improves clinical outcome without increasing the number of completely dependent patients. Hypothermia is another promising treatment option but still needs evidence of efficacy from randomised controlled trials before it may be recommended for clinical routine use. This review gives the reader an integrated view of the current status of treatment options in massive hemispheric brain infarction, based on the available data of clinical trials, including the most recent data from randomised trials published in 2007.

Factors predictive of fatality in massive middle cerebral artery territory infarction and clinical experience of decompressive hemicraniectomy

To determine the factors predictive of fatality in massive middle cerebral artery (MCA) territory infarction and outcome of decompressive hemicraniectomy, 62 patients who were retrospectively verified with first event massive MCA infarctions were enrolled in this study. Amongst them, 21 received decompressive hemicraniectomy during hospitalization. Clinical data between early and late hemicraniectomy groups were also compared. Significant deterioration occurred in 40 cases, 21 of whom received decompressive hemicraniectomy. The other 19 received conservative treatment. The mortality rate of these 40 cases between decompressive hemicraniectomy and conservative treatment was 29% (six of 21) and 42% (eight of 19), respectively. Factors that predicted fatalities in our massive MCA infarction patients with or without decompressive hemicraniectomy were total scores of baseline GCS at the time of admission, associated with coronary artery diseases, and significant deterioration during hospitalization. This study confirms the lifesaving procedure of hemicraniectomy that prevents death in patients deteriorating because of cerebral edema after infarction, although it may produce severe disability with an unacceptably poor quality of life in survival. Despite high mortality and morbidity, decompressive hemicraniectomy to prevent cerebral herniation when significant deterioration is demonstrated are essential for maximizing the potential for survival.

Long-term outcome after hemicraniectomy for space occupying right hemispheric MCA infarction

OBJECTIVE

To examine the long-term prognosis in patients with 'malignant' supratentorial ischemia of the right hemisphere treated with hemicraniectomy, especially in respect to depression, with a focus on age as a possible predictor of outcome.

METHODS

We performed a prospective, long-term, follow-up examination in 23 survivors of 32 patients (mortality 28.1%) treated with hemicraniectomy for malignant middle cerebral artery (MCA) infarction of the right hemisphere, who were identified in our data bank since 1993. Long-term was defined as at least 20 months after craniectomy. Outcome data consisted of the items functionality, depression and quality of life. Tests applied included the Barthel Index (BI), the modified Rankin Scale (mRS), Beck Depression Inventory (BDI) and stroke-specific quality of life (QoL) scale.

RESULTS

Of the 23 patients 15 (65.2%) had a BI>or=60, 11 (47.8%) a mRS<4 and 9 (39.1%) a SS-QOL>or=60%, each representing a favourable outcome. In retrospect, 14 (60.9%) patients approved the surgery. Depression, i.e. a BDI>9, was diagnosed in 13 (56.5%) patients and 5 (38.5%) of them were treated with antidepressants. In a multiple linear regression analysis age at craniectomy was a predictor of a low BI (beta=-0.863; p=0.031), but not of the other outcome parameters.

CONCLUSIONS

Depression is a common and rarely treated long-term complication after 'malignant' right hemispheric ischemia. While high age is a strong predictor of poor functional outcome, it has no impact on depression and retrospective approval of craniectomy.

Outcome after decompressive craniectomy in patients with severe ischemic stroke

Decompressive craniectomy after space occupying infarction of the middle cerebral artery (MCA) tends to decrease mortality and increase functional outcome. The aim of this retrospective study was to evaluate mortality rates and functional outcome in our centre and to identify predictors of prognosis. The charts of 30 consecutive patients (6 women, 24 men, mean age 59.3 +/- 11.0 years) who underwent craniectomy after space occupying MCA-infarction from 1996 to 2002 were analyzed. Functional outcome was assessed by semistructured telephone interview as Barthel-Index, modified Rankin scale and extended Barthel-Index. Five patients (mean age 67.2 +/- 6.1 years) died within 5.2 +/- 2.4 days (range 2-8 days) after the first symptoms due to herniation. Nine patients (mean age 63.1 +/- 7.1 years) died 141.0 +/- 92.5 days (range 40-343) after stroke onset due to internal complications. 16 patients survived (mean surviving time 2.1 +/- 1.5 years, mean age 54.1 +/- 11.4 years). Mortality was related to age and the number of risk factors/comorbidity, and functional outcome was dependent on the number of risk factors/comorbidity. Our small observational, retrospective study suggests that hemicraniectomy in patients with space occupying MCA-infarction decreases mortality rate and increases functional outcome. Further randomized trials may prove useful to better define the indications, timing and prognosis for this procedure.

Recovery From Aphasia After Hemicraniectomy for Infarction of the Speech-Dominant Hemisphere

Background and Purpose— The space-occupying effect of cerebral edema limits survival chances of patients with severe ischemic stroke. Besides conventional therapies to reduce intracranial pressure, hemicraniectomy can be considered as a therapeutic option after space-occupying cerebral infarction. There is controversy regarding the use of this method in patients with infarction of the speech-dominant hemisphere.

Methods— In 14 patients with infarction of the dominant hemisphere and subsequent treatment with hemicraniectomy, recovery from aphasic symptoms was evaluated retrospectively. A group of patients who were treated between 1994 and 2003 in our aphasia ward was selected for the study. In all patients, a psychometric quantification was accomplished applying the Aachen Aphasia Test at least twice within a mean observation period of 470 days.

Results— A significant improvement of the statistical parameters representing different aspects of aphasia was observed in 13 of 14 patients. Also, an increase of the ability to communicate was evident in 13 patients. Young age at the time of stroke and early poststroke decompressive surgery were identified as main predictors for recovery from aphasia.

Conclusions— A significant improvement of aphasic symptoms can be observed in a preselected group of patients after a massive stroke of the speech-dominant hemisphere treated by consecutive hemicraniectomy. Therefore, decompressive surgery can be considered for the treatment of this kind of stroke.

Early external decompressive craniectomy with duroplasty improves functional recovery in patients with massive hemispheric embolic infarction: timing and indication of decompressive surgery for malignant cerebral infarction

BACKGROUND

Extensive cerebral hemispheric infarction associated with massive brain swelling is known as malignant infarction because of the rapid clinical deterioration and mortality as high as 80% unless appropriate treatment is performed. Decompressive craniectomy is an effective treatment, but patient selection, timing, functional recovery, and complications remain unclear.

METHODS

Seventy-one patients with massive embolic hemispheric infarctions (infarct volume >200 cm(3)) associated with brain swelling were retrospectively divided into 3 groups according to the therapeutic modalities: 21 patients were treated conservatively (conservative group); 50 patients were treated by external decompressive craniectomy with duroplasty in 2 groups; 29 patients treated after the appearance of clinical and radiologic findings of brain herniation (late surgery group); and 21 patients treated before the onset of brain herniation (early surgery group).

RESULTS

The mortality at 1 and 6 months in the conservative group were 61.9% and 71.4%, respectively. The mortality at 1 and 6 months in the late surgery group were significantly improved to 17.2% and 27.6%, respectively, (p < 0.01) and in the early surgery group were further improved to 4.8% and 19.1%, respectively. The functional recovery of the patients was estimated by the Glasgow Outcome Scale (GOS) and Barthel Index (BI) at 6 months after the ictus. The GOS scores of the early surgery group were significantly better than that of the late surgery group (p < 0.05). The mean BI score of the survivors in the late surgery group (26.9 +/- 30.4) was not significantly different from that of the conservative group (28.3 +/- 42.2), but was significantly improved in the early surgery group (52.9 +/- 34.2) compared with the late surgery group (p < 0.05).

CONCLUSIONS

Early decompressive craniectomy with duroplasty before the onset of brain herniation should be performed to achieve satisfactory functional recovery if the infarct volume of the hemispheric cerebral infarction is more than 200 cm(3) and computed tomography on the second day after the ictus shows mass effect.

[Decompressive craniectomy in malignant infarction of the middle cerebral artery]

INTRODUCTION

Medically managed malignant infarction of the middle cerebral artery (MCA) is associated with an 80% mortality rate. However, several studies report a 40-50% increase in survival rates when decompressive craniectomy is performed. We present our experience with such surgical treatment and a literature review.

PATIENTS AND METHODS

Seven decompressive craniectomies were performed on five patients for spaceoccupying MCA infarctions. Age ranged from 33 to 57 years-old (three males and two females). Preoperative GCS score was 9-13. Cranial CT was performed within the first 12 hours. Intracranial pressure (ICP) was continuously measured in four patients. Two infarcts occurred in the dominant hemisphere and three in the non-dominant side. Wide fronto-parieto-temporal craniectomies were performed. The duramater was opened and a large heterologous dura graft was placed.

RESULTS

Surgery was performed on the second day after the onset of symptoms (median: 47 hours). Preoperative ICP ranged from 27 to 50 mmHg (median: 30.5 mmHg), with immediate postoperative ICP under 15 mmHg in all patients. Two patients (both non-dominant side) survived with good (after reoperation) and excellent functional outcome. They remain stable after ten and five months of follow-up. Three patients died five, five and thirteen days after admission due to uncontrollable high ICP. In our experience, bone removal itself was more relevant than dural opening for ICP control. Initial wide craniectomies may spare reoperations.

CONCLUSION

The significant mortality rate reduction, a wide therapeutic window (2-3 days) and a low incidence of intraoperative complications make decompressive craniectomy a relevant treatment in malignant cerebral MCA infarction.

Clinical Course and Surgical Management of Massive Cerebral Infarction

OBJECTIVE:

Acute occlusion of the proximal middle cerebral artery (MCA) can lead to rapid development of fatal brain swelling and ischemic strokes. Decompressive surgery, if performed early in this subpopulation of patients, can reduce mortality and result in a favorable outcome. In this article, we describe our surgical approach for treating malignant MCA syndrome and compare it with other management strategies.

METHODS:

This is a retrospective review of patients who developed acute occlusion of the proximal MCA and underwent aggressive surgical decompression (large craniectomy, anterior temporal lobectomy, resection of infarcted tissue, and duraplasty). The outcome of this management strategy is compared with the previously published outcomes of hemicraniectomy and dural augmentation.

RESULTS:

Twelve patients were included in the study. The group consisted of six men and six women (mean age, 46.8 yr). Nine patients had right MCA stroke, and three had left MCA infarction. The causes of the strokes were cardioembolic, iatrogenic, small-vessel occlusive disease, and others. The interval between infarction and clinical evidence of herniation varied from 24 hours to 10 days. Two patients died, five were independent or had moderate disabilities, and five had severe disability.

CONCLUSION:

Surgical decompression consisting of a large craniectomy, anterior temporal lobectomy, resection of infarcted tissue, and duraplasty is beneficial to a significant number of patients with massive MCA stroke and clinical signs of herniation.

Hemicraniectomy for Massive Middle Cerebral Artery Territory Infarction

BACKGROUND AND PURPOSE

Hemicraniectomy and durotomy have been proposed in many small series to relieve intracranial hypertension and tissue shifts in patients with large hemispheric infarcts, thereby preventing death from herniation. Our objective was to review the literature to identify patients most likely to benefit from hemicraniectomy.

METHODS

All available individual cases from the English literature were reviewed and analyzed to determine whether age, vascular territory of infarction, side of infarction, reported time to surgery, and signs of herniation predict outcome in patients after hemicraniectomy. All studies included were retrospective and uncontrolled; there were no randomized controlled trials.

RESULTS

Of 15 studies screened, 12 studies describing 129 patients met the criteria for analysis; 9 patients treated at our institution were added, for a total of 138 patients. After a minimum follow-up of 4 months, 10 patients (7%) were functionally independent, 48 (35%) were mildly to moderately disabled, and 80 (58%) died or were severely disabled. Of 75 patients who were >50 years of age, 80% were dead or severely disabled compared with 32% of 63 patients <or=50 years of age (P<0.00001). The timing of surgery, hemisphere infarcted, presence of signs of herniation before surgery, and involvement of other vascular territories did not significantly affect outcome.

CONCLUSIONS

Age may be a crucial factor in predicting functional outcome after hemicraniectomy in patients with large middle cerebral artery territory infarction.

Ultra-early decompressive craniectomy for malignant middle cerebral artery infarction

BACKGROUND

Early surgical decompressive craniectomy (less than 24 hours) for malignant middle cerebral artery infarction (MCA) provides life-saving benefits. Detection of the infarction territory with computed tomography (CT) scan is usually less sensitive and delayed than diffusion-weighted imaging (DWI) that is capable of defecting the infarction territory in as little as 5 minutes after onset. Based on the DWI and clinical neurologic evaluations, ultra-early (less than 6 hours) decompressive craniectomy for malignant MCA infarction may be very helpful in improving mortality and morbidity rates.

METHODS

We treated 52 patients with malignant MCA infarction. Clinical neurologic presentation was evaluated using the National Institutes of Health Stroke Scale (NIHSS) and the Glasgow Coma Scale (GCS). The infarction territory was evaluated by either DWI or CT. Patients were divided into three groups (Group A: ultra-early, Group B: craniectomy beyond 6 hours, and Group C: no operation). Anterior temporal lobectomy was performed according to the ICP levels (ICP >30 mm Hg) after decompressive craniectomy.

RESULTS

Group A had statistically lower mortality rates than Groups B and C (8.7% in Group A, 36.7% in Group B and 80% in Group C). Group A patients also had better prognosis of conscious recovery on the 7th day of onset (91.7% in Group A, 55% in Group B and 0% in Group C). Group A had statistically better Barthel Indexes than Group B, p < 0.05. Group A and Group B had better GOS levels than Group C, p < 0.001. Diagnosis by CT was accurate in only 33% of patients while the accuracy of DWI to detect malignant MCA infarction was 100% within 6 hours of onset. In surgical Group A and B, thirteen patients underwent anterior temporal lobectomy, and 67% survived. All patients with ICP levels of more than 30 mm Hg who did not undergo further anterior temporal lobectomy died.

CONCLUSIONS

Patients who underwent decompressive surgery had better outcomes than patients who did not have the operation. Ultra-early intervention with decompressive craniectomy with ICP monitoring before neurologic conditions become worse may reduce the mortality rate, increase the conscious recovery rate, and improve neurologic sequels for malignant MCA infarction. DWI with clinical neurologic evaluation (NIHSS, hemiplegia, down-hill GCS) provides for early diagnosis and treatment of malignant MCA infarction. Anterior temporal lobectomy may further reduce intraoperative ICP and reduce mortality, especially when the infarction is at multiple arterial territories.

Management of large hemispheric strokes in the neurological intensive care unit

BACKGROUND

Patients with large hemispheric strokes frequently develop neurologic deterioration secondary to cerebral edema. Despite supportive care in the intensive care unit and traditional forms of therapy for cerebral edema, they have a high morbidity and mortality. New forms of therapy are being investigated to improve outcome in these patients.

REVIEW SUMMARY

This article begins with a discussion of the clinical and radiologic features of large hemispheric strokes. The role of increased intracranial pressure in neurologic deterioration and the predictors of outcome in these patients are reviewed. The various therapeutic options for management of cerebral edema in these patients, including the role of osmotic therapy, hypothermia, and hemicraniectomy, are explored.

CONCLUSIONS

Neurologic deterioration in patients with large hemispheric strokes necessitates admission to the intensive care unit for management of the airway, blood pressure, and cerebral edema. New promising therapies, such as hemicraniectomy and hypothermia, need to be further evaluated to define their role in the management of these patients.

Surgical decompression for cerebral oedema in acute ischaemic stroke

BACKGROUND

The high mortality that follows a large cerebral infarction is in part due to brain oedema. Oedema causes mass-effect with raised intracranial pressure and herniation. Medical therapies are used to reduce intracranial pressure but outcome is poor in spite of treatment. Decompressive surgical techniques that attempt to relieve high intracranial pressure due to oedema have been described, but their efficacy in reducing case fatality and disability is uncertain.

OBJECTIVES

To compare medical therapy plus decompressive surgery with medical therapy alone on the outcomes death and 'death or dependency' in patients with an acute ischaemic stroke complicated by clinical and radiologically confirmed cerebral oedema.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (4 October 2001). In addition, we searched the following electronic databases: the Cochrane Controlled Trials Register (Cochrane Library, issue 3, 2001), MEDLINE (1966 - April 2002), EMBASE (1980 - April 2002), and SCISEARCH (to April 2002). We also searched the reference lists of all relevant articles retrieved and contacted individual investigators and experts in the field.

SELECTION CRITERIA

Randomised controlled studies comparing the outcome of treatment with decompressive surgical intervention with treatment not involving surgery. We aimed to include only those studies with low or moderate risk of bias.

DATA COLLECTION AND ANALYSIS

Titles retrieved by searching were assessed for relevance by one author. Data were extracted independently by two authors with discussion to resolve differences. Relevant sub-group analyses were planned and we planned to calculate Peto odds ratios with 95% confidence intervals.

MAIN RESULTS

Over 9000 citations were retrieved and inspected for relevance. We identified no randomised-controlled trials to include in a meta-analysis. Five observational studies reporting comparative data were found along with a number of small series and single case reports. Two ongoing randomised-controlled trials were identified.

REVIEWER'S CONCLUSIONS

There is no evidence from randomised-controlled trials to support the use of decompressive surgery for the treatment of cerebral oedema in acute ischaemic stroke. Evidence from randomised-controlled trials is needed to accurately assess the effect of decompressive surgery.

Is decompressive craniectomy for acute cerebral infarction of any benefit?

BACKGROUND

Acute occlusion of the major cerebral arteries results in ischaemic changes to the brain, without time for reperfusion by the collateral circulation. The subsequent cellular events lead to a breakdown of the blood-brain barrier, causing malignant cerebral edema manifested clinically by a rapid neurological deterioration. The aim of this study was to determine the value of surgical decompression in patients who present with acute cerebral infarction.

METHODS

Retrospective review of patients with deteriorating consciousness level from massive cerebral ischemia and secondary edema, treated by decompressive craniectomy. RESULTSThere were 10 patients over a 2-year period from 1997-99, consisting of seven male and three female patients (mean age 47.56 years) with a mean preoperative Glasgow Coma Scale (GCS) score of 6/15. Three patients had dominant middle cerebral artery (MCA) infarction, four had nondominant MCA infarction, one had posterior cerebral artery infarction, and the remaining two had cerebellar infarction. At a mean follow-up period of 7 months, two patients had died (20% mortality), four patients (40%) were vegetative or severely disabled, and the remaining four patients (40%) had mild disability or good outcome. Favorable prognostic factors were younger age (less than 50 years) and good initial GCS score (14 or better).

CONCLUSION

Decompressive craniectomy in the setting of acute brain swelling from cerebral infarction is a life-saving procedure and should be considered in younger patients who have a rapidly deteriorating neurologic status.

Ventricular pressure monitoring during bilateral decompression with dural expansion

OBJECT

The management of massive brain swelling remains an unsolved problem in neurosurgery. Despite newly developed medical and pharmacological therapy, the rates of mortality and morbidity caused by massive brain swelling remain high. According to many recent reports, surgical decompression with dural expansion is superior to medical management in patients with massive brain swelling. To show the quantitative effect of decompressive surgery on intracranial pressure (ICP), the authors performed a ventricular puncture and measured the ventricular ICP continuously during decompressive surgery and the postoperative period.

METHODS

Twenty patients with massive brain swelling who underwent bilateral decompressive craniectomy with dural expansion were included in this study. In all patients, ventricular puncture was performed at Kocher's point on the side opposite the massive brain swelling. The ventricular puncture tube was connected to the continuous monitor via a transducer device. The ventricular pressure was monitored continuously, during the bilateral decompressive procedures and postoperative period. The initial ventricular ICP was variable, ranging from 16 to 65.8 mm Hg. Immediately after the bilateral craniectomy, the mean ventricular ICP decreased to 50.2+/-16.6% of the initial ICP (range 5-51.5 mm Hg). Additional opening of the dura decreased the mean ICP by an additional 34.5% and reduced the ventricular pressure to 15.7+/-10.7% of the initial pressure (range 0-15 mm Hg). Ventricular pressure measured postoperatively in the neurosurgical intensive care unit was lowered to 15.1+/-16.5% of the initial ICP. The ventricular ICP trend in the first 24 hours after decompressive surgery was an important prognostic factor; if it was greater than 35 mm Hg, the mortality rate was 100%.

CONCLUSIONS

Bilateral decompression with dural expansion is an effective therapeutic modality in the control of ICP. To obtain favorable clinical outcomes in patients with massive brain swelling, early decision making and proper patient selection are very important.