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Sampaio RP, Fogaroli MO, Botta FP, Módolo GP, Luvizutto GJ, Betting LE, Zanini MA, Bazan R, Hamamoto Filho PT. Decompressive Craniectomy in Patients with Malignant Stroke with Additional Vascular Territory. World Neurosurg 2024; 189:e948-e952. [PMID: 39002773 DOI: 10.1016/j.wneu.2024.07.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Accepted: 07/05/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Decompressive craniectomy substantially reduces mortality and disability rates following a malignant stroke. This procedure remains a life-saving option, especially in contexts with little access to mechanical thrombectomy despite downward trends in the performance of decompressive craniectomy due to discussions on the acceptance of living with severe disabilities. However, the outcomes of the surgery in cases involving concomitant occlusion of anterior or posterior cerebral arteries have not been extensively studied. METHODS In this retrospective cohort study, spanning January 2010 to December 2022 and including patients who underwent decompressive craniectomy, we compared outcomes between patients with and without additional vascular territory involvement. Independent variables included age, sex, comorbidities, admission National Institutes of Health Stroke Scale and Glasgow Coma Scale scores, time elapsed between stroke and surgery, laterality of the stroke, midline shift, and postoperative infarction volume. Outcomes included mortality and modified Rankin Score at the 3-month follow-up. RESULTS Of the 86 patients analyzed, 61 (70.9%) and 25 (29.1%) demonstrated no territory and additional territory involvement, respectively. Patients with involvement of additional territories exhibited lower admission Glasgow Coma Scale scores, higher National Institutes of Health Stroke Scale scores, and larger postoperative infarction volumes. However, these variables were not associated with poor outcomes. Univariate analyses revealed no differences in mortality or severe disability. Even after adjustment, the differences remained insignificant for mortality and severe disability. Age emerged as the sole variable linked to increased mortality. CONCLUSIONS Our data suggest that, for patients with malignant stroke undergoing decompressive craniectomy, the outcomes for patients with and without involvement of additional vascular territory are similar.
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Affiliation(s)
- Raul Pansardis Sampaio
- Department of Neurology, Psychology and Psychiatry, UNESP - São Paulo State University, Botucatu Medical School, Botucatu, Brazil
| | - Marcelo Ortolani Fogaroli
- Department of Neurology, Psychology and Psychiatry, UNESP - São Paulo State University, Botucatu Medical School, Botucatu, Brazil
| | - Fabio Pires Botta
- Department of Neurology, Psychology and Psychiatry, UNESP - São Paulo State University, Botucatu Medical School, Botucatu, Brazil
| | - Gabriel Pinheiro Módolo
- Department of Neurology, Psychology and Psychiatry, UNESP - São Paulo State University, Botucatu Medical School, Botucatu, Brazil
| | - Gustavo José Luvizutto
- Deparment of Applied Physiotherapy, UFTM - Triângulo Mineiro Federal University, Health Sciences Institute, Uberaba, Brazil
| | - Luiz Eduardo Betting
- Department of Neurology, Psychology and Psychiatry, UNESP - São Paulo State University, Botucatu Medical School, Botucatu, Brazil
| | - Marco Antônio Zanini
- Department of Neurology, Psychology and Psychiatry, UNESP - São Paulo State University, Botucatu Medical School, Botucatu, Brazil
| | - Rodrigo Bazan
- Department of Neurology, Psychology and Psychiatry, UNESP - São Paulo State University, Botucatu Medical School, Botucatu, Brazil
| | - Pedro Tadao Hamamoto Filho
- Department of Neurology, Psychology and Psychiatry, UNESP - São Paulo State University, Botucatu Medical School, Botucatu, Brazil.
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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.
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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
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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.
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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
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Schwake M, Schipmann S, Müther M, Stögbauer L, Hanning U, Sporns PB, Ewelt C, Dziewas R, Minnerup J, Holling M, Stummer W. Second-look strokectomy of cerebral infarction areas in patients with severe herniation. J Neurosurg 2020; 132:1-9. [PMID: 30611135 DOI: 10.3171/2018.8.jns18692] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/14/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Decompressive craniectomies (DCs) are performed on patients suffering large cerebral infarctions. The efficacy of this procedure has been demonstrated in several trials. In some cases, however, this procedure alone is not sufficient and patients still suffer refractory elevations of intracranial pressure (ICP). The goal of this study was to determine whether resection of infarcted tissue, termed strokectomy, performed as a second-look procedure after DC, improves outcome in selected cases. METHODS The authors retrospectively evaluated data of patients who underwent a DC due to a cerebral infarction at their institution from 2009 to 2016, including patients who underwent a strokectomy procedure after DC. Clinical records, imaging data, outcome scores, and neurological symptoms were analyzed, and clinical outcomes and mortality rates in the strokectomy group were compared to those for similar patients in recently published randomized controlled trials. RESULTS Of 198 patients who underwent DC due to cerebral infarction, 12 patients underwent strokectomy as a second surgical procedure, with a median National Institutes of Health Stroke Scale (NIHSS) score of 19 for patients with versus 16 for those without secondary strokectomy (p = 0.029). Either refractory increases of ICP > 20 mm Hg or dilated pupils in addition to herniation visible on CT images were triggers for strokectomy surgery. Ten of 12 (83%) patients had infarctions in more than one territory (p < 0.001). After 12 months, 43% of patients had a good outcome according to the modified Rankin Scale (mRS) score (≤ 3). In the subgroup of patients suffering infarctions in more than one vascular territory, functional outcome after 12 months was better (mRS ≤ 3 in 40% of patients in comparison to 9%; p = 0.027). A 1:3 case-control analysis matched to age, side of infarction, sex, and vascular territory confirmed these results (mRS ≤ 3, 42% in comparison to 11%; p = 0.032). Age, NIHSS score on admission, and number of vascular territories involved were identified as risk factors in multivariate analysis (p < 0.05). Patients in the strokectomy group had more infections (p < 0.001). According to these results, the authors developed a scale (Münster Stroke Score, 0-6 points) to predict whether patients might benefit from additional strokectomy. Receiver-operating characteristic (ROC) curve analysis revealed an area under the curve (AUC) of 0.86 (p < 0.001). The authors recommend a Münster Stroke Score of ≥ 3 as a cutoff, with a sensitivity of 92% and specificity of 66%, for predicting benefit from strokectomy. CONCLUSIONS In this study in comparison to former studies, mortality rates were lower and clinical outcome was comparable to that of previously published trials regarding large cerebral infarctions. Second surgery including strokectomy may help achieve better outcomes, especially in cases of infarction of more than one vascular territory.
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Affiliation(s)
- Michael Schwake
- 1Department of Neurosurgery, University Hospital Münster, Münster
| | | | - Michael Müther
- 1Department of Neurosurgery, University Hospital Münster, Münster
| | - Louise Stögbauer
- 1Department of Neurosurgery, University Hospital Münster, Münster
| | - Uta Hanning
- 2Institute for Clinical Radiology, Münster
- 3Department of Diagnostic and Interventional Neuroradiology, University of Hamburg, Hamburg; and
| | | | - Christian Ewelt
- 1Department of Neurosurgery, University Hospital Münster, Münster
| | - Rainer Dziewas
- 4Department of Neurology, University Hospital Münster, Münster, Germany
| | - Jens Minnerup
- 4Department of Neurology, University Hospital Münster, Münster, Germany
| | - Markus Holling
- 1Department of Neurosurgery, University Hospital Münster, Münster
| | - Walter Stummer
- 1Department of Neurosurgery, University Hospital Münster, Münster
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Daou B, Kent AP, Montano M, Chalouhi N, Starke RM, Tjoumakaris S, Rosenwasser RH, Jabbour P. Decompressive hemicraniectomy: predictors of functional outcome in patients with ischemic stroke. J Neurosurg 2016; 124:1773-9. [DOI: 10.3171/2015.6.jns15729] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Patients presenting with large-territory ischemic strokes may develop intractable cerebral edema that puts them at risk of death unless intervention is performed. The purpose of this study was to identify predictors of outcome for decompressive hemicraniectomy (DH) in ischemic stroke.
METHODS
The authors conducted a retrospective electronic medical record review of 1624 patients from 2006 to 2014. Subjects were screened for DH secondary to ischemic stroke involving the middle cerebral artery, internal carotid artery, or both. Ninety-five individuals were identified. Univariate and multivariate analyses were performed for an array of clinical variables in relationship to functional outcome according to the modified Rankin Scale (mRS). Clinical outcome was assessed at 90 days and at the latest follow-up (mean duration 16.5 months).
RESULTS
The mean mRS score at 90 days and at the latest follow-up post-DH was 4. Good functional outcome was observed in 40% of patients at 90 days and in 48% of patient at the latest follow-up. The mortality rate at 90 days was 18% and at the last follow-up 20%. Univariate analysis identified a greater likelihood of poor functional outcome (mRS scores of 4–6) in patients with a history of stroke (OR 6.54 [95% CI1.39–30.66]; p = 0.017), peak midline shift (MLS) > 10 mm (OR 3.35 [95% CI 1.33–8.47]; p = 0.011), or a history of myocardial infarction (OR 8.95 [95% CI1.10–72.76]; p = 0.04). Multivariate analysis demonstrated elevated odds of poor functional outcome associated with a history of stroke (OR 9.14 [95% CI 1.78–47.05]; p = 0.008), MLS > 10 mm (OR 5.15 [95% CI 1.58–16.79; p = 0.007), a history of diabetes (OR 5.63 [95% CI 1.52–20.88]; p = 0.01), delayed time from onset of stroke to DH (OR 1.32 [95% CI 1.02–1.72]; p = 0.037), and evidence of pupillary dilation prior to DH (OR 4.19 [95% CI 1.06–16.51]; p = 0.04). Patients with infarction involving the dominant hemisphere had higher odds of unfavorable functional outcome at 90 days (OR 4.73 [95% CI 1.36–16.44]; p = 0.014), but at the latest follow-up, cerebral dominance was not significantly related to outcome (OR 1.63 [95% CI 0.61–4.34]; p = 0.328).
CONCLUSIONS
History of stroke, diabetes, myocardial infarction, peak MLS > 10 mm, increasing duration from onset of stroke to DH, and presence of pupillary dilation prior to intervention are associated with a worse functional outcome.
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Affiliation(s)
- Badih Daou
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia
| | - Anthony P. Kent
- 2Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - Maria Montano
- 2Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - Nohra Chalouhi
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia
| | - Robert M. Starke
- 3Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Stavropoula Tjoumakaris
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia
| | - Robert H. Rosenwasser
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia
| | - Pascal Jabbour
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia
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