1
|
Paracino R, De Domenico P, Rienzo ADI, Dobran M. Radiologic and Blood Markers Predicting Long-Term Neurologic Outcome Following Decompressive Craniectomy for Malignant Ischemic Stroke: A Preliminary Single-Center Study. J Neurol Surg A Cent Eur Neurosurg 2024. [PMID: 38657675 DOI: 10.1055/a-2312-9448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
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.
Collapse
Affiliation(s)
- Riccardo Paracino
- Department of Neurosurgery, Azienda Ospedaliera di Perugia, Perugia, Italy
| | | | | | - Mauro Dobran
- Department of Neurosurgery, Università Politecnica delle Marche, Ancona, Italy
| |
Collapse
|
2
|
Im SH, Yoo DS, Park HK. Proper Indication of Decompressive Craniectomy for the Patients with Massive Brain Edema after Intra-arterial Thrombectomy. J Korean Neurosurg Soc 2024; 67:227-236. [PMID: 38173228 PMCID: PMC10924906 DOI: 10.3340/jkns.2023.0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 08/21/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE Numerous studies have indicated that early decompressive craniectomy (DC) for patients with major infarction can be life-saving and enhance neurological outcomes. However, most of these studies were conducted by neurologists before the advent of intra-arterial thrombectomy (IA-Tx). This study aims to determine whether neurological status significantly impacts the final clinical outcome of patients who underwent DC following IA-Tx in major infarction. METHODS This analysis included 67 patients with major anterior circulation major infarction who underwent DC after IA-Tx, with or without intravenous tissue plasminogen activator. We retrospectively reviewed the medical records, radiological findings, and compared the neurological outcomes based on the "surgical time window" and neurological status at the time of surgery. RESULTS For patients treated with DC following IA-Tx, a Glasgow coma scale (GCS) score of 7 was the lowest score correlated with a favorable outcome (p=0.013). Favorable outcomes were significantly associated with successful recanalization after IA-Tx (p=0.001) and perfusion/diffusion (P/D)-mismatch evident on magnetic resonance imaging performed immediately prior to IA-Tx (p=0.007). However, the surgical time window (within 36 hours, p=0.389; within 48 hours, p=0.283) did not correlate with neurological outcomes. CONCLUSION To date, early DC surgery after major infarction is crucial for patient outcomes. However, this study suggests that the indication for DC following IA-Tx should include neurological status (GCS ≤7), as some patients treated with early DC without considering the neurological status may undergo unnecessary surgery. Recanalization of the occluded vessel and P/D-mismatch are important for long-term neurological outcomes.
Collapse
Affiliation(s)
- Sang-Hyuk Im
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do-Sung Yoo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hae-Kwan Park
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
3
|
Sadeghi-Hokmabadi E, Mirzaei F, Yazdchi M, Jalili J, Sadeghpour Y, Nemati-Anari B, Farhoudi M, HamianRoumiani P. Efficacy and safety of decompressive craniectomy in acute ischemic stroke patients treated with intravenous thrombolysis. BMC Neurol 2023; 23:125. [PMID: 36978002 PMCID: PMC10045929 DOI: 10.1186/s12883-022-03014-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 12/07/2022] [Indexed: 03/30/2023] Open
Abstract
Introduction The optimal timing for decompressive hemicraniectomy (DHC) after intravenous thrombolysis (IVT) remains unclear. This study in patients with acute ischemic stroke treated with IVT aimed to assess the safety of DHC and patient outcome. Methods Data was extracted from the Tabriz stroke registry from June 2011 up to September 2020. In all, 881 patients were treated with IVT. Among these, 23 patients underwent DH. Six patients were excluded due to symptomatic intracranial hemorrhage (parenchymal hematoma type 2 based on SITS-MOST definition) after IVT, but other types of bleeding after venous thrombolysis, including HI1, HI2, and PH1 were not excluded; so the remaining 17 patients were enrolled in the study. Functional Outcome was defined as the proportion of patients who achieved mRS score of 2–3 (moderate disability), 4–5 (severe disability), or 6 (mortality) at 90 days after stroke. mRSwas assess by trained neurologist at the hospital clinic with direct interview Safety outcome was assessed by comparison of two scans just prior to and after craniectomy. Any new hemorrhage or worsening of previous hemorrhage was reported. Parenchymal hematoma type 2, based on ECASS II definition, was considered as major surgical complication. This study was approved by the local ethics committee of the Tabriz University of Medical Sciences (Ethics Code: IR.TBZMED.REC.1398.420). Results At the three-month mRS follow up, six patients (35%) had moderate and five (29%) had severe disability. The outcome of death was observed in six patients (35%).Nine of 15 patients (60%) underwent surgery in the first 48 hours after onset of symptoms. No patient over 60 years of age survived to the three-month follow up; 67% of those who were under60 years and underwent DH in the first 48 hours had favorable outcome. Hemorrhagic complication was seen in 64% of patients but none was major. Conclusion Results of this study showed that the rate of major bleeding and outcome of acute ischemic stroke patients who underwent DHC after IVT is comparable with the reported data in the literature and intentionally waiting for the fibrinolytic effects of IVT to disappear may not outweigh the benefits of DHC. Although the findings of the study should be interpreted with caution and larger studies are needed to confirm the results. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-03014-4.
Collapse
Affiliation(s)
- Elyar Sadeghi-Hokmabadi
- grid.412888.f0000 0001 2174 8913Neurosciences Research Center (NSRC), Department of Neurology, Imam-Reza hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farhad Mirzaei
- grid.412888.f0000 0001 2174 8913Department of Neurosurgery, Imam-Reza hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Yazdchi
- grid.412888.f0000 0001 2174 8913Department of Neurology, Imam-Reza hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Javad Jalili
- grid.412888.f0000 0001 2174 8913Interventional Radiology, Department of Radiology, Imam-Reza hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Yalda Sadeghpour
- grid.412888.f0000 0001 2174 8913Neurosciences Research Center (NSRC), Department of Neurology, Imam-Reza hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Behzad Nemati-Anari
- grid.411426.40000 0004 0611 7226Department of Neurology, Imam-Reza hospital, Ardebil University of Medical Sciences, Ardebil, Iran
| | - Mehdi Farhoudi
- grid.412888.f0000 0001 2174 8913Neurosciences Research Center (NSRC), Department of Neurology, Imam-Reza hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Pouneh HamianRoumiani
- grid.412888.f0000 0001 2174 8913Neurosciences Research Center (NSRC), Department of Neurology, Imam-Reza hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| |
Collapse
|
4
|
Rodrigues TP, Rodrigues MAS, Bocca LF, Chaddad-Neto FE, Cavalheiro S, Junior EA, Silva GS, Suriano IC, Centeno RS. Decompressive craniectomy index: Does the size of decompressive craniectomy matter in malignant middle cerebral artery infarction? Surg Neurol Int 2022; 13:580. [PMID: 36600778 PMCID: PMC9805638 DOI: 10.25259/sni_895_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022] Open
Abstract
Background Malignant middle cerebral artery (MCA) infarction is associated with high mortality, mainly due to intracranial hypertension. This malignant course develops when two-thirds or more of MCA territory is infarcted. Randomized clinical trials demonstrated that in patients with malignant MCA infarction, decompressive craniectomy (DC) is associated with better prognosis. In these patients, some prognostic predictors are already known, including age and time between stroke and DC. The size of bone flap was not associated with long-term prognosis in the previous studies. Therefore, this paper aims to further expand the analysis of the bone removal toward a more precise quantification and verify the prognosis implication of the bone flap area/whole supratentorial hemicranium relation in patients treated with DC for malignant middle cerebral infarcts. Methods This study included 45 patients operated between 2015 and 2020. All patients had been diagnosed with a malignant MCA infarction and were submitted to DC to treat the ischemic event. The primary endpoint was dichotomized modified Rankin scale (mRS) 1 year after surgery (mRS≤4 or mRS>4). Results Patients with bad prognosis (mRS 5-6) were on average: older and with a smaller decompressive craniectomy index (DCI). In multivariate analysis, with adjustments for "age" and "time" from symptoms onset to DC, the association between DCI and prognosis remained. Conclusion In our series, the relation between bone flap size and theoretical maximum supratentorial hemicranium area (DCI) in patients with malignant MCA infarction was associated with prognosis. Further studies are necessary to confirm these findings.
Collapse
Affiliation(s)
- Thiago Pereira Rodrigues
- Department of Neurology and Neurosurgery, Federal University of Sao Paulo, São Paulo, Brazil.,Corresponding author: Thiago Pereira Rodrigues, Department of Neurology and Neurosurgery, Federal University of Sao Paulo, São Paulo, Brazil.
| | | | - Leonardo Favi Bocca
- Department of Neurology and Neurosurgery, Federal University of Sao Paulo, São Paulo, Brazil
| | | | - Sergio Cavalheiro
- Department of Neurology and Neurosurgery, Federal University of Sao Paulo, São Paulo, Brazil
| | | | | | - Italo Capraro Suriano
- Department of Neurology and Neurosurgery, Federal University of Sao Paulo, São Paulo, Brazil
| | - Ricardo Silva Centeno
- Department of Neurology and Neurosurgery, Federal University of Sao Paulo, São Paulo, Brazil
| |
Collapse
|
5
|
Räty S, Georgiopoulos G, Aarnio K, Martinez-Majander N, Uhl E, Ntaios G, Strbian D. Hemicraniectomy for Dominant vs Nondominant Middle Cerebral Artery Infarction: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2021; 30:106102. [PMID: 34536811 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 08/31/2021] [Indexed: 11/30/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Helsinki 00290, Finland.
| | - Georgios Georgiopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Greece; School of Biomedical Engineering and Imaging Sciences, King's College, London, UK
| | - Karoliina Aarnio
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Helsinki 00290, Finland
| | - Nicolas Martinez-Majander
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Helsinki 00290, Finland
| | - Eberhard Uhl
- Department of Neurosurgery, Justus-Liebig-University, Giessen, Germany
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Helsinki 00290, Finland
| |
Collapse
|
6
|
Karasin B, Grzelak M, Rizzo G, Hardinge T, Eskuchen L, Boyce M, Watkinson J. Decompressive Hemicraniectomy for Middle Cerebral Artery Stroke: Indications and Perioperative Care. AORN J 2021; 114:34-46. [PMID: 34181258 DOI: 10.1002/aorn.13430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/15/2020] [Indexed: 11/05/2022]
Abstract
Decompressive hemicraniectomy (DHC) is a procedure performed in the setting of malignant cerebral edema after a large middle cerebral artery stroke. The decision to proceed with surgical decompression is one that must be made judiciously and rapidly. Although this can be a life-saving surgery, it does not necessarily improve the patient's quality of life. The neurosurgical team must thoroughly discuss the patient's comorbidities, age, dominant versus nondominant hemispheric injury, and neurological expectations, and the procedure itself (ie, risks, benefits, expected postoperative course, goals of care) with the patient and his or her family before DHC. This article briefly reviews the anatomy of the brain and stroke presentation and provides an overview of DHC and the perioperative course. The article concludes with a case study of a patient with a medical history of hypertension and prediabetes who presents to the emergency department after a fall and undergoes an emergent DHC.
Collapse
|
7
|
Xu Z, Duan J, Yang B, Huang X, Liang G, Duan Y. Hyperdense middle cerebral artery sign predicts favorable outcome after decompressive craniectomy in patients with malignant middle cerebral artery infarction. Acta Radiol 2021; 63:1255-1261. [PMID: 34350770 DOI: 10.1177/02841851211035899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Malignant middle cerebral artery infarction (MMI) is a life-threatening cerebral vascular event. Early decompressive craniectomy (DC) has proven to be an effective treatment strategy. However, the ideal candidate for DC continues to be debated. PURPOSE To investigate whether a hyperdense middle cerebral artery sign (HMCAS) provides prognostic value after DC in patients with MMI. MATERIAL AND METHODS We reviewed clinical information and radiological parameters on computed tomography of 42 patients with MMI who underwent DC. Functional outcome was assessed according to the modified Rankin scale (mRS) at three months as follows: favorable outcome (mRS ≤ 4) versus unfavorable outcome (mRS > 4). Logistic regression analysis was used to identify predictors of functional outcome after DC in patients with MMI. RESULTS Age (odds ratio [OR] = 0.87; 95% confidence interval [CI] = 0.78-0.97; P = 0.014) and HMCAS (OR = 7.40; 95% CI = 1.35-40.48; P = 0.021) were associated with functional outcome. The area under the receiver operating characteristic curve for predicting favorable outcome using the combination of age and HMCAS was 0.882, and the sensitivity and specificity were 0.947 and 0.696, respectively. CONCLUSION Patients with MMI with HMCAS, as well as younger patients, often showed a favorable outcome after DC in this study.
Collapse
Affiliation(s)
- Zhihua Xu
- Department of Radiology, Tongde Hospital of Zhejiang Province, TongDe Hospital of Zhejiang Province, Hangzhou, PR China
- Department of Radiology, General Hospital of Northern Theater Command, Shenyang, PR China
| | - Jinfeng Duan
- Department of Surgery, Shengjing Hospital of China Medical University, Shenyang, PR China
| | - Benqiang Yang
- Department of Radiology, General Hospital of Northern Theater Command, Shenyang, PR China
| | - Xin Huang
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, PR China
| | - Guobiao Liang
- Department of Neurosurgery, General Hospital of Northern Theater Command, Shenyang, PR China
| | - Yang Duan
- Department of Radiology, General Hospital of Northern Theater Command, Shenyang, PR China
| |
Collapse
|
8
|
Yuan R, Wu S, Cheng Y, Ye K, Hao Z, Zhang S, Liu Y, Liu M. Association Between Preoperative Midline Shift Growing Rate and Outcomes of Decompressive Craniectomy in Patients with Malignant Middle Cerebral Artery Infarction. Curr Neurovasc Res 2021; 17:131-139. [PMID: 32031070 DOI: 10.2174/1567202617666200207125552] [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: 12/05/2019] [Revised: 01/08/2020] [Accepted: 01/14/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Whether preoperative midline shift and its growing rate are associated with outcomes of decompressive craniectomy in patients with malignant middle cerebral artery infarction is unknown. METHODS We retrospectively included patients: 1) who underwent decompressive craniectomy for malignant middle cerebral artery infarction in West China Hospital from August 2010 to December 2, 2018) who had at least two brain computed tomography scans before decompressive craniectomy. Midline shift was measured on the first and last preoperative computed tomography scans. Midline shift growing rate was calculated by dividing Δmidline shift value using Δ time. The primary outcome was inadequate decompression of the mass effect. Secondary outcomes were 3 month death and unfavorable outcomes. RESULTS Sixty-one patients (mean age 53.7 years, 57.4% (35/61) male) were included. Median time from onset to decompressive craniectomy was 51.8 h (interquartile range: 39.7-77.8). Rates of inadequate decompression, 3 month death, 3 month modified Rankin Scale 5-6 and 4-6 were 50.8% (31/61), 50.9% (29/57), 64.9% (37/57) and 84.2% (48/57), respectively. The inadequate decompression group had a higher midline shift growing rate than the adequate decompression group (median: 2.7 mm/8 h vs. 1.4 mm/8 h, P=0.041). No intergroup difference of 3 month outcomes was found in terms of preoperative midline shift growing rate. CONCLUSION Higher preoperative midline shift growing rate was associated with inadequate decompression of decompressive craniectomy in patients with malignant middle cerebral artery infarction.
Collapse
Affiliation(s)
- Ruozhen Yuan
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Simiao Wu
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Yajun Cheng
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Kaili Ye
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Zilong Hao
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Shihong Zhang
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ming Liu
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
9
|
Lim JX, Vedicherla SV, Chan SKS, Primalani NK, Tan AJL, Saffari SE, Lee L. Decompressive craniectomy for internal carotid artery and middle carotid artery infarctions: a long-term comparative outcome study. Neurosurg Focus 2021; 51:E10. [PMID: 34198256 DOI: 10.3171/2021.4.focus21123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Malignant internal carotid artery (ICA) infarction is an entirely different disease entity when compared with middle cerebral artery (MCA) infarction. Because of an increased area of infarction, it is assumed to have a poorer prognosis; however, this has never been adequately investigated. Decompressive craniectomy (DC) for malignant MCA infarction has been shown to improve mortality rates in several randomized controlled trials. Conversely, aggressive surgical decompression for ICA infarction has not been recommended. The authors sought to compare the functional outcomes and survival between patients with ICA infarctions and those with MCA infarctions after DC in the largest series to date to investigate this assumption. METHODS A multicenter retrospective review of 154 consecutive DCs for large territory cerebral infarctions performed from 2005 to 2020 were analyzed. Patients were divided into ICA and MCA groups depending on the territory of infarction. Variables, including age, sex, medical comorbidities, laterality of the infarction, preoperative neurological status, primary stroke treatment, and the time from stroke onset to DC, were recorded. Univariable and multivariable analyses were performed for the clinical exposures for functional outcomes (modified Rankin Scale [mRS] score) on discharge and at the 1- and 6-month follow-ups, and for mortality, both inpatient and at the 1-year follow-up. A favorable mRS score was defined as 0-2. RESULTS There were 67 patients (43.5%) and 87 patients (56.5%) in the ICA and MCA groups, respectively. Univariable analysis showed that the ICA group had a comparably favorable mRS (OR 0.15 [95% CI 0.18-1.21], p = 0.077). Inpatient mortality (OR 1.79 [95% CI 0.79-4.03], p = 0.16) and 1-year mortality (OR 2.07 [95% CI 0.98-4.37], p = 0.054) were comparable between the groups. After adjustment, a favorable mRS score at 6 months (OR 0.17 [95% CI 0.018-1.59], p = 0.12), inpatient mortality (OR 1.02 [95% CI 0.29-3.57], p = 0.97), and 1-year mortality (OR 0.94 [95% CI 0.41-2.69], p = 0.88) were similar in both groups. The overall survival, plotted using the Cox proportional hazard regression, did not show a significant difference between the ICA and MCA groups (HR 0.581). CONCLUSIONS Unlike previous smaller studies, this study found that patients with malignant ICA infarction had a functional outcome and survival that was similar to those with MCA infarction after DC. Therefore, DC can be offered for malignant ICA infarction for life-saving purposes with limited functional recovery.
Collapse
Affiliation(s)
- Jia Xu Lim
- 1Department of Neurosurgery, National Neuroscience Institute; and
| | | | | | | | - Audrey J L Tan
- 1Department of Neurosurgery, National Neuroscience Institute; and
| | | | - Lester Lee
- 1Department of Neurosurgery, National Neuroscience Institute; and.,3Duke-NUS Medical School, Singapore
| |
Collapse
|
10
|
Chen X, Hao Q, Yang SZ, Wang S, Zhao YL, Zhang D, Ye X, Wang H. Improvement in Midline Shift Is a Positive Prognostic Predictor for Malignant Middle Cerebral Artery Infarction Patients Undergoing Decompressive Craniectomy. Front Neurol 2021; 12:652827. [PMID: 34093400 PMCID: PMC8176305 DOI: 10.3389/fneur.2021.652827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/30/2021] [Indexed: 12/25/2022] Open
Abstract
Objective: The aim of this retrospective study is to evaluate the risk factors of malignant middle cerebral artery infarction (MMCAI) patients and explore an applicable prognostic predictor for MMCAI patients undergoing decompressive craniectomy (DC). Methods: Clinical data from the period 2012-2017 were retrospectively evaluated. Forty-three consecutive MMCAI patients undergoing DC were enrolled in this study. The 30-day mortality was assessed, and age, location, hypertension, pupil dilation, onset to operation duration, midline shift, and Glasgow Coma Scale (GCS) score were identified by univariate analysis and binary logistic regression. Results: In this retrospective study for DC patients, the 30-day mortality was 44.2%. In the univariate analysis, advanced age (≥60 years), right hemispheric location, hypertension, pupil dilation, shorter onset to operation duration (<48 h), improved midline shift (t = 4.214, p < 0.01), and lower pre-operation GCS score were significant predictors of death within 30 days. In binary logistic regression analysis, age [odds ratio (OR) = 1.141, 95% CI 1.011-1.287], the improvement of the midline shift (OR = 0.764, 95% CI 0.59-0.988), and pupillary dilation (OR = 15.10, 95% CI 1.374-165.954) were independent influencing factors. For the receiver operating characteristic (ROC) analysis of the relationship between post-operation outcomes and midline shift improvement, the area under the curve (AUC) was 0.844, and the cutoff point of midline shift improvement was 0.83 cm. Conclusion: Improved midline shift was a significant predictor of 30-day mortality. The improved midline shift of >0.83 cm indicated survival at 30 days.
Collapse
Affiliation(s)
- Xin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qiang Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shu-Zhe Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuan-Li Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
11
|
Sueiras M, Thonon V, Santamarina E, Sánchez-Guerrero Á, Riveiro M, Poca MA, Quintana M, Gándara D, Sahuquillo J. Is Spreading Depolarization a Risk Factor for Late Epilepsy? A Prospective Study in Patients with Traumatic Brain Injury and Malignant Ischemic Stroke Undergoing Decompressive Craniectomy. Neurocrit Care 2020; 34:876-888. [PMID: 33000378 DOI: 10.1007/s12028-020-01107-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 09/05/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Spreading depolarizations (SDs) have been described in patients with ischemic and haemorrhagic stroke, traumatic brain injury, and migraine with aura, among other conditions. The exact pathophysiological mechanism of SDs is not yet fully established. Our aim in this study was to evaluate the relationship between the electrocorticography (ECoG) findings of SDs and/or epileptiform activity and subsequent epilepsy and electroclinical outcome. METHODS This was a prospective observational study of 39 adults, 17 with malignant middle cerebral artery infarction (MMCAI) and 22 with traumatic brain injury, who underwent decompressive craniectomy and multimodal neuromonitoring including ECoG in penumbral tissue. Serial electroencephalography (EEG) recordings were obtained for all surviving patients. Functional disability at 6 and 12 months after injury were assessed using the Barthel, modified Rankin (mRS), and Extended Glasgow Outcome (GOS-E) scales. RESULTS SDs were recorded in 58.9% of patients, being more common-particularly those of isoelectric type-in patients with MMCAI (p < 0.04). At follow-up, 74.7% of patients had epileptiform abnormalities on EEG and/or seizures. A significant correlation was observed between the degree of preserved brain activity on EEG and disability severity (R [mRS]: + 0.7, R [GOS-E, Barthel]: - 0.6, p < 0.001), and between the presence of multifocal epileptiform abnormalities on EEG and more severe disability on the GOS-E at 6 months (R: - 0.3, p = 0.03) and 12 months (R: - 0.3, p = 0.05). Patients with more SDs and higher depression ratios scored worse on the GOS-E (R: - 0.4 at 6 and 12 months) and Barthel (R: - 0.4 at 6 and 12 months) disability scales (p < 0.05). The number of SDs (p = 0.064) and the depression ratio (p = 0.1) on ECoG did not show a statistically significant correlation with late epilepsy. CONCLUSIONS SDs are common in the cortex of ischemic or traumatic penumbra. Our study suggests an association between the presence of SDs in the acute phase and worse long-term outcome, although no association with subsequent epilepsy was found. More comprehensive studies, involving ECoG and EEG could help determine their association with epileptogenesis.
Collapse
Affiliation(s)
- Maria Sueiras
- Department of Clinical Neurophysiology, Vall d'Hebron University Hospital, Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain. .,Neurotrauma and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR), Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain. .,Universitat Autònoma de Barcelona (UAB), Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Vanessa Thonon
- Department of Clinical Neurophysiology, Vall d'Hebron University Hospital, Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Estevo Santamarina
- Epilepsy Unit, Department of Neurology, Vall d'Hebron University Hospital, Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Ángela Sánchez-Guerrero
- Neurotrauma and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR), Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Marilyn Riveiro
- Neurotrauma Intensive Care Unit, Vall d'Hebron University Hospital, Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Maria-Antonia Poca
- Neurotrauma and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR), Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Universitat Autònoma de Barcelona (UAB), Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Department of Neurosurgery, Vall d'Hebron University Hospital, Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Manuel Quintana
- Epilepsy Unit, Department of Neurology, Vall d'Hebron University Hospital, Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Dario Gándara
- Neurotrauma and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR), Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Department of Neurosurgery, Vall d'Hebron University Hospital, Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Juan Sahuquillo
- Neurotrauma and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR), Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Universitat Autònoma de Barcelona (UAB), Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Department of Neurosurgery, Vall d'Hebron University Hospital, Paseo Vall d'Hebron 119-129, 08035, Barcelona, Spain
| |
Collapse
|
12
|
Goedemans T, Verbaan D, Coert BA, Kerklaan B, van den Berg R, Coutinho JM, van Middelaar T, Nederkoorn PJ, Vandertop WP, van den Munckhof P. Outcome After Decompressive Craniectomy for Middle Cerebral Artery Infarction: Timing of the Intervention. Neurosurgery 2020; 86:E318-E325. [PMID: 31943069 PMCID: PMC7061200 DOI: 10.1093/neuros/nyz522] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 09/29/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Based on randomized controlled trials (RCTs), clinical guidelines for the treatment of space-occupying hemispheric infarct employ age (≤60 yr) and time elapsed since stroke onset (≤48 h) as decisive criteria whether to perform decompressive craniectomy (DC). However, only few patients in these RCTs underwent DC after 48 h. OBJECTIVE To study the association between the timing of DC and (un)favorable outcome in patients with space-occupying middle cerebral artery (MCA) infarct undergoing DC. METHODS We performed a single-center cohort study from 2007 to 2017. Unfavorable outcome at 1 yr was defined as a Glasgow outcome scale 1 to 3. Additionally, we systematically reviewed the literature up to November 2018, including studies reporting on the timing of DC and other predictors of outcome. We performed Firth penalized likelihood and random-effects meta-analysis with odds ratio (OR) on unfavorable outcome. RESULTS A total of 66 patients were enrolled. A total of 26 (39%) patients achieved favorable and 40 (61%) unfavorable outcomes (13 [20%] died). DC after 48 h since stroke diagnosis did not significantly increase the risk of unfavorable outcome (OR 0.8, 95% CI 0.3-2.3). Also, in the meta-analysis, DC after 48 h of stroke onset was not associated with a higher risk of unfavorable outcome (OR 1.11; 95% CI 0.89-1.38). CONCLUSION The outcome of DC performed after 48 h in patients with malignant MCA infarct was not worse than the outcome of DC performed within 48 h. Contrary to current guidelines, we, therefore, advocate not to set a restriction of ≤48 h on the time elapsed since stroke onset in the decision whether to perform DC.
Collapse
Affiliation(s)
- Taco Goedemans
- Neurosurgical Centre Amsterdam, Amsterdam Medical Centre, Amsterdam University Medical Centres (UMC), University of Amsterdam, Amsterdam, the Netherlands
| | - Dagmar Verbaan
- Neurosurgical Centre Amsterdam, Amsterdam Medical Centre, Amsterdam University Medical Centres (UMC), University of Amsterdam, Amsterdam, the Netherlands
| | - Bert A Coert
- Neurosurgical Centre Amsterdam, Amsterdam Medical Centre, Amsterdam University Medical Centres (UMC), University of Amsterdam, Amsterdam, the Netherlands
| | - Bertjan Kerklaan
- Department of Neurology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, and Zaans Medical Centre (ZMC), Zaandam, the Netherlands
| | - René van den Berg
- Department of Radiology, Amsterdam Medical Centre, Amsterdam UMC, Amsterdam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam Medical Centre, Amsterdam UMC, Amsterdam, the Netherlands
| | - Tessa van Middelaar
- Department of Neurology, Amsterdam Medical Centre, Amsterdam UMC, Amsterdam, the Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam Medical Centre, Amsterdam UMC, Amsterdam, the Netherlands
| | - W Peter Vandertop
- Neurosurgical Centre Amsterdam, Amsterdam Medical Centre, Amsterdam University Medical Centres (UMC), University of Amsterdam, Amsterdam, the Netherlands
| | - Pepijn van den Munckhof
- Neurosurgical Centre Amsterdam, Amsterdam Medical Centre, Amsterdam University Medical Centres (UMC), University of Amsterdam, Amsterdam, the Netherlands
| |
Collapse
|
13
|
Casolla B, Kyheng M, Kuchcinski G, Lejeune JP, Hanafi R, Bodenant M, Leys D, Labreuche J, Allart E, Jourdain M, Cordonnier C, Henon H. Predictors of outcome in 1-month survivors of large middle cerebral artery infarcts treated by decompressive hemicraniectomy. J Neurol Neurosurg Psychiatry 2020; 91:469-474. [PMID: 32165377 DOI: 10.1136/jnnp-2019-322280] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 12/04/2019] [Accepted: 01/22/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Decompressive hemicraniectomy (DH) increases survival without severe dependency in patients with large middle cerebral artery (LMCA) infarcts. The objective was to identify predictors of 1-year outcome after DH for LMCA infarct. METHODS We conducted this study in consecutive patients who underwent DH for LMCA infarcts, in a tertiary stroke centre. Using multivariable logistic regression analyses, we evaluated predictors of (1) 30-day mortality and (2) poor outcome after 1 year (defined as a modified Rankin Scale score of 4-6) in 30-day survivors. RESULTS Of 212 patients (133 men, 63%; median age 51 years), 35 (16.5%) died within 30 days. Independent predictors of mortality were infarct volume before DH (OR 1.10 per 10 mL increase, 95% CI 1.04 to 1.16), delay between symptom onset and DH (OR 0.41, 95% CI 0.23 to 0.73 per 12 hours increase) and midline shift after DH (OR 2.59, 95% CI 1.09 to 6.14). The optimal infarct volume cut-off to predict death was 210 mL or more. Among the 177 survivors, 77 (43.5%) had a poor outcome at 1 year. Independent predictors of poor outcome were age (OR 1.08 per 1 year increase, 95% CI 1.03 to 1.12) and weekly alcohol consumption of 300 g or more (OR 5.30, 95% CI 2.20 to 12.76), but not infarct volume. CONCLUSION In patients with LMCA infarcts treated by DH, stroke characteristics (infarct volume before DH, midline shift after DH and early DH) predict 30-day mortality, while patients' characteristics (age and excessive alcohol intake) predict 1-year outcome survivors.
Collapse
Affiliation(s)
- Barbara Casolla
- Neurology, Stroke Unit, CHU Lille, Inserm U1171, Lille, France
| | | | | | | | | | | | - Didier Leys
- Neurology, Stroke Unit, CHU Lille, Inserm U1171, Lille, France
| | | | | | | | | | - Hilde Henon
- Neurology, Stroke Unit, CHU Lille, Inserm U1171, Lille, France
| |
Collapse
|
14
|
Spellicy SE, Kaiser EE, Bowler MM, Jurgielewicz BJ, Webb RL, West FD, Stice SL. Neural Stem Cell Extracellular Vesicles Disrupt Midline Shift Predictive Outcomes in Porcine Ischemic Stroke Model. Transl Stroke Res 2019; 11:776-788. [PMID: 31811639 PMCID: PMC7340639 DOI: 10.1007/s12975-019-00753-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 12/11/2022]
Abstract
Magnetic resonance imaging (MRI) is a clinically relevant non-invasive imaging tool commonly utilized to assess stroke progression in real time. This study investigated the utility of MRI as a predictive measure of clinical and functional outcomes when a stroke intervention is withheld or provided, in order to identify biomarkers for stroke functional outcome under these conditions. Fifteen MRI and ninety functional parameters were measured in a middle cerebral artery occlusion (MCAO) porcine ischemic stroke model. Multiparametric analysis of correlations between MRI measurements and functional outcome was conducted. Acute axial and coronal midline shift (MLS) at 24 h post-stroke were associated with decreased survival and recovery measured by modified Rankin scale (mRS) and were significantly correlated with 52 measured acute (day 1 post) and chronic (day 84 post) gait and behavior impairments in non-treated stroked animals. These results suggest that MLS may be an important non-invasive biomarker that can be used to predict patient outcomes and prognosis as well as guide therapeutic intervention and rehabilitation in non-treated animals and potentially human patients that do not receive interventional treatments. Neural stem cell–derived extracellular vesicle (NSC EV) was a disruptive therapy because NSC EV administration post-stroke disrupted MLS correlations observed in non-treated stroked animals. MLS was not associated with survival and functional outcomes in NSC EV–treated animals. In contrast to untreated animals, NSC EVs improved stroked animal outcomes regardless of MLS severity.
Collapse
Affiliation(s)
- Samantha E Spellicy
- Regenerative Bioscience Center, University of Georgia, Athens, GA, 30602, USA
- Department of Animal and Dairy Science, University of Georgia, Athens, GA, 30602, USA
| | - Erin E Kaiser
- Regenerative Bioscience Center, University of Georgia, Athens, GA, 30602, USA
- Department of Animal and Dairy Science, University of Georgia, Athens, GA, 30602, USA
| | - Michael M Bowler
- Regenerative Bioscience Center, University of Georgia, Athens, GA, 30602, USA
| | - Brian J Jurgielewicz
- Regenerative Bioscience Center, University of Georgia, Athens, GA, 30602, USA
- Department of Animal and Dairy Science, University of Georgia, Athens, GA, 30602, USA
| | | | - Franklin D West
- Regenerative Bioscience Center, University of Georgia, Athens, GA, 30602, USA
- Department of Animal and Dairy Science, University of Georgia, Athens, GA, 30602, USA
| | - Steven L Stice
- Regenerative Bioscience Center, University of Georgia, Athens, GA, 30602, USA.
- Department of Animal and Dairy Science, University of Georgia, Athens, GA, 30602, USA.
- ArunA Biomedical, Athens, GA, 30602, USA.
| |
Collapse
|
15
|
Yang G, Liu Z, Wang L, Chen X, Wang X, Dong Q, Zhang D, Yang Z, Zhou Q, Sun J, Xue L, Wang X, Gao M, Li L, Yi R, Ilgiz G, Ai J, Zhao S. MicroRNA-195 protection against focal cerebral ischemia by targeting CX3CR1. J Neurosurg 2019; 131:1445-1454. [PMID: 30497184 DOI: 10.3171/2018.5.jns173061] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 05/29/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE It has been reported that microRNA-195 (miR-195) protects against chronic brain injury induced by chronic brain hypoperfusion. However, neither the expression profile of miR-195 nor its potential role during acute ischemic stroke has been investigated. In this study, the authors' aim was to verify the mechanism of miR-195 in acute ischemic stroke. METHODS The plasma levels of miR-195 expression were assessed using real-time PCR in 96 patients with acute ischemic stroke, and the correlation with the National Institutes of Health Stroke Scale score was evaluated. In addition, cerebral infarct volume, neurological score, and levels of miR-195 and CX3CL1/CX3CR1 mRNA and protein expression were assessed in mice subjected to middle cerebral artery occlusion (MCAO) with or without intra-cerebroventricular infusion of lentiviral vector. The inflammatory cytokines tumor necrosis factor-α (TNFα), interleukin (IL)-1β, and IL-6 of mouse brains after MCAO and BV2 cells treated with oxygen-glucose deprivation were measured using enzyme-linked immunosorbent assay, and apoptotic proteins were examined by Western blotting. Direct targeting of CX3CL1/CX3CR1 by miR-195 was determined by immunoblotting and dual luciferase assay. RESULTS In ischemic stroke patients, miR-195 was significantly downregulated and expression levels of miR-195 in these patients negatively correlated with the National Institutes of Health Stroke Scale score. In mice after MCAO, miR-195 overexpression decreased infarct volume, alleviated neurological deficits, and most importantly, suppressed an inflammatory response. Meanwhile, miR-195 suppressed the expression of the inflammatory cytokines TNFα, IL-1β, and IL-6 in vitro and in vivo. The authors further discovered that both CX3CL1 and CX3CR1 are direct targets of miR-195, but miR-195 exerts neuroprotective roles mainly through inhibiting CX3CR1-mediated neuroinflammation and subsequent neuronal cell apoptosis. CONCLUSIONS Taken together, these findings suggest that miR-195 promotes neuronal cell survival against chronic cerebral ischemic damage by inhibiting CX3CR1-mediated neuroinflammation. This indicates that miR-195 may represent a novel target that regulates neuroinflammation and brain injury, thus offering a new treatment strategy for cerebral ischemic disorders.
Collapse
Affiliation(s)
- Guang Yang
- 1Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin
- 2Institute of Brain Science, Harbin Medical University, Harbin
| | - Zhendong Liu
- 1Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin
- 2Institute of Brain Science, Harbin Medical University, Harbin
| | - Lu Wang
- 3Department of Urology, The Fourth Hospital of Harbin Medical University, Harbin
| | - Xin Chen
- 1Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin
- 2Institute of Brain Science, Harbin Medical University, Harbin
| | - Xiaoxiong Wang
- 1Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin
- 2Institute of Brain Science, Harbin Medical University, Harbin
| | - Qi Dong
- 4Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin
| | - Daming Zhang
- 1Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin
- 2Institute of Brain Science, Harbin Medical University, Harbin
| | - Zhao Yang
- 1Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin
- 2Institute of Brain Science, Harbin Medical University, Harbin
| | - Qi Zhou
- 5Research Administration Office, The First Affiliated Hospital of Harbin Medical University, Harbin
| | - Jingxian Sun
- 1Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin
- 2Institute of Brain Science, Harbin Medical University, Harbin
| | - Linmeng Xue
- 1Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin
- 2Institute of Brain Science, Harbin Medical University, Harbin
| | - Xinzhuang Wang
- 1Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin
- 2Institute of Brain Science, Harbin Medical University, Harbin
| | - Ming Gao
- 1Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin
- 2Institute of Brain Science, Harbin Medical University, Harbin
| | - Lili Li
- 1Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin
| | - Ran Yi
- 6Department of Endocrinology and Metabolism, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Gareev Ilgiz
- 1Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin
- 7Department of Medical Rehabilitation with courses of Neurosurgery and Acupuncture IAPE, Bashkir State Medical University, Ufa, Republic of Bashkortostan, Russia; and
| | - Jing Ai
- 8Department of Pharmacology, The State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, College of Pharmacy of Harbin Medical University, Harbin, China
| | - Shiguang Zhao
- 1Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin
- 2Institute of Brain Science, Harbin Medical University, Harbin
| |
Collapse
|
16
|
Kwak Y, Kim BJ, Park J. Maximum Decompressive Hemicraniectomy for Patients with Malignant Hemispheric Infarction. J Cerebrovasc Endovasc Neurosurg 2019; 21:138-143. [PMID: 31886148 PMCID: PMC6911931 DOI: 10.7461/jcen.2019.21.3.138] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/02/2019] [Accepted: 09/18/2019] [Indexed: 12/01/2022] Open
Abstract
Objective The authors applied maximum external decompression for malignant hemispheric infarction and investigated the functional outcome according to the patient age. Methods Twenty-five patients with malignant hemispheric infarction were treated using a hemicraniectomy with maximum external decompression, comprising a larger (>14cm) hemicraniectomy, resection of the temporalis muscle and its fascia, spaciously expansive duraplasty, and approximation of the skin flap. The medical and diagnostic imaging records for the patients were reviewed, and 1-year functional outcome data obtained for the younger group (aged ≤ 60 years) and elderly group (aged > 60 years). Results The patients (n=25) who underwent maximum surgical decompression revealed a minimal mortality rate (n=2, 8.0%). The patients (n=14) in the younger group all survived with mRS scores of 2 (n=1, 7.1%), 3 (n=7, 50.0%), 4 (n=3, 21.4%), or 5 (n=3, 21.4%). A majority of the younger patients (57.1% with mRS ≤3) lived with functional independence. When the 1-year mRS scores were dichotomized between favorable (mRS ≤3) and unfavorable (mRS ≥4) outcomes, the younger group had significantly more patients with a favorable outcome than the elderly group (57.1% versus 9.1%, p=0.033). In contrast, in the elderly group, most patients showed unfavorable outcomes with the mRS scores of 4 (n=5, 45.5%), 5 (n=3, 27.3%), or 6 (n=2, 18.2%), whereas only one patient showed favorable outcome (mRS 3). A majority of the elderly patients (45.5% with mRS 4) survived with moderately severe disability. Conclusion For malignant hemispheric infarction, a hemicraniectomy with maximum external decompression was found to considerably increase survival with a favorable outcome in functional independence (mRS ≤3) for younger patients aged ≤60 years. It can be optimal surgical treatment for younger patients.
Collapse
Affiliation(s)
- Youngseok Kwak
- Department of Neurosurgery, School of Medicine, Catholic University of Daegu, Daegu, Republic of Korea
| | - Byoung-Joon Kim
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jaechan Park
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| |
Collapse
|
17
|
Harrigan MR. Commentary: Novel Hemicraniectomy Technique for Malignant Middle Cerebral Artery Infarction: Technical Note. Oper Neurosurg (Hagerstown) 2019; 17:E96-E97. [PMID: 30888425 DOI: 10.1093/ons/opz045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 02/14/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mark R Harrigan
- Department of Neurosurgery, University of Alabama, Birmingham
| |
Collapse
|
18
|
Al Saiegh F, Chalouhi N, Schmidt RF, Jabbour P, Tjoumakaris S, Gooch MR, Herial N, Zarzour H, Smith M, Rosenwasser RH. The Neurosurgeon as a Stroke Specialist. Neurosurgery 2019; 66:13-15. [PMID: 31428760 DOI: 10.1093/neuros/nyz256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 04/21/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| |
Collapse
|
19
|
Pandhi A, Tsivgoulis G, Goyal N, Ishfaq MF, Male S, Boviatsis E, Chang JJ, Zand R, Voumvourakis K, Elijovich L, Alexandrov AW, Malkoff MD, Hoit D, Arthur AS, Alexandrov AV. Hemicraniectomy for Malignant Middle Cerebral Artery Syndrome: A Review of Functional Outcomes in Two High-Volume Stroke Centers. J Stroke Cerebrovasc Dis 2018; 27:2405-2410. [PMID: 29776804 DOI: 10.1016/j.jstrokecerebrovasdis.2018.04.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/11/2018] [Accepted: 04/23/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND AND PURPOSE Despite recent landmark randomized controlled trials showing significant benefits for hemicraniectomy (HCT) compared with medical therapy (MT) in patients with malignant middle cerebral artery infarction (MMCAI), HCT rates have not substantially increased in the United States. We sought to evaluate early outcomes in patients with MMCAI who were treated with HCT (cases) in comparison to patients treated with MT due to the perception of procedural futility by families (controls). METHODS We retrospectively evaluated consecutive patients with acute MMCAI treated in 2 tertiary care centers during a 7-year period. Pretreatment National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 3 months were documented. Functional independence (FI) and survival without severe disability (SWSD) were defined as mRS of 0-2 and 0-4, respectively. RESULTS A total of 66 patients (37 cases and 29 controls) fulfilled the study inclusion criteria (mean age 59 ± 15 years, 52% men, median admission NIHSS score: 19 points [interquartile range {IQR}: 16-22]). Cases were younger (51 ± 11 versus 68 ± 13 years; P < .001) and tended to have lower median admission NIHSS than controls (18 [IQR:16-20] versus 20 [IQR:18-23]; P = .072). The rates of FI and SWSD at 3 months were higher in cases than controls (16% versus 0% [P = .031] and 62% versus 0% [P < .001]), while 3-month mortality was lower (24% versus 77%; P < .001). Multivariable Cox regression analyses adjusting for potential confounders identified HCT as the most important predictor of lower risk of 3-month mortality (hazard ratio: .02, 95% confidence interval: .01-0.10; P < .001). CONCLUSIONS HCT is a critical and effective therapy for patients with MMCAI but cannot provide a guarantee of functional recovery.
Collapse
Affiliation(s)
- Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee.
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee; Second Department of Neurology, "Attikon University Hospital", School of Medicine, University of Athens, Athens, Greece
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Muhammad F Ishfaq
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Shailesh Male
- Department of Neurology, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Efstathios Boviatsis
- Second Department of Neurosurgery, "Attikon University Hospital", School of Medicine, University of Athens, Athens, Greece
| | - Jason J Chang
- Neurointensivist, Medstar Washington Hospital Medical Center, Washington, DC
| | - Ramin Zand
- Neurology Director of Clinical Stroke Operations & Northeastern Regional Stroke Director, Geisinger Health System
| | | | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Anne W Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee; Professor and US Principle Investigator, Australian Catholic University, Sydney, Australia
| | - Marc D Malkoff
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Daniel Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| |
Collapse
|
20
|
Hecht N, Neugebauer H, Fiss I, Pinczolits A, Vajkoczy P, Jüttler E, Woitzik J. Infarct volume predicts outcome after decompressive hemicraniectomy for malignant hemispheric stroke. J Cereb Blood Flow Metab 2018; 38:1096-1103. [PMID: 28665171 PMCID: PMC5999005 DOI: 10.1177/0271678x17718693] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The decision to perform decompressive hemicraniectomy (DHC) by default in malignant hemispheric stroke (MHS) remains controversial. Even under ideal conditions, DHC usually results in moderate to severe disability. The present study for the first time uses neuroimaging to identify independent outcome predictors in a prospective cohort of 96 MHS patients undergoing DHC. The primary outcome was functional status according to the modified Rankin Scale (mRS) at 12 months and categorized as favorable (mRS 0-3) or unfavorable (mRS 4-6). At 12 months, 19 patients (20%) reached favorable and 77 patients (80%) unfavorable outcome. The overall mean infarct volume was 328 ± 114 ml. Multivariable logistic regression identified age per year (OR 1.14, 95% CI 1.04-1.24; p = 0.005), infarct volume per cm3 (OR 1.012, 95% CI 1.003-1.022; p = 0.013), thalamic involvement (OR 8.65, 95% CI 1.04-72.15; p = 0.046) and postoperative pneumonia (OR 5.52, 95% CI 1.03-29.57; p = 0.046) as independent outcome predictors, which was confirmed by multivariable ordinal regression for age ( p = 0.004) and infarct volume ( p = 0.015). The infarct volume threshold for reasonable prediction of unfavorable outcome in our patients was 270 cm3, which in the future may help prognostication and development of clinical trials on DHC and outcome in MHS.
Collapse
Affiliation(s)
- Nils Hecht
- 1 Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Ingo Fiss
- 3 Department of Neurosurgery, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Alexandra Pinczolits
- 1 Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- 1 Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Eric Jüttler
- 2 Department of Neurology, Universitätsklinikum Ulm, Ulm, Germany.,4 Department of Neurology, Ostalb-Klinikum Aalen, Aalen, Germany
| | - Johannes Woitzik
- 1 Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
21
|
Factors that Can Help Select the Timing for Decompressive Hemicraniectomy for Malignant MCA Stroke. Transl Stroke Res 2018; 9:600-607. [DOI: 10.1007/s12975-018-0616-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 02/10/2018] [Accepted: 02/14/2018] [Indexed: 10/17/2022]
|
22
|
Hinduja A, Samant R, Feng D, Hannawi Y. Herniation despite Decompressive Hemicraniectomy in Large Hemispherical Ischemic Strokes. J Stroke Cerebrovasc Dis 2018; 27:418-424. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/04/2017] [Accepted: 09/14/2017] [Indexed: 01/25/2023] Open
|
23
|
Kürten S, Munoz C, Beseoglu K, Fischer I, Perrin J, Steiger HJ. Decompressive hemicraniectomy for malignant middle cerebral artery infarction including patients with additional involvement of the anterior and/or posterior cerebral artery territory-outcome analysis and definition of prognostic factors. Acta Neurochir (Wien) 2018; 160:83-89. [PMID: 28965156 DOI: 10.1007/s00701-017-3329-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 09/08/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND According to current evidence, adding decompressive craniectomy (DC) to best medical therapy reduces case fatality rate of malignant middle cerebral artery infarction by 50-75%. There is currently little information available regarding the outcome of subgroups, in particular of patients with extensive infarctions exceeding the territory of the middle cerebral artery. METHODS The records of 101 patients with large hemispheric infarctions undergoing DC were retrospectively reviewed. Twenty-seven patients had additional ACA and/or PCA infarcts. Sequential CTs were used for postoperative follow-up. Intracranial pressure (ICP) was monitored via a ventricular catheter in comatose patients. The main aim of treatment was to keep midline shift below 10 mm and ICP below 20 mmHg. If midline shift increased despite preceding DC, repeat surgery with removal of clearly necrotic tissue was considered. For the current analysis, Glasgow Coma Scale (GCS) at 14 days and modified Rankin Scale (mRS) at 3 months were used as outcome parameters. mRS 2 and 3 were defined as "moderate disability", mRS 4 as "severe disability", and mRS 5 and 6 as "poor outcome". These outcome parameters were correlated to age, gender, side, vascular territory, and time delay after stroke, GCS at the time of decompression, maximum ICP, maximum midline shift, and delay of maximum shift. RESULTS The median age of the 39 female and 62 male patients was 56 years (range, 5-79 years). Overall, 12 patients died in the acute stage (11.9%). Twenty-three (22.8%) patients recovered to moderate disability at 3 months (mRS ≤ 3), 45 (44.6%) to severe disability and 33 (32.6%) suffered a poor outcome (mRS 5 or 6). Twenty patients (19.8%) required additional necrosectomy due to secondary increasing midline shift and/or intracranial hypertension. Patients recovering to moderate disability at 3 months were in the median 10 years younger than patients with less favorable outcome (P < 0.001) and had a higher GCS prior to surgery (P < 0.001). Eleven of the 27 patients with infarctions exceeding the MCA territory needed secondary surgery, indicating a higher necrosectomy rate as for isolated MCA infarction. At 3 months, the distribution of the outcomes in terms of mRS was comparable between the patients suffering from extended infarctions and patients having isolated MCA stroke. Infarctions exceeding the territory of the middle cerebral artery were seen in 30% of the group recovering to moderate disability and thus as frequent as in the groups suffering a less favorable outcome. CONCLUSIONS Intensified postoperative management including possible secondary decompression with necrosectomy may further reduce case fatality rate of patients with large hemispheric infarction. Age above 60 years and severely reduced level of consciousness are the most significant factors heralding unfavorable recovery. Patients suffering infarctions exceeding the MCA territory have a comparable chance of favorable recovery as patients with isolated MCA infarction.
Collapse
|
24
|
Portran P, Cour M, Hernu R, de la Salle S, Argaud L. Pupillary abnormalities in non-selected critically ill patients: an observational study. J Thorac Dis 2017; 9:2528-2533. [PMID: 28932559 DOI: 10.21037/jtd.2017.07.58] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Repeated pupillary examination is a key element of neurologic surveillance in intensive care units (ICU). However, in non-selected critically ill patients, the clinical interest of monitoring pupillary diameter and light reflex is poorly documented. We aimed to determine the prevalence and the etiologies of pupillary abnormalities (PAs) in this ICU patient population. METHODS We performed a prospective, observational study in a medical university affiliated ICU over a 6-month period. All patients with at least one pupillary examination were included. PA was defined as areflexia and/or anisocoria present at the time of ICU admission or occurring during the ICU stay. RESULTS During the study period, we included 297 patients who had 6±9 pupillary examinations per day (totaling 11,360 pupillary assessments). The majority of patients (n=161, 54%) were admitted to the ICU for acute respiratory or cardiovascular failure. A total of 128 PAs were recorded in 109 patients: 78 areflexia alone (61%), 33 anisocoria alone (26%) and 17 (13%) with associated anisocoria and areflexia. The main causes of PAs were related to acute brain ischemia (n=41, 32%) and sedation/analgesia (n=50, 39%). Among the PAs, 59 (46%) were present upon ICU admission. The etiologies of the PAs at admission did not differ from those occurring during ICU stay (P=NS). Interestingly, 9 (7%) PAs were attributed to ipratropium nebulization in patients with chronic obstructive pulmonary disease exacerbation. CONCLUSIONS The high prevalence of PAs, frequently associated with both brain organic lesions and drug side effects, highlights the clinical interest of pupillary surveillance in non-selected critically ill patients.
Collapse
Affiliation(s)
- Philippe Portran
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Réanimation Médicale, F-69437, Lyon, France
| | - Martin Cour
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Réanimation Médicale, F-69437, Lyon, France.,Université de Lyon, Université Claude Bernard Lyon 1, Faculté de médecine Lyon-Est, F-69373, Lyon, France
| | - Romain Hernu
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Réanimation Médicale, F-69437, Lyon, France
| | - Sylvie de la Salle
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Réanimation Médicale, F-69437, Lyon, France
| | - Laurent Argaud
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Réanimation Médicale, F-69437, Lyon, France.,Université de Lyon, Université Claude Bernard Lyon 1, Faculté de médecine Lyon-Est, F-69373, Lyon, France
| |
Collapse
|
25
|
Bongiorni GT, Hockmuller MCJ, Klein C, Antunes ÁCM. Decompressive craniotomy for the treatment of malignant infarction of the middle cerebral artery: mortality and outcome. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:424-428. [PMID: 28746427 DOI: 10.1590/0004-282x20170053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 02/14/2017] [Indexed: 11/22/2022]
Abstract
Objective To assess, by Rankin scale, the functional disability of patients who had a malignant middle cerebral artery (MCA) ischemic stroke, who underwent decompressive craniotomy (DC) within the first 30 days. Methods A cross-sectional study in a University hospital. Between June 2007 and December 2014, we retrospectively analyzed the records of all patients submitted to DC due to a malignant MCA infarction. The mortality rate was defined during the hospitalization period. The modified outcome Rankin score (mRS) was measured 30 days after the procedure, for stratification of the quality of life. Results The DC mortality rate was 30% (95% CI 14.5 to 51.9) for the 20 patients reported. The mRS 30 days postoperatively was ≥ 4 [3.3 to 6] for all patients thereafter. Conclusion DC is to be considered a real alternative for the treatment of patients with a malignant ischemic MCA infarction.
Collapse
Affiliation(s)
- Gianise Toboliski Bongiorni
- Universidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Ciências Médicas - Ciência Cirúrgica, Porto Alegre RS, Brasil
| | | | - Cristini Klein
- Universidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Ciências Médicas, Porto Alegre RS, Brasil
| | - Ápio Cláudio Martins Antunes
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Serviço de Neurocirurgia, Porto Alegre RS, Brasil
| |
Collapse
|
26
|
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.
Collapse
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
| |
Collapse
|
27
|
Basu P, Jenkins H, Tsang K, Vakharia VN. National Survey of Neurosurgeons and Stroke Physicians on Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction. World Neurosurg 2017; 102:320-328. [DOI: 10.1016/j.wneu.2017.02.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 10/20/2022]
|
28
|
Sundseth J, Sundseth A, Jacobsen EA, Pripp AH, Sorteberg W, Altmann M, Lindegaard KF, Berg-Johnsen J, Thommessen B. Predictors of early in-hospital death after decompressive craniectomy in swollen middle cerebral artery infarction. Acta Neurochir (Wien) 2017; 159:301-306. [PMID: 27942881 DOI: 10.1007/s00701-016-3049-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 12/01/2016] [Indexed: 11/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- Jarle Sundseth
- Department of Neurosurgery, Oslo University Hospital Rikshospitalet, Postboks 4950 Nydalen, 0424, Oslo, Norway.
| | - Antje Sundseth
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Neurology, Medical Division, Akershus University Hospital, Lørenskog, Norway
| | - Eva Astrid Jacobsen
- Department of Radiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Are Hugo Pripp
- Oslo Centre of Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Wilhelm Sorteberg
- Department of Neurosurgery, Oslo University Hospital Rikshospitalet, Postboks 4950 Nydalen, 0424, Oslo, Norway
| | - Marianne Altmann
- Department of Neurology, Medical Division, Akershus University Hospital, Lørenskog, Norway
| | - Karl-Fredrik Lindegaard
- Department of Neurosurgery, Oslo University Hospital Rikshospitalet, Postboks 4950 Nydalen, 0424, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jon Berg-Johnsen
- Department of Neurosurgery, Oslo University Hospital Rikshospitalet, Postboks 4950 Nydalen, 0424, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Bente Thommessen
- Department of Neurology, Medical Division, Akershus University Hospital, Lørenskog, Norway
| |
Collapse
|
29
|
Almhdawi KA, Mathiowetz VG, White M, delMas RC. Efficacy of Occupational Therapy Task-oriented Approach in Upper Extremity Post-stroke Rehabilitation. Occup Ther Int 2016; 23:444-456. [DOI: 10.1002/oti.1447] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 09/04/2016] [Accepted: 09/21/2016] [Indexed: 01/16/2023] Open
Affiliation(s)
- Khader A. Almhdawi
- Department of Rehabilitation Sciences; Jordan University of Science and Technology; Irbid Jordan
| | - Virgil G. Mathiowetz
- Department of Rehabilitation Science; University of Minnesota; Minneapolis MN USA
| | - Matthew White
- Abbott Northwestern Hospital; Courage Kenny Rehabilitation Institute; Minneapolis MN USA
| | - Robert C delMas
- Department of Educational Psychology; University of Minnesota; Minneapolis MN USA
| |
Collapse
|