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Roy S, Awuah WA, Ahluwalia A, Adebusoye FT, Ferreira T, Tan JK, Bharadwaj HR, Tenkorang PO, Abdul‐Rahman T, Papadakis M. Current trends and challenges: The landscape of perioperative mortality in intracranial surgeries in low- and middle-income settings: A narrative review. Health Sci Rep 2024; 7:e1838. [PMID: 38274132 PMCID: PMC10809023 DOI: 10.1002/hsr2.1838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 01/27/2024] Open
Abstract
Background and Aims Intracranial surgeries are pivotal in treating cerebral pathologies, particularly in resource-limited contexts, utilizing techniques such as craniotomy, transsphenoidal approaches, and endoscopy. However, challenges in low and middle income countries (LMICs), including resource scarcity, diagnostic delays, and a lack of skilled neurosurgeons, lead to elevated perioperative mortality (POM). This review seeks to identify major contributors to these challenges and recommend solutions for improved patient outcomes in neurosurgical care within LMICs. Methods This review examines POM in LMICs using a detailed literature search, focusing on studies from these regions. Databases like PubMed, EMBASE, and Google Scholar were utilized using specific terms related to "intracranial surgery," "perioperative mortality," "traumatic brain injuries," and "LMICs." Inclusion criteria covered various study designs and both pediatric and adult populations while excluding stand-alone abstracts and case reports. Results POM rates for intracranial surgeries differ widely across many low and middle-income regions: Africa sees rates from 2.5% to 39.1%, Asia between 3.6% and 34.8%, and Latin America and the Caribbean have figures ranging from 1.3% to 12%. The POM rates in LMICs were relatively higher compared to most first-world countries. The high POM rates in LMICs can be attributed to considerable delays and compromises in neurosurgical care delivery, exacerbated by late diagnoses and presentations of neurosurgical pathologies. This, coupled with limited resources, underdeveloped infrastructure, and training gaps, complicates intracranial disease management, leading to elevated POM. Conclusion Intracranial POM is a pronounced disparity within the neurosurgical field in LMICs. To mitigate intracranial POM, it is imperative to bolster healthcare infrastructure, amplify personnel training, foster global partnerships, and harness technologies like telemedicine. Tackling socioeconomic obstacles and prioritizing early detection through sustained funding and policy shifts can substantially enhance patient outcomes.
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Affiliation(s)
- Sakshi Roy
- School of MedicineQueen's University BelfastBelfastUK
| | | | | | | | - Tomas Ferreira
- Department of Clinical Neurosciences, School of Clinical MedicineUniversity of CambridgeCambridgeUK
| | | | | | | | | | - Marios Papadakis
- Department of Surgery II, University Hospital Witten‐HerdeckeUniversity of Witten‐HerdeckeWuppertalGermany
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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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3
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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.
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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
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4
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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.
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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
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5
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Oulehri W, Cristinar M, Ajob G, Marguerite S, Heger B, Cebula H, Kindo M, Mertes PM. Decompressive hemicraniectomy for acute ischemic stroke in a patient implanted with a left ventricular assist device: a case report. BMC Cardiovasc Disord 2020; 20:281. [PMID: 32522145 PMCID: PMC7285430 DOI: 10.1186/s12872-020-01576-0] [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: 08/16/2019] [Accepted: 06/04/2020] [Indexed: 11/24/2022] Open
Abstract
Background Thromboembolic ischemic stroke (IS) is one of the most feared complications of left ventricular assist device (LVAD) placement and represents a challenge to surgical management because of concomitant anticoagulant therapy. Case presentation A 39-year-old man presented with cardiogenic shock following an out-of-hospital cardiac arrest. After a period of stabilization, the patient was referred for LVAD placement. Upon recovery from anesthesia, he presented with acute neurological deficits suggestive of IS. A brain computed tomography confirmed the diagnosis, and an emergency decompressive hemicraniectomy (DHC) was performed. Anticoagulation was managed empirically. The patient’s neurological status progressively improved and he was referred for heart transplantation at five months from DHC. One month later, cranioplasty was performed. Conclusions This report suggests an anticoagulation management approach in combination with decompressive craniectomy after IS in a patient with LVAD placement was successful. An optimized anticoagulation management and collaborative team-based practice may contribute to successful outcomes in complex cases.
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Affiliation(s)
- Walid Oulehri
- Pôle Anesthésie Réanimation Chirurgicale, service de Réanimation Chirurgicale, Hôpitaux Universitaires de Strasbourg NHC, 1, Place de l'Hôpital, 67000, Strasbourg, France. .,EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Institut de Physiologie, Université de Strasbourg, 67000, Strasbourg, France.
| | - Mircea Cristinar
- Pôle Anesthésie Réanimation Chirurgicale, service de Réanimation Chirurgicale, Hôpitaux Universitaires de Strasbourg NHC, 1, Place de l'Hôpital, 67000, Strasbourg, France
| | - Gharib Ajob
- Pôle Anesthésie Réanimation Chirurgicale, service de Réanimation Chirurgicale, Hôpitaux Universitaires de Strasbourg NHC, 1, Place de l'Hôpital, 67000, Strasbourg, France
| | - Sandrine Marguerite
- Pôle Anesthésie Réanimation Chirurgicale, service de Réanimation Chirurgicale, Hôpitaux Universitaires de Strasbourg NHC, 1, Place de l'Hôpital, 67000, Strasbourg, France
| | - Bob Heger
- Pôle Anesthésie Réanimation Chirurgicale, service de Réanimation Chirurgicale, Hôpitaux Universitaires de Strasbourg NHC, 1, Place de l'Hôpital, 67000, Strasbourg, France.,EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Institut de Physiologie, Université de Strasbourg, 67000, Strasbourg, France
| | - Hélène Cebula
- Pôle Tête et Cou, service de Neurochirurgie, Hôpitaux Universitaires de Strasbourg NHC, 67000, Strasbourg, France
| | - Michel Kindo
- EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Institut de Physiologie, Université de Strasbourg, 67000, Strasbourg, France.,Pôle Cardiologie, service de Chirurgie Cardiovasculaire, Hôpitaux Universitaires de Strasbourg NHC, 67000, Strasbourg, France
| | - Paul Michel Mertes
- Pôle Anesthésie Réanimation Chirurgicale, service de Réanimation Chirurgicale, Hôpitaux Universitaires de Strasbourg NHC, 1, Place de l'Hôpital, 67000, Strasbourg, France.,EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Institut de Physiologie, Université de Strasbourg, 67000, Strasbourg, France
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6
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García-Feijoo P, Isla A, Díez-Tejedor E, Mansilla B, Palpan Flores A, Sáez-Alegre M, Vivancos C. Decompressive craniectomy in malignant middle cerebral artery infarction: family perception, outcome and prognostic factors. Neurocirugia (Astur) 2019; 31:7-13. [PMID: 31445797 DOI: 10.1016/j.neucir.2019.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 05/27/2019] [Accepted: 07/07/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The prognosis of one hemisphere malignant infarction creates doubt among neurosurgeons about decompressive hemicraniectomy indication. What results are achieved in the short to medium term? Are families satisfied with the surgery once the patient is at home? In the present study, we analyze our experience in this matter during the last thirteen years. MATERIAL AND METHODS In our review, twenty-one patients were included from 2004 to 2017, according to the protocol for the management of ischaemic stroke that is implemented in our institution. The relatives were interviewed by telephone. The functional outcome at discharge, 3 months, 1 year, and at present was measured using the modified Rankin scale (mRS). RESULTS Patient age was shown to be directly related to the mRS (r=0.56; p=0.035) and 37.5% achieved a good outcome (mRS≤3); 78.9% of the interviewed relatives would repeat the surgical decision. CONCLUSIONS We present a 21 patients group where the best outcome was achieved in patients ≤60 years old. The severe neurological sequelae in patients with malignant infarction subjected to decompressive hemicraniectomy are tolerated and accepted by most families to the benefit of survival. We must not let this family satisfaction hide the prognosis, having to contextualize it within the real ambulatory situation of the patients.
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Affiliation(s)
| | - Alberto Isla
- Servicio de Neurocirugía, Hospital Universitario La Paz, Madrid, España
| | | | - Beatriz Mansilla
- Servicio de Neurocirugía, Hospital Universitario La Paz, Madrid, España
| | | | | | - Catalina Vivancos
- Servicio de Neurocirugía, Hospital Universitario La Paz, Madrid, España
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7
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Clavijo A, Khan AA, Mendoza J, Montenegro JH, Johnson ED, Adeleye AO, Rubiano AM. The Role of Decompressive Craniectomy in Limited Resource Environments. Front Neurol 2019; 10:112. [PMID: 30863354 PMCID: PMC6399379 DOI: 10.3389/fneur.2019.00112] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 01/28/2019] [Indexed: 12/12/2022] Open
Abstract
Decompressive craniectomy (DC) is a neurosurgical procedure useful to prevent and manage the impact of high intracranial pressure (ICP) that leads to brain herniation and brain's tissue ischemia. In well-resourced environment this procedure has been proposed as a last tier therapy when ICP is not controlled by medical therapies in the management of different neurosurgical emergencies like traumatic brain injury (TBI), stroke, infectious diseases, hydrocephalus, tumors, etc. The purpose of this narrative review is to discuss the role of DC in areas of low neurosurgical and neurocritical care resources. We performed a literature review with a specific search strategy in web repositories and some local and regional journals from Low and Middle-Income Countries (LMICs). The most common publications include case reports, case series and observational studies describing the benefits of the procedure on different pathologies but with several types of biases due to the absence of robust studies or clinical registries analysis in these kinds of environments.
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Affiliation(s)
- Angélica Clavijo
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia
| | - Ahsan A Khan
- MEDITECH Foundation, Clinical Research, Cali, Colombia.,Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Juliana Mendoza
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia
| | - Jorge H Montenegro
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia.,MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Erica D Johnson
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Amos O Adeleye
- Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom.,College of Medicine, University of Ibadan, and University College Hospital (UCH), Ibadan, Nigeria
| | - Andrés M Rubiano
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia.,MEDITECH Foundation, Clinical Research, Cali, Colombia.,Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
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8
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A Systematic Review and Meta-Analysis of the Effectiveness of Surgical Decompression in Treating Patients with Malignant Middle Cerebral Artery Infarction. World Neurosurg 2018; 120:e902-e920. [DOI: 10.1016/j.wneu.2018.08.189] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 11/18/2022]
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9
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Refaat MI, Abdallah OY. Decompressive craniectomy in malignant middle cerebral artery infarctions: outcome of 25 cases. EGYPTIAN JOURNAL OF NEUROSURGERY 2018. [DOI: 10.1186/s41984-018-0020-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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10
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Elsawaf A, Galhom A. Decompressive Craniotomy for Malignant Middle Cerebral Artery Infarction: Optimal Timing and Literature Review. World Neurosurg 2018; 116:e71-e78. [DOI: 10.1016/j.wneu.2018.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 04/01/2018] [Accepted: 04/02/2018] [Indexed: 10/17/2022]
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11
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Gao H, Sun X, Li W, Gao Q, Zhang J, Zhang Y, Ma Y, Yang X, Kang X, Jiang W. Development and validation of a risk score to predict 30-day mortality in patients with atrial fibrillation-related stroke: GPS-GF score. Neurol Res 2018; 40:532-540. [PMID: 29544401 DOI: 10.1080/01616412.2018.1451431] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Hua Gao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xiaolong Sun
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- Department of Rehabilitation Medicine, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Wen Li
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Qiong Gao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Jing Zhang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Yi Zhang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Yue Ma
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xiai Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xiaogang Kang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
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12
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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.
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13
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Xu L, Lu T, Tao X, Wang D, Liu W, Li J, Liu B. Decompressive craniectomy for malignant middle cerebral artery infarctions: a meta-analysis. Chin Neurosurg J 2017. [DOI: 10.1186/s41016-017-0083-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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14
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Kamal Alam B, Bukhari AS, Assad S, Muhammad Siddique P, Ghazanfar H, Niaz MJ, Kundi M, Shah S, Siddiqui M. Functional Outcome After Decompressive Craniectomy in Patients with Dominant or Non-Dominant Malignant Middle Cerebral Infarcts. Cureus 2017; 9:e997. [PMID: 28286721 PMCID: PMC5338989 DOI: 10.7759/cureus.997] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The use of decompressive craniectomy (DC) has been studied in the setting of different conditions, including traumatic brain injury, subarachnoid hemorrhage, and malignant middle cerebral artery (MCA) infarction. The rationale of this study is to determine the functional outcome after DC in patients with malignant MCA infarcts. METHODS A longitudinal cohort study was performed based on patients diagnosed with malignant MCA territory infarction admitted to the Neurosurgery Department of a tertiary care hospital in Islamabad, Pakistan between July 2015 and November 2016. All patients had a clinical diagnosis of stroke according to the World Health Organization (WHO) stroke criteria. RESULTS A total of 34 patients participated in this study, out of which 20/31 (64.5%) were males while 11/31 (35.5%) were females with a mean age of 51.61 ± 13.96 years. The mean time from diagnosis to surgery was 60.61 ± 49.83 hours. Out of 31 patients, 18 (58.1%) had a right middle cerebral artery infarct (RMCAI) and 13 (41.9%) had a left middle cerebral artery infarct (LCAI). Logistic regression was applied to assess the association between the type of MCA infarct with the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), modified Barthel Index (mBI) scores, and upper and lower limb motor power. However, the logistic regression model was not statistically significant χ2 (4) = 3.896, p = 0.866. There was a statistically significant mild improvement of neurological scores and upper and lower motor power over a course of six months, but the overall functional outcome was poor with mBI < 60 and mRS > 4 (p < 0.001) with total mortality of 8.7%. CONCLUSION Decompressive craniectomy is a life-saving surgery that appears to benefit patients with malignant MCA infarcts of either the dominant or non-dominant cerebral hemisphere. Decompressive craniectomy results in mild improvements in neurological scores but still poor functional outcome after six months.
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Affiliation(s)
- Bilal Kamal Alam
- Department of Internal Medicine, Fairview Hospital, Cleveland Clinic, USA
| | - Ahmed S Bukhari
- Research Associate, Department of Neurology, Shifa International Hospital, Islamabad, Pakistan
| | - Salman Assad
- Department of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | | | - Haider Ghazanfar
- Department of Neurology, Shifa International Hospital, Islamabad, Pakistan
| | - Muhammad Junaid Niaz
- Department of Genito-urinary Oncology, Weill Medical College of Cornell University
| | - Maryam Kundi
- Department of Internal Medicine, Carthage Area Hospital, New York, USA
| | - Saima Shah
- Department of General Medicine, Hayatabad Medical Complex, Peshawar, Pakistan
| | - Maimoona Siddiqui
- Consultant Neurologist, Department of Neurology, Shifa International Hospital, Islamabad, Pakistan
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15
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Neurologic Functional Outcomes of Decompressive Hemicraniectomy Versus Conventional Treatment for Malignant Middle Cerebral Artery Infarction: A Systematic Review and Meta-Analysis. World Neurosurg 2016; 99:709-725.e3. [PMID: 28024976 DOI: 10.1016/j.wneu.2016.12.069] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 12/12/2016] [Accepted: 12/15/2016] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The aims of this study were to evaluate decompressive hemicraniectomy (DHC) versus conventional treatment (CT) for patients with malignant middle cerebral artery (MCA) infarction and to investigate the impact of age and surgical timing on neurologic function and mortality. METHODS We searched English and Chinese databases for randomized controlled trials or observational studies published before August 2016. Outcomes included good functional outcome (GFO), mortality, and National Institutes of Health Stroke Scale and Barthel index scores. RESULTS This meta-analysis included 25 studies (1727 patients). There were statistically significant differences between DHC and CT groups in terms of GFO (P < 0.0001), mortality (P < 0.00001), and National Institutes of Health Stroke Scale and Barthel index scores (P < 0.0001) at different follow-up points. Significant differences were observed between the groups in survival with moderately severe disability (P < 0.00001); no differences were observed in survival with severe disability. In the subgroup analysis, in the DHC group, GFO was less in patients >60 years old (9.65%) versus ≤60 years old (38.94%); more patients >60 years old had moderately severe or severe disability (55.27%) compared with patients ≤60 years old (44.21%). CONCLUSIONS DHC could significantly improve GFO and reduces mortality of patients of all ages with malignant MCA infarction compared with CT, without increasing the number of patients surviving with severe disability. However, patients in the DHC group more frequently had moderately severe disability. Patients >60 years old with malignant MCA infarction had a higher risk of surviving with moderately severe or severe disability and less GFO.
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16
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Abstract
Decompressive craniectomy (DC) has been used for many years in the management of patients with elevated intracranial pressure and cerebral edema. Ongoing clinical trials are investigating the clinical and cost effectiveness of DC in trauma and stroke. While DC has demonstrable efficacy in saving life, it is accompanied by a myriad of non-trivial complications that have been inadequately highlighted in prospective clinical trials. Missing from our current understanding is a comprehensive analysis of all potential complications associated with DC. Here, we review the available literature, we tabulate all reported complications, and we calculate their frequency for specific indications. Of over 1500 records initially identified, a final total of 142 eligible records were included in our comprehensive analysis. We identified numerous complications related to DC that have not been systematically reviewed. Complications were of three major types: (1) Hemorrhagic (2) Infectious/Inflammatory, and (3) Disturbances of the CSF compartment. Complications associated with cranioplasty fell under similar major types, with additional complications relating to the bone flap. Overall, one of every ten patients undergoing DC may suffer a complication necessitating additional medical and/or neurosurgical intervention. While DC has received increased attention as a potential therapeutic option in a variety of situations, like any surgical procedure, DC is not without risk. Neurologists and neurosurgeons must be aware of all the potential complications of DC in order to properly advise their patients.
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17
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Abdou A, Liu J, Carroll M, Vivaldi G, Rizzo JR, Im B. Motor and neurocognitive recovery in the syndrome of the trephined: A case report. Ann Phys Rehabil Med 2015; 58:183-5. [PMID: 25864913 DOI: 10.1016/j.rehab.2014.11.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 11/23/2014] [Accepted: 11/26/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Andrew Abdou
- Ambulatory Care Center, New York University, Room 17-76, 17th Floor, 240 East 38th Street, New York, NY 10016, United States.
| | - Jackson Liu
- Ambulatory Care Center, New York University, Room 17-76, 17th Floor, 240 East 38th Street, New York, NY 10016, United States
| | - Michelle Carroll
- Ambulatory Care Center, New York University, Room 17-76, 17th Floor, 240 East 38th Street, New York, NY 10016, United States
| | - Giselle Vivaldi
- Ambulatory Care Center, New York University, Room 17-76, 17th Floor, 240 East 38th Street, New York, NY 10016, United States
| | - John-Ross Rizzo
- Ambulatory Care Center, New York University, Room 17-76, 17th Floor, 240 East 38th Street, New York, NY 10016, United States
| | - Brian Im
- Ambulatory Care Center, New York University, Room 17-76, 17th Floor, 240 East 38th Street, New York, NY 10016, United States
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