Journal articles on the topic 'Decompressive hemicraniectomy (DHC)'
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Hecht, Nils, Hermann Neugebauer, Ingo Fiss, Alexandra Pinczolits, Peter Vajkoczy, Eric Jüttler, and Johannes Woitzik. "Infarct volume predicts outcome after decompressive hemicraniectomy for malignant hemispheric stroke." Journal of Cerebral Blood Flow & Metabolism 38, no. 6 (June 30, 2017): 1096–103. http://dx.doi.org/10.1177/0271678x17718693.
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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.
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Joarder, MA, AKMB Karim, T. Kamal, T. Sujon, N. Akhter, K. Islam, MZ Hossain, et al. "Retrospective comparison of decompressive hemicraniectomy and hematoma evacuation for spontaneous supratentorial intracerebral hematoma." Pulse 7, no. 1 (May 7, 2015): 16–21. http://dx.doi.org/10.3329/pulse.v7i1.23245.
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Objectives: The aim of this study was to test the hypothesis that decompressive hemicraniectomy (DHC), compared with craniotomy with evacuation of hematoma, and would improve clinical outcomes of patients with supratentorial intracerebral hemorrhage (SICH).Methods: We compared patients (November 2008February 2014) with supratentorial ICH treated with DHC without hematoma evacuation and craniotomy with hematoma evacuation. DHC measured at least 150 mm and included opening of the dura. We analyzed clinical, radiological, and surgical characteristics. Outcome at 6 months was divided into good (modified Rankin Scale 04) and poor (modified Rankin Scale 56).Results: Fifteen patients (mean age 58 years) with ICH were treated by DHC. Median hematoma volume was 61 ml and mean preoperative Glasgow Coma Scale (GCS) was 7. Ten patients had good and five had poor outcomes. In hematoma evacuation group 29 patients were treated. Median hematoma volume was 55 ml and mean preoperative Glasgow Coma Scale (GCS) was 8. Seventeen patients had good and twelve had poor outcomes.Conclusions: DHC is more effective than hematoma evacuation in patients with SICH. Based on this small cohort, DHC may reduce mortality. Larger prospective study is warranted to assess safety and efficacy.Pulse Vol.7 January-December 2014 p.16-21
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Youssef, Omar, Taher M. Ali, Khaled Anbar, Osama El-Shahawy, and Abdelrhman Enayet. "Value of Adding Cisternostomy to Decompressive Hemicraniectomy in the Management of Traumatic Acute Subdural Hematoma Patients." Open Access Macedonian Journal of Medical Sciences 8, B (July 31, 2020): 1014–22. http://dx.doi.org/10.3889/oamjms.2020.4423.
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BACKGROUND: Surgical evacuation of acute subdural hematoma has remained the mainstay of the treatment for acute subdural hematoma (ASDH) in patients with progressive neurological deficits, increasing intracranial pressure (ICP), or significant mass effect. Cisternostomy entails opening the basal cisterns aiming to their opening to atmospheric pressure and therefore reducing the intraparenchymal pressure.
AIM: We aimed to evaluate value of adding cisternostomy to decompressive craniotomy on outcome of traumatic ASDH patients.
METHODS: Prospective study included 40 patients who presented to Cairo University hospital emergency department with traumatic acute subdural hematoma in the period between January 2018 and June 2019 and matching our inclusion criteria: Age from 12 to 65 years, traumatic acute subdural hematoma with thickness ≥ 10 mm or midline shift ≥ 5 mm, and Glasgow Coma Scale (GCS) on admission < 10, with no associated intraparenchymal hematoma ≥ 1 cm or severe comorbidities. Patients were randomized into one of two groups according to their order of coming. The first group patients were operated on by decompressive craniotomy (DHC) plus cisternostomy and the second group was operated on by decompressive craniotomy only. Glasgow Outcome Score (GOS) was used for outcome assessment.
RESULTS: Outcome was better 2nd but not statistically significant – in the first group (DHC+ cisternostomy) in terms of mortality: 7/20 patients (35%) (p = 0.337) and median GOS: 3 (p = 0.337), compared to the second group (DHC only) in which mortality occurred in 10/20 (50%) and median GOS was 1. Adding cisternostomy to decompressive craniotomy increased surgery time with 35.5 minutes in average. In our study, older age and lower GCS on admission had significantly worse outcome.
CONCLUSION: Adding cisternostomy to decompressive craniotomy in traumatic patients had better 2nd but not statistically significant outcome. Whether it should replace the routine decompressive craniotomy in these cases or not needs further larger clinical trials.
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Joarder, Md Aliuzzaman, AKM Bazlul Karim, Shariful Islam Sujon, Nahid Akhter, Md Waheeduzzaman, Dorai Raj Krupa Shankar, Salim Mohammad Jahangir, and Mathew J. Chandy. "Decompressive Hemicraniectomy in Hypertensive Basal Ganglia Hemorrhages." Pulse 8, no. 1 (June 6, 2016): 38–42. http://dx.doi.org/10.3329/pulse.v8i1.28100.
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Objectives: The aim of this study was to analyze efficacy and safety of decompressive hemicraniectomy (DHC) in hypertensive basal ganglia hemorrhage (HBGH). Neurosurgical management of HBGH is still a controversial issue. Surgical techniques are diverse, from the open large craniotomy, to the minimally invasive techniques like stereotactic aspiration of the HBGH, endoscopic evacuation and stereotactic catheter drainage after instillation of thrombolytic agents. Decompressive hemicraniectomy lowers intracranial pressure and improves outcome in patients with HBGH.Methods: 8 patients with HBGH who underwent decompressive craniectomy in the last 2 years were analyzed. Parameters investigated included clinical presentations, radiologic profile, time interval from ictus to surgery, and modified Rankin Scale score at 6 months.Results: The patients mean age 55 years, the mean Glasgow Coma Scale (GCS) score was 7 (range 513), the mean ICH volume was 58 ml (range 4070 ml), and the mean midline shift was 10.62 mm (range 6-16 mm). The outcome after 6 months was appreciated as good (modified Rankin Scale 04) or poor (modified Rankin Scale 5-6). Five patients had good and three had poor outcomes (including two deaths).Conclusion: We conclude, based on this small cohort, that DC can reduce mortality in some cases. Larger prospective studies are needed to assess safety and efficacy of this method.Pulse Vol.8 January-December 2015 p.38-42
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Neugebauer, Hermann, Ingo Fiss, Alexandra Pinczolits, Nils Hecht, Jens Witsch, Nora F. Dengler, Peter Vajkoczy, Eric Jüttler, and Johannes Woitzik. "Large Size Hemicraniectomy Reduces Early Herniation in Malignant Middle Cerebral Artery Infarction." Cerebrovascular Diseases 41, no. 5-6 (2016): 283–90. http://dx.doi.org/10.1159/000443935.
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Background: Decompressive hemicraniectomy (DHC) reduces mortality and improves outcome after malignant middle cerebral artery infarction (MMI) but early in-hospital mortality remains high between 22 and 33%. Possibly, this circumstance is driven by cerebral herniation due to space-occupying brain swelling despite decompressive surgery. As the size of the removed bone flap may vary considerably between surgeons, a size too small could foster herniation. Here, we investigated the effect of the additional volume created by an extended DHC (eDHC) on early in-hospital mortality in patients suffering from MMI. Methods: We performed a retrospective single-center cohort study of 97 patients with MMI that were treated either with eDHC (n = 40) or standard DHC (sDHC; n = 57) between January 2006 and June 2012. The primary study end point was defined as in-hospital mortality due to transtentorial herniation. Results: In-hospital mortality due to transtentorial herniation was significantly lower after eDHC (0 vs. 11%; p = 0.04), which was paralleled by a significantly larger volume of the craniectomy (p < 0.001) and less cerebral swelling (eDHC 21% vs. sDHC 25%; p = 0.03). No statistically significant differences were found in surgical or non-surgical complications and postoperative intensive care treatment. Conclusion: Despite a more aggressive surgical approach, eDHC may reduce early in-hospital mortality and limit transtentorial herniation. Prospective studies are warranted to confirm our results and assess general safety of eDHC.
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Barrientos, Ricardo, Carlos Sisniega, Samanta Catueno, Robin Hougen, Ashley Hanna, and Utpal Bhalala. "Decompressive Hemicraniectomy and Favorable Outcome in a Pediatric Patient with Malignant Middle Cerebral Artery Infarction." Case Reports in Pediatrics 2022 (September 13, 2022): 1–5. http://dx.doi.org/10.1155/2022/6500488.
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We report a rare case of middle cerebral artery (MCA) stroke in a teenage girl with initial improvement, followed by progression to malignant MCA infarction, requiring an urgent decompressive hemicraniectomy (DHC). Additionally, we report improvement in all areas, including language, comprehension, and motor skills at discharge and the 4-month follow-up. This rare presentation highlights the importance of monitoring the neurological status of a patient with an MCA infarct for progression to a life-threatening malignant MCA infarct. This case report also highlights the importance of consideration of DHC for a favorable outcome of the MMCA infarction.
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Ghulam, Naseeruddin, Kashif Ali Sultan, Mohammad Ashraf, Nabeel Choudhary, Usman Ahmad Kamboh, Nazir Ahmad, Muhammad Asif Raza, Waqa Latif, Syed Shahzad Hussain, and Naveed Ashraf. "Prognostic Factors for Decompressive Hemicraniectomy in Severe Traumatic Brain Injury Patients with Traumatic Mass Lesions: A Prospective Experience from a Developing Country." Pakistan Journal Of Neurological Surgery 25, no. 4 (January 19, 2022): 537–49. http://dx.doi.org/10.36552/pjns.v25i4.606.
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Objective: To evaluate the prognostic factors affecting functional clinical outcomes in severe traumatic brain injury patients with traumatic mass lesions undergoing decompressive hemicraniectomy (DHC).
Materials and Methods: A prospective cohort of 85 patients of severe traumatic brain injury patients with traumatic mass lesions underwent a unilateral decompressive hemicraniectomy. Functional outcomes were assessed using the Glasgow Outcome Score at 28 days, 3 months, and 6 months. Bivariate analysis (chi-squared) was used to identify parameters that resulted in poor outcomes and multiple regression was used to identify independent factors predicting poor outcomes.
Results: 85 patients were recruited. Functional outcomes were dichotomised as favourable (Glasgow Outcome Score of 4 – 5) and poor (Glasgow Outcome Score 1-3) and evaluated at 28 days, 3 and 6 months. A total of 59 patients expired (69.4%). Bivariate analysis revealed GCS 3 – 5 at presentation (P = 0.002), midline shift greater than 7.5mm (P < 0.001), the volume of the mass lesion more than 40ml (P = 0.006) resulted in a poor outcome. Age dichotomised to less than or more than 50 years bordered statistical significance (P = 0.063). Only GCS at presentation and midline shift were independent factors that predicted poor outcomes when controlling for covariates.
Conclusion: Decompressive hemicraniectomy can be a lifesaving intervention in managing severe traumatic brain injury patients with traumatic mass lesions. However, its use needs to be employed judiciously.
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Kamran, Saadat, Naveed Akhtar, Abdul Salam, Ayman Alboudi, Kainat Kamran, Arsalan Ahmed, Rabia A. Khan, Mohsin K. Mirza, Jihad Inshasi, and Ashfaq Shuaib. "Revisiting Hemicraniectomy: Late Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke and the Role of Infarct Growth Rate." Stroke Research and Treatment 2017 (2017): 1–8. http://dx.doi.org/10.1155/2017/2507834.
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Objective and Methods.The outcome in late decompressive hemicraniectomy in malignant middle cerebral artery stroke and the optimal timings of surgery has not been addressed by the randomized trials and pooled analysis. Retrospective, multicenter, cross-sectional study to measure outcome following DHC under 48 or over 48 hours using the modified Rankin scale [mRS] and dichotomized as favorable ≤4 or unfavorable >4 at three months.Results.In total, 137 patients underwent DHC. Functional outcome analyzed as mRS 0–4 versus mRS 5-6 showed no difference in this split between early and late operated on patients [P=0.140] and mortality [P=0.975]. Multivariate analysis showed that age ≥ 55 years, MCA with additional infarction, septum pellucidum deviation ≥1 cm, and uncal herniation were independent predictors of poor functional outcome at three months. In the “best” multivariate model, second infarct growth rate [IGR2] >7.5 ml/hr, MCA with additional infarction, and patients with temporal lobe involvement were independently associated with surgery under 48 hours. Both first infarct growth rate [IGR1] and second infarct growth rate [IGR2] were nearly double [P<0.001] in patients with early surgery [under 48 hours].Conclusions.The outcome and mortality in malignant middle cerebral artery stroke patients operated on over 48 hours of stroke onset were comparable to those of patients operated on less than 48 hours after stroke onset. Our data identifies IGR, temporal lobe involvement, and middle cerebral artery with additional infarct as independent predictors for early surgery.
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Heuts, Simon G., Samuel S. Bruce, Brad E. Zacharia, Zachary L. Hickman, Christopher P. Kellner, Eric S. Sussman, Michael M. McDowell, Rachel A. Bruce, and E. Sander Connolly. "Decompressive hemicraniectomy without clot evacuation in dominant-sided intracerebral hemorrhage with ICP crisis." Neurosurgical Focus 34, no. 5 (May 2013): E4. http://dx.doi.org/10.3171/2013.2.focus1326.
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Object Large intracerebral hemorrhage (ICH), compounded by perihematomal edema, can produce severe elevations of intracranial pressure (ICP). Decompressive hemicraniectomy (DHC) with or without clot evacuation has been considered a part of the armamentarium of treatment options for these patients. The authors sought to assess the preliminary utility of DHC without evacuation for ICH in patients with supratentorial, dominant-sided lesions. Methods From September 2009 to May 2012, patients with ICH who were admitted to the neurological ICU at Columbia University Medical Center were prospectively enrolled in that institution's ICH Outcomes Project (ICHOP). Five patients with spontaneous supratentorial dominant-sided ICH underwent DHC without clot evacuation for recalcitrant elevated ICP. Data pertaining to the patients' characteristics and outcomes of treatment were prospectively collected. Results The patients' median age was 43 years (range 30–55 years) and the ICH etiology was hypertension in 4 of 5 patients, and systemic lupus erythematosus vasculitis in 1 patient. On admission, the median Glasgow Coma Scale (GCS) score was 7 (range 5–9). The median ICH volume was 53 cm3 (range 28–79 cm3), and the median midline shift was 7.6 mm (range 3.0–11.3 mm). One day after surgery, the median decrease in midline shift was 2.7 mm (range 1.5–4.6 mm), and the median change in GCS score was +1 (range −3 to +5). At discharge, all patients were still alive, and the median GCS score was 10 (range 9–11), the median modified Rankin Scale (mRS) score was 5 (range 5–5), and the median NIHSS (National Institutes of Health Stroke Scale) score was 22 (range 17–27). Six months after hemorrhage, 1 patient had died, 2 were functionally dependent (mRS Score 4–5), and 2 were functionally independent (mRS Score 0–3). Outcomes for the patients treated with DHC were good compared with 1) outcomes for all patients with spontaneous supratentorial ICH admitted during the same period (n = 144) and 2) outcomes for matched patients (dominant ICH, GCS Score 5–9, ICH volume 28–79 cm3, age < 60 years) whose cases were managed nonoperatively (n = 5). Conclusions Decompressive hemicraniectomy without clot evacuation appears feasible in patients with large ICH and deserves further investigation, preferably in a randomized controlled setting.
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Koirala, Sagar, Shreeram Bhandari, and Subash Lohani. "Factors affecting outcome of decompressive hemicraniectomy in malignant middle cerebral artery infarction." Nepal Journal of Neuroscience 18, no. 3 (September 1, 2021): 35–38. http://dx.doi.org/10.3126/njn.v18i3.37109.
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Introduction: Decompressive Hemicraniectomy (DHC) is a standard surgical management of malignant MCA (MMCA) infarction. This study was conducted to review the outcome of surgery and to find out factors associated with favorable outcomes at a tertiary level neurosurgery referral centre. Methods and Materials: This is a retrospective study conducted over a period of three years from 2017 to 2019. Patient charts were reviewed for variable like age, sex, timing of surgery, GCS at presentation, length of ventilation, length of ICU admission and length of hospital stay. Primary outcome measure was GOSE: favorable (<=4) and unfavorable (>=5). SPSS version 23 was used for analysis. Results: A total of 28 patients underwent DHC out of which 21 patients were available for analysis. Mean age of patients was 58.62 years. Mean GCS on arrival was 11.86. Mean interval duration between event and surgery was 51.88 hours. Mean duration of ventilation was 4.43 days. Mean length of ICU stay was 5.95 days. Mean hospital stay was 22.33 days. Mean GOSE was 2. Mean age was significantly lower in patients with favorable GOSE. Early surgery had better mean GOSE which was not significant statistically. Conclusion: Patients with age less than 50 years have favorable GOSE despite MMCA infarction if decompressive hemicraniectomy is performed to accommodate brain swelling. Early surgery at presentation rather than waiting for deterioration might improve the outcome.
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Brondani, Rosane, Andrea Garcia de Almeida, Pedro Abrahim Cherubini, Suelen Mandelli Mota, Luiz Carlos de Alencastro, Apio Cláudio Martins Antunes, and Marino Bianchin Muxfeldt. "High Risk of Seizures and Epilepsy after Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke." Cerebrovascular Diseases Extra 7, no. 1 (March 30, 2017): 51–61. http://dx.doi.org/10.1159/000458730.
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Background: Decompressive hemicraniectomy (DHC) is a life-saving procedure for treatment of large malignant middle cerebral artery (MCA) strokes. Post-stroke epilepsy is an additional burden for these patients, but its incidence and the risk factors for its development have been poorly investigated. Objective: To report the prevalence and risk factors for post-stroke seizures and post-stroke epilepsy after DHC for treatment of large malignant MCA strokes in a cohort of 36 patients. Methods: In a retrospective cohort study of 36 patients we report the timing and incidence of post-stroke epilepsy. We analyzed if age, sex, vascular risk factors, side of ischemia, reperfusion therapy, stroke etiology, extension of stroke, hemorrhagic transformation, ECASS scores, National Institutes of Health Stroke Scale (NIHSS) scores, or modified Rankin scores were risk factors for seizure or epilepsy after DHC for treatment of large MCA strokes. Results: The mean patient follow-up time was 1,086 days (SD = 1,172). Out of 36 patients, 9 (25.0%) died before being discharged. After 1 year, a total of 11 patients (30.6%) had died, but 22 (61.1%) of them had a modified Rankin score ≤4. Thirteen patients (36.1%) developed seizures within the first week after stroke. Seizures occurred in 22 (61.1%) of 36 patients (95% CI = 45.17–77.03%). Out of 34 patients who survived the acute period, 19 (55.9%) developed epilepsy after MCA infarcts and DHC (95% CI = 39.21–72.59%). In this study, no significant differences were observed between the patients who developed seizures or epilepsy and those who remained free of seizures or epilepsy regarding age, sex, side of stroke, presence of the clinical risk factors studied, hemorrhagic transformation, time of craniectomy, and Rankin score after 1 year of stroke. Conclusion: The incidence of seizures and epilepsy after malignant MCA infarcts submitted to DHC might be very high. Seizure might occur precociously in patients who are not submitted to anticonvulsant prophylaxis. The large stroke volume and the large cortical ischemic area seem to be the main risk factors for seizure or epilepsy development in this subtype of stroke.
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Veldeman, Michael, Mathias Geiger, and Hans Clusmann. "How I do it—the posterior question mark incision for decompressive hemicraniectomy." Acta Neurochirurgica 163, no. 5 (March 31, 2021): 1447–50. http://dx.doi.org/10.1007/s00701-021-04812-4.
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Abstract Background Decompressive hemicraniectomy (DHC) is a lifesaving procedure which every neurosurgeon should master early on. As indications for the procedure are growing, the number of patients eventually requiring skull reconstruction via cranioplasty also increases. The posterior question mark incision is a straightforward alternative to the classic trauma-flap and can easily be adopted. Some particularities exist one should consider beforehand and are discussed here in detail. Methods Surgical steps, aids, and pitfalls are comprehensively discussed to prepare surgeons who wish to gain experience with this type of incision. Conclusion Due to the lower complication rate after cranioplasty, the posterior question mark incision has superseded the traditional pre-auricular starting anterior question mark incisions, in our department for the performance of decompressive hemicraniectomies.
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Dowlati, Ehsan, Armin Mortazavi, Gregory Keating, Ribhu Tushar Jha, Daniel R. Felbaum, Jason J. Chang, Mani N. Nair, et al. "The Retroauricular Incision as an Effective and Safe Alternative Incision for Decompressive Hemicraniectomy." Operative Neurosurgery 20, no. 6 (February 11, 2021): 549–58. http://dx.doi.org/10.1093/ons/opab021.
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Abstract BACKGROUND The reverse question mark (RQM) incision has been traditionally utilized to perform decompressive hemicraniectomies (DHC) to relieve refractory intracranial hypertension. Alternative incisions have been proposed in the literature but have not been compared directly. OBJECTIVE To present the retroauricular (RA) incision as an alternative incision that we hypothesize will increase calvarium exposure to maximize the removal of the hemicranium and will decrease wound-related complications compared to the RQM incision. METHODS This study is a retrospective review of all DHCs performed at our institution over a span of 34 mo, stratified based on the type of scalp incision. The surface areas of the cranial defects were calculated, normalizing to their respective skull diameters. For those patients surviving beyond 1 wk, complications were examined from both cohorts. RESULTS A total of 63 patients in the RQM group and 43 patients in the RA group were included. The average surface area for the RA and RQM incisions was 117.0 and 107.8 cm2 (P = .0009), respectively. The ratio of average defect size to skull size for RA incision was 0.81 compared to 0.77 for the RQM group (P = .0163). Of those who survived beyond 1 wk, the absolute risk for surgical site complications was 14.0% and 8.3% for RQM and RA group (P = .5201), respectively. CONCLUSION The RA incision provides a safe and effective alternative incision to the traditional RQM incision used for DHC. This incision affords a potentially larger craniectomy while mitigating postoperative wound complications.
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Hirschmann, Dorian, Beate Kranawetter, Matthias Tomschik, Jonathan Wais, Fabian Winter, Josa M. Frischer, Matthias Millesi, Johannes Herta, Karl Roessler, and Christian Dorfer. "New-onset seizures after cranioplasty—a different view on a putatively frequently observed phenomenon." Acta Neurochirurgica 163, no. 5 (February 1, 2021): 1437–42. http://dx.doi.org/10.1007/s00701-021-04720-7.
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Abstract Background New-onset seizures after cranioplasty (NOSAC) are reported to be a frequent complication of cranioplasty (CP) after decompressive hemicraniectomy (DHC). There are considerable differences in the incidence of NOSAC and contradictory data about presumed risk factors in the literature. We suggest NOSAC to be a consequence of patients’ initial condition which led to DHC, rather than a complication of subsequent CP. We conducted a retrospective analysis to verify our hypothesis. Methods The medical records of all patients ≥ 18 years who underwent CP between 2002 and 2017 at our institution were evaluated including incidence of seizures, time of seizure onset, and presumed risk factors. Indication for DHC, type of implant used, timing of CP, patient age, presence of a ventriculoperitoneal shunt (VP shunt), and postoperative complications were compared between patients with and without NOSAC. Results A total of 302 patients underwent CP between 2002 and 2017, 276 of whom were included in the outcome analysis and the incidence of NOSAC was 23.2%. Although time between DHC and CP differed significantly between DHC indication groups, time between DHC and seizure onset did not differ, suggesting the occurrence of seizures to be independent of the procedure of CP. Time of follow-up was the only factor associated with the occurrence of NOSAC. Conclusion New-onset seizures may be a consequence of the initial condition leading to DHC rather than of CP itself. Time of follow-up seems to play a major role in detection of new-onset seizures.
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Ragoschke-Schumm, Andreas, Christina Junk, Martin Lesmeister, Silke Walter, Stefanie Behnke, Julia Schumm, and Klaus Fassbender. "Retrospective Consent to Hemicraniectomy after Malignant Stroke among the Elderly, Despite Impaired Functional Outcome." Cerebrovascular Diseases 40, no. 5-6 (2015): 286–92. http://dx.doi.org/10.1159/000441194.
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Background: Decompressive hemicraniectomy (DHC) after space-occupying strokes among patients older than 60 years has been shown to reduce mortality rates but at the cost of severe disability. There is an ongoing debate about what could be considered an acceptable outcome for these patients. Data about retrospective consent to the procedure after lengthy time periods are lacking. Methods: This study included 79 consecutive patients who underwent DHC during a 7.75-year period. Surviving patients were assessed for functional and psychological outcome, quality of life (QoL) and retrospective consent for the procedure. Patients younger than 60 years were compared with older patients. Results: Of our 79 patients, 44 were younger than 60 years (median 50 years, interquartile range (IQR) 19-59 years) and 35 were older (median 68 years, interquartile range 60-87 years). The 30-day mortality rate was higher for the older group, but the difference was not statistically significant. Functional outcome was significantly better in the younger group: 31% of the patients in this group vs. 10% in the older group had a modified Rankin Scale score of 0-3 (p = 0.046). The mean National Institutes of Health Stroke Scale score was 17 ± 14 for the younger group and 29 ± 15 for the older group (p = 0.002). On the 36-Item Short Form Health Survey, with the exception of the item ‘General health', the older group reported higher values for all items, with statistically significant differences between the 2 groups on the items ‘Role limitation emotional' (p = 0.0007) and ‘Vitality' (p = 0.02). In the younger group, 29% of patients retrospectively declined consent for DHC opposed to 0% of patients in the older group (p = 0.07). Conclusions: Despite impaired functional outcome after DHC, indicators of QoL and retrospective consent are higher for patients older than 60 years over the long term. This finding should be taken into account by those who counsel patients and caregivers with regard to this serious procedure.
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Deng, Hansen, Ezequiel Goldschmidt, Enyinna Nwachuku, John K. Yue, Federico Angriman, Zhishuo Wei, Nitin Agarwal, Ava M. Puccio, and David O. Okonkwo. "Hydrocephalus and Cerebrospinal Fluid Analysis Following Severe Traumatic Brain Injury: Evaluation of a Prospective Cohort." Neurology International 13, no. 4 (October 19, 2021): 527–34. http://dx.doi.org/10.3390/neurolint13040052.
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The development of hydrocephalus after severe traumatic brain injury (TBI) is an under-recognized healthcare phenomenon and can increase morbidity. The current study aims to characterize post-traumatic hydrocephalus (PTH) in a large cohort. Patients were prospectively enrolled age 16–80 years old with Glasgow Coma Scale (GCS) score ≤8. Demographics, GCS, Injury Severity Score (ISS), surgery, and cerebrospinal fluid (CSF) were analyzed. Outcomes were shunt failure and Glasgow Outcome Scale (GOS) at 6 and 12-months. Statistical significance was assessed at p < 0.05. In 402 patients, mean age was 38.0 ± 16.7 years and 315 (78.4%) were male. Forty (10.0%) patients developed PTH, with predominant injuries being subdural hemorrhage (36.4%) and diffuse axonal injury (36.4%). Decompressive hemicraniectomy (DHC) was associated with hydrocephalus (OR 3.62, 95% CI (1.62–8.07), p < 0.01). Eighteen (4.5%) patients had shunt failure and proximal obstruction was most common. Differences in baseline CSF cell count were associated with increased shunt failure. PTH was not associated with worse outcomes at 6 (p = 0.55) or 12 (p = 0.47) months. Hydrocephalus is a frequent sequela in 10.0% of patients, particularly after DHC. Shunt placement and revision procedures are common after severe TBI, within the first 4 months of injury and necessitates early recognition by the clinician.
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Heiss, Wolf-Dieter. "Malignant MCA Infarction: Pathophysiology and Imaging for Early Diagnosis and Management Decisions." Cerebrovascular Diseases 41, no. 1-2 (November 19, 2015): 1–7. http://dx.doi.org/10.1159/000441627.
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Background: Malignant middle cerebral artery infarction is a devastating condition, with up to 80% mortality in conservatively treated patients. The pathophysiology of this stroke is characterized by a large core of severe ischemia and only a relatively small rim of penumbra. Due to the fast development of irreversible morphological damage, cytotoxic edema occurs immediately in a large portion of the ischemic territory. The subsequent damage of the tight junctions leads to the breakdown of the blood brain barrier and vasogenic brain edema, resulting in space-occupying brain swelling. The progressive vasogenic edema reaches its maximum after 1 to several days and exerts a mechanical force on surrounding tissue structures leading to midline shift and transtentorial herniation and finally brain stem compression and death. Summary: Early severe neurological symptoms - hemiparesis, gaze deviation, higher cortical signs - followed by headache, vomiting, papillo edema and reduced consciousness may predict the deleterious course. Imaging supports the suspected diagnosis with hypodense changes on CT extending beyond 50% of the MCA territory. The size of the probably infarcted tissue and a midline shift on CT as well as the size of the lesion on diffusion-weighted MRI are predictive of a malignant course. Reduction of cerebral blood flow below a critical value and volume of irreversible tissue damage detected by positron emission tomography in the early hours after the stroke are indicative of progression to malignant infarction with increased intracranial pressure (ICP) and decreased tissue oxygen tension observed by multimodal neuromonitoring in the later course. Treatment options of malignant infarction include general measures to limit the extent of space-occupying edema, but these therapies have not been efficacious. Only surgical intervention with decompressive hemicraniectomy (DHC) was successful in relieving the effects of increased ICP and of the deleterious shifts of brain tissue. Several controlled clinical trials have proven the efficacy of DHC with a significant decrease in mortality and improved functional outcome. However, DHC must be performed early and with a large diameter, regardless of the age of patients, but in patients beyond 60 years, the higher likelihood of resulting severe disability should be taken into consideration. Key Messages: Malignant MCA infarction can be predicted early with a high sensitivity by neuroimaging. The early diagnosis is mandatory for DHC, which was shown to reduce mortality and improve functional outcome in several controlled clinical trials.
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Stiefel, Michael F., Gregory G. Heuer, Michelle J. Smith, Stephanie Bloom, Eileen Maloney-Wilensky, Vincente H. Gracias, M. Sean Grady, and Peter D. Leroux. "Cerebral oxygenation following decompressive hemicraniectomy for the treatment of refractory intracranial hypertension." Journal of Neurosurgery 101, no. 2 (August 2004): 241–47. http://dx.doi.org/10.3171/jns.2004.101.2.0241.
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Object. Medically intractable intracranial hypertension is a major cause of morbidity and mortality after severe brain injury. One potential treatment for intracranial hypertension is decompressive hemicraniectomy (DCH). Whether and when to use DCH, however, remain unclear. The authors therefore studied the effects of DCH on cerebral O2 to develop a better understanding of the effects of this treatment on the recovery from injury and disease. Methods. The study focused on seven patients (mean age 30.6 ± 9.7 years) admitted to the hospital after traumatic brain injury (five patients) or subarachnoid hemorrhage (two patients) as part of a prospective observational database at a Level I trauma center. At admission the Glasgow Coma Scale (GCS) score was 6 or less in all patients. Patients received continuous monitoring of intracranial pressure (ICP), cerebral perfusion pressure (CPP), blood pressure, and arterial O2 saturation. Cerebral oxygenation was measured using the commercially available Licox Brain Tissue Oxygen Monitoring System manufactured by Integra NeuroSciences. A DCH was performed when the patient's ICP remained elevated despite maximal medical management. Conclusions. All patients tolerated DCH without complications. Before the operation, the mean ICP was elevated in all patients (26 ± 4 mm Hg), despite maximal medical management. After surgery, there was an immediate and sustained decrease in ICP (19 ± 11 mm Hg) and an increase in CPP (81 ± 17 mm Hg). Following DCH, cerebral oxygenation improved from a mean of 21.2 ± 13.8 mm Hg to 45.5 ± 25.4 mm Hg, a 114.8% increase. The change in brain tissue O2 and the change in ICP after DCH demonstrated only a modest relationship (r2 = 0.3). These results indicate that the use of DCH in the treatment of severe brain injury is associated with a significant improvement in brain O2.
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Veldeman, Michael, Miriam Weiss, Lorina Daleiden, Walid Albanna, Henna Schulze-Steinen, Omid Nikoubashman, Hans Clusmann, Anke Hoellig, and Gerrit Alexander Schubert. "Decompressive hemicraniectomy after aneurysmal subarachnoid hemorrhage—justifiable in light of long-term outcome?" Acta Neurochirurgica, May 21, 2022. http://dx.doi.org/10.1007/s00701-022-05250-6.
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Abstract Purpose Decompressive hemicraniectomy (DHC) is a potentially lifesaving procedure in refractory intracranial hypertension, which can prevent death from brainstem herniation but may cause survival in a disabled state. The spectrum of indications is expanding, and we present long-term results in a series of patients suffering from aneurysmal subarachnoid hemorrhage (SAH). Methods We performed a retrospective analysis of previously registered data including all patients treated for SAH between 2010 and 2018 in a single institution. Patients treated with decompressive hemicraniectomy due to refractory intracranial hypertension were identified. Clinical outcome was assessed by means of the Glasgow outcome scale after 12 months. Results Of all 341 SAH cases, a total of 82 (24.0%) developed intracranial hypertension. Of those, 63 (18.5%) patients progressed into refractory ICP elevation and were treated with DHC. Younger age (OR 0.959, 95% CI 0.933 to 0.984; p = 0.002), anterior aneurysm location (OR 0.253, 95% CI 0.080 to 0.799; 0.019; p = 0.019), larger aneurysm size (OR 1.106, 95% CI 1.025 to 1.194; p = 0.010), and higher Hunt and Hess grading (OR 1.944, 95% CI 1.431 to 2.641; p < 0.001) were independently associated with the need for DHC. After 1 year, 10 (15.9%) patients after DHC were categorized as favorable outcome. Only younger age was independently associated with favorable outcome (OR 0.968 95% CI 0.951 to 0.986; p = 0.001). Conclusions Decompressive hemicraniectomy, though lifesaving, has only a limited probability of survival in a clinically favorable condition. We identified young age to be the sole independent predictor of favorable outcome after DHC in SAH.
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Xia, Chao, Xia Wang, Richard I. Lindley, Candice Delcourt, Xiaoying Chen, Zien Zhou, Rui Guo, et al. "Early decompressive hemicraniectomy in thrombolyzed acute ischemic stroke patients from the international ENCHANTED trial." Scientific Reports 11, no. 1 (August 13, 2021). http://dx.doi.org/10.1038/s41598-021-96087-z.
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AbstractDecompressive hemicraniectomy (DHC) can improve outcomes for patients with severe forms of acute ischemic stroke (AIS), but the evidence is mainly derived from non-thrombolyzed patients. We aimed to determine the characteristics and outcomes of early DHC in thrombolyzed AIS participants of the international Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED). Post-hoc analyses of ENCHANTED, an international, partial-factorial, open, blinded outcome-assessed, controlled trial in 4557 thrombolysis-eligible AIS patients randomized to low- versus standard-dose intravenous alteplase (Arm A, n = 2350), intensive versus guideline-recommended blood pressure control (Arm B, n = 1280), or both (Arms A + B, n = 947). Logistic regression models were used to identify baseline variables associated with DHC, with inverse probability of treatment weights employed to eliminate baseline imbalances between those with and without DHC. Logistic regression was also used to determine associations of DHC and clinical outcomes of death/disability, major disability, and death (defined by scores 2–6, 3–5, and 6, respectively, on the modified Rankin scale) at 90 days post-randomization. There were 95 (2.1%) thrombolyzed AIS patients who underwent DHC, who were significantly younger, of non-Asian ethnicity, and more likely to have had prior lipid-lowering treatment and severe neurological impairment from large vessel occlusion than other patients. DHC patients were more likely to receive other management interventions and have poor functional outcomes than non-DHC patients, with no relation to different doses of intravenous alteplase. Compared to other thrombolyzed AIS patients, those who received DHC had a poor prognosis from more severe disease despite intensive in-hospital management.
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Oravec, Chesney S., Christine Tschoe, Kyle M. Fargen, Carol A. Kittel, Alejandro Spiotta, Eyad Almallouhi, Robert M. Starke, et al. "Trends in mechanical thrombectomy and decompressive hemicraniectomy for stroke: A multicenter study." Neuroradiology Journal, July 16, 2021, 197140092110305. http://dx.doi.org/10.1177/19714009211030526.
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Background and purpose Acute ischemic stroke has increasingly become a procedural disease following the demonstrated benefit of mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) on clinical outcomes and tissue salvage in randomized trials. Given these data and anecdotal experience of decreased numbers of decompressive hemicraniectomies (DHCs) performed for malignant cerebral edema, we sought to correlate the numbers of strokes, thrombectomies, and DHCs performed over the timeline of the 2013 failed thrombolysis/thrombectomy trials, to the 2015 modern randomized MT trials, to post-DAWN and DEFUSE 3. Materials and methods This is a multicenter retrospective compilation of patients who presented with ELVO in 11 US high-volume comprehensive stroke centers. Rates of tissue plasminogen activator (tPA), thrombectomy, and DHC were determined by current procedural terminology code, and specificity to acute ischemic stroke confirmed by each institution. Endpoints included the incidence of stroke, thrombectomy, and DHC and rates of change over time. Results Between 2013 and 2018, there were 55,247 stroke admissions across 11 participating centers. Of these, 6145 received tPA, 4122 underwent thrombectomy, and 662 patients underwent hemicraniectomy. The trajectories of procedure rates over time were modeled and there was a significant change in MT rate ( p = 0.002) without a concomitant change in the total number of stroke admissions, tPA administration rate, or rate of DHC. Conclusions This real-world study confirms an increase in thrombectomy performed for ELVO while demonstrating stable rates of stroke admission, tPA administration and DHC. Unlike prior studies, increasing thrombectomy rates were not associated with decreased utilization of hemicraniectomy.
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Kamran, Saadat, Naveed Akhtar, Zain A. Bhutta, Abdul Salam, Aymen Alboudi, Hiba Rashid, Kainat Kamran, et al. "Abstract TP124: Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke: South Asian Experience." Stroke 48, suppl_1 (February 2017). http://dx.doi.org/10.1161/str.48.suppl_1.tp124.
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Objective: The randomized trials and pooled analysis showed improved outcome and reduced mortality in malignant middle cerebral artery [MMCA] undergoing decompressive hemicraniectomy (DHC) within 48 hours of stroke onset. This could be due to highly selective patient population in trials, not reflecting real world practice. Furthermore, with ischemic stroke being so common in the South Asian and Middle Eastern population, there still exists very little published data on DHC in MMCA stroke patients. Methods: Retrospective, multicenter cross-sectional study to measure outcome following DHC using the modified Rankin Scale [mRS] and dichotomized as favorable ≤4 or unfavorable >4, at three months. Results: In total 137 patients underwent DHC. At 90 days, mortality was 16.8%, 61.3% of patients survived with an mRS ≤4 and 38.7% had an mRS of >4. Age (55 years), diabetes [p=0.004], hypertension [p=0.021], pupillary abnormality [p=0.048], uncal herniation [p=0.007], temporal lobe involvement [p=0.016], additional infarction [MCA + ACA, PCA] [P=0.001], and infarction growth rates [P=0.025] was significantly higher in patients with unfavorable prognosis in univariate analysis. Multivariate analysis showed age, additional infarction, septum pellucidum deviation >1cm and uncal herniation to be associated with a significantly poor prognosis. Time to surgery had no impact on outcome [p=0.109]. Conclusions: Similar to the effects observed in the studies from the West, DHC improves functional outcome in predominantly South Asian patients with MMCA stroke. Increasing age, MCA with additional infarctions, septum pellucidum deviation 1cm and uncal herniation were significant predictors of disability and poor functional outcomes. Time to surgery had no impact on functional outcome.
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Hinduja, Archana, Yousef Hannawi, Dongxia Feng, and Rohan Samant. "Abstract WP339: Herniation Despite Decompressive Hemicraniectomy in Large Hemispherical Ischemic Stroke Patients." Stroke 48, suppl_1 (February 2017). http://dx.doi.org/10.1161/str.48.suppl_1.wp339.
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Background: Despite timely decompressive hemicraniectomy (DHC), clinical failure or progressive herniation requiring a second decompression procedure and mortality has been reported in acute middle cerebral artery (MCA) strokes. Hypothesis: Our objective was to determine the stroke and surgical parameters measured on head CT scan that are associated with progressive herniation despite DHC in patients with large hemispheric MCA strokes. Methods: Retrospective chart review of all medical records and imaging features of patients with malignant hemispheric infarction who underwent DHC for cerebral edema from July 2010 to June 2015, was performed. Patients who died from postoperative hemorrhagic complications were excluded. Infarct volume was calculated using ABC/2 method on CT scans within 48 hours of symptom onset (Kostov et al, 2012, World Neurosurg). Radiologic parameters of the craniectomy bone flap (length, width, area) and brain volume protruding out of the skull (height and volume) were measured (Chung et al, 2011, Neurologist). Images were reviewed by a board certified neuroradiologist to determine whether the craniectomy bed was sufficiently centered on the stroke bed (Zweckberger et al, 2014, Cerebrovasc Dis) and the brain volume not included in the craniectomy bed. Groups were compared using Fisher exact test for categorical variables and T-test or Mann-Whitney U test for continuous variables, as appropriate. Results: Out of 41 patients who underwent DHC for cerebral edema (mean age 53.1 ±12, 48.7% females, 36.5% African Americans) 7 had progressive herniation leading to mortality. Radiographic parameters that were significantly different between both groups were presence of malignant edema (p=0.047), insufficient centering of the craniectomy bed on the stroke bed (p=0.03), large infarct volume not centered on the craniectomy bed (p=0.011), presence of anterior cerebral artery infarction (p=0.047), and smaller craniectomy length (p=0.05). There was a trend in protruding brain volume (p=0.056). Conclusion: Besides the craniectomy length, sufficient centering of the craniectomy over the stroke bed may be required to prevent progressive herniation.
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Heiferman, Daniel M., Georgios Tsivgoulis, Savdeep Singh, Diana Alsbrook, Ghaida Zaid, Leila Gachechiladze, Balaji Krishnaiah, et al. "Predictors of Decompressive Hemicraniectomy in Successfully Recanalized Patients With Anterior Circulation Emergency Large‐Vessel Occlusion." Stroke: Vascular and Interventional Neurology, June 2, 2022. http://dx.doi.org/10.1161/svin.121.000252.
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BACKGROUND Mechanical thrombectomy (MT) has been shown to improve functional outcome in patients with anterior circulation strokes and emergent large‐vessel occlusion (ELVO). Despite successful recanalization, some of these patients require decompressive hemicraniectomy (DHC). We aimed to study the predictors of DHC in successfully recanalized anterior circulation ELVO patients. METHODS Consecutive patients with anterior circulation ELVO treated with MT during a 6‐year period were evaluated. Only successfully recanalized patients (modified Thrombolysis in Cerebral Infarction grades 2b, 2c, or 3) after MT were included in the analysis. Baseline demographic, clinical, and procedural variables were compared between patients requiring DHC after successful recanalization versus those who did not. RESULTS Of 453 successfully recanalized patients with ELVO, 47 who underwent DHC had higher admission blood glucose levels (170±88 versus 142±66 mg/dL; P =0.008), lower median Alberta Stroke Program Early CT Scores (9 [interquartile range, 8–10] versus 10 [interquartile range, 9–10]; P =0.002), higher prevalence of poor collaterals on pretreatment computed tomography angiogram (75% versus 26%; P <0.001), and required more passes during MT (median, 3 [interquartile range, 3–4] versus 2 [interquartile range, 1–2]; P =0.001) compared with those who did not undergo DHC. In a multivariable model after adjusting for multiple confounders, higher admission blood glucose levels ( P =0.031), poor collaterals on computed tomography angiography ( P <0.001), and higher number of passes during MT ( P <0.001) emerged as independent predictors of DHC in successfully recanalized patients with ELVO. CONCLUSIONS Higher admission blood glucose levels, poor collateral pattern on computed tomography angiography, and higher number of passes during MT were independently associated with DHC in patients with anterior circulation ELVO achieving successful recanalization following MT.
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Kamran, Saadat, Naveed Akhtar, Abdul Salam, Aymen Alboudi, Kainat Kamran, Arsalan Ahmed, Zain A. Bhutta, Furqan B. Irfan, and Ashfaq Shuaib. "Abstract TP135: Late Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke: Role of Infarct Growth." Stroke 48, suppl_1 (February 2017). http://dx.doi.org/10.1161/str.48.suppl_1.tp135.
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Objective: The purpose of this multi-institutional pooled data analyses from three countries was to determine the impact of DHC timing on the functional outcomes in patients operated beyond 48 hours in comparison with DHC under 48 hours. In addition factors leading to early or late DHC were also identified. Methods: Retrospective, multicenter cross-sectional study to measure outcome following DHC <48 or >48 hours using the modified Rankin Scale [mRS] and dichotomized as favorable ≤4 or unfavorable >4, at three months. Results: In total 137 patients underwent DHC. There was no significant difference in the functional outcome [P=0.140] and mortality [P=0.975] but with a trend towards better outcome in patients operated over 48 hours. Multivariate analysis showed age ≥ 55, MCA with additional infarction, septum pellucidum deviation ≥1cm, and uncal herniation was independent predictor of poor functional outcome at three months. In the ‘‘best’’ multivariate model IGR >7.5ml/hr, MCA with additional infarction, and patients with temporal lobe involvement were independently associated with surgery under 48 hours. Both first infarct growth rate [IGR1] [DHC<48 hours, 15.2± 8.1ml/hr vs. >48 hours, 7.1 ± 5.03ml/hr] [P<0.001] and second infarct growth rate [IGR2] [DHC 48 13.64 ±8.76 ml/hr, > 48 hours 7.15 ±6.23 ml/hr [P<0.001] were nearly double in patients with early surgery [<48 hours]. Conclusions: There was no significant difference in the functional outcome and mortality in patients operated >48 hours of stroke onset compared to early [<48 hours]. Time to surgery had no impact on functional outcome. Our data identifies IGR, temporal lobe involvement and MCA with additional infarct were independent predictors of early surgery.
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Ramiro, Joanna I., Rajat Dhar, Eli Feen, and Abhay Kumar. "Abstract T P405: Improvement in Midline Shift is Associated with Survival After Decompressive HemiCraniectomy in Large Hemispheric Infarctions." Stroke 46, suppl_1 (February 2015). http://dx.doi.org/10.1161/str.46.suppl_1.tp405.
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Background and Purpose: It remains uncertain which patients with malignant edema after large hemispheric infarction (LHI) remain at risk of death despite decompressive hemicraniectomy (DHC). We investigated factors associated with in-hospital mortality in a cohort of patients with LHI who underwent DHC. Methodology: This retrospective cohort study conducted over a five-year period identified 24 LHI patients who underwent DHC. Patient demographics, pre- and post-DHC clinical and neuro-imaging data were recorded (including midline shift [MLS] at the level of lateral ventricles). These variables were then analyzed in relation to in-hospital mortality. Results: Patients were predominantly male (17/24), with mean age of 55±15 years and baseline NIHSS score of 18.5± 4. Despite DHC, performed at a median of 52 hours, mortality still occurred in 9 patients (38%), with 11 (46%) going to acute rehabilitation and remainder to long-term care facility (LTC). Patients had a mean pre-operative MLS of 11 ± 3 mm. When compared with a head CT obtained 48 hours after DHC, MLS improved the most in patients going to rehabilitation (by 6 ± 4.2 mm), compared to those going to LTC (3.2 ± 5 mm), while the least improvement was seen in those who died (1 ± 5 mm). Survivors had significant improvement in MLS (5.3 ± 4.4 mm) compared to the non-survivors (1 ± 5 mm), p = 0.04. The survivors were also significantly younger (50 ± 17 years) compared to those who died (62 ± 7 years). Thirteen patients (54% of the cohort) received intracranial pressure (ICP) monitors ipsilateral to the infarct during DHC but measured ICPs were statistically similar in survivors vs non-survivors. Other variables (baseline NIHSS score, MLS and time to surgery) did not predict death in the cohort. Conclusion: Mortality remains high in LHI patients even after DHC. Improvement in MLS after DHC appears to separate survivors from non-survivors while post-DHC ICPs do not. However, our sample size is small and additional studies with larger population sizes are required for validation of our findings.
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Olm-Shipman, Casey, Victoria Marquevich, Jonathan Rosand, Aman Patel, Emad Eskandar, Aurelie Cordier, Alison Ayres, Lee H. Schwamm, and Aneesh B. Singhal. "Abstract W P299: Impact of an Institutional Guideline on Implementing Early Decompressive Hemicraniectomy (DHC) for Large Middle Cerebral Artery Stroke." Stroke 46, suppl_1 (February 2015). http://dx.doi.org/10.1161/str.46.suppl_1.wp299.
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Background: Recent AHA Acute Stroke Guidelines endorse DHC (Class 1, Level B) based on clinical trials showing benefit of early DHC on outcome and mortality. In 2011, our multidisciplinary quality improvement team developed a process to translate DHC guideline recommendations into clinical practice. Methods: Our consensus guideline includes a tool (STATE Criteria, based on inclusion/exclusion criteria of DHC clinical trials) to rapidly identify and triage potential DHC candidates, and provide specific guidelines for pre- and post-surgical management, adjunctive therapy, and DHC after IV/IA thrombolysis. Patients meeting all STATE Criteria including age ≤ 60 years are sent for urgent DHC. Patients meeting all criteria except age ≤ 60 years receive DHC only if age < 75 years and Neurology and Neurosurgery teams reach consensus about benefit. Patients not meeting criteria are observed and referred for DHC if criteria are met within 48 hours of onset. The guideline was disseminated to all stakeholders via email, conferences, and intranet. In this study, we retrospectively analyzed process and outcome measures for DHC before and after guideline implementation in February 2011. Results: Of 1518 stroke patients age ≤ 60 years admitted between January 2007 and April 2014, 47 (3%) received DHC (22 pre- and 25 post-guideline implementation; 28% female, 13% Hispanic). Mean admission NIHSS was similar (17±7 vs 18±5; p=.82). Mean time from admission to DHC improved significantly from 45±30 hours to 29±18 hours (p=0.04). The percentage of patients undergoing DHC beyond 48 hours decreased from 27% to 16% (p=0 .35). The degree of midline shift evident on CT or MRI prior to DHC significantly decreased from 9±4 mm to 5±4 mm (p=.01). There was no significant difference in length of stay, frequency of tracheostomy, gastrostomy, pneumonia, or urinary tract infection, or percentage of patients who died within 30 days of DHC. Conclusion: Our institutional guideline has facilitated the rapid identification and triage of patients with large MCA stroke to DHC. Follow-up is ongoing to determine the impact of our guideline on functional outcome after stroke.
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Park, Christine, Martin Weiss, Scott Le, Shreyansh Shah, Mary Guhwe, Brian Mac Grory, L. Fernando Gonzalez, and Wayne Feng. "Abstract P254: Decompressive Hemicraniectomy and Functional Outcomes After Malignant Cerebral Infarction: Real World Experience From a Comprehensive Stroke Center." Stroke 52, Suppl_1 (March 2021). http://dx.doi.org/10.1161/str.52.suppl_1.p254.
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Background: Decompressive hemicraniectomy (DHC), performed in select patients with malignant infarction (MCI), reduces mortality. However, there is conflicting evidence surrounding the use of DHC in improving disability outcomes in this patient population. This is in part due to differing definitions of functional recovery in prior studies. The purpose of this study is to characterize a cohort of patients with ischemic stroke who underwent DHC and compare the outcomes data with pooled data from three major trials published for DHC (DECIMAL, DESTINY, and HAMLET). Methods: This was a retrospective, observational cohort study of consecutive patients who underwent DHC as part of best clinical care during 2015-2020. We report our cohort using descriptive statistics. Results: Of the 44 patients underwent DHC at our institution, 33 were included for analysis after applying the inclusion and exclusion criteria based on the three major trials. Our DHC cohort tended to have higher rates of comorbidities including hypertension and diabetes (Table 1). A greater number of our DHC patients had unfavorable modified Rankin Scale (mRS) scores of 4 or 5 at 6-month follow-up compared to those who underwent DHC or received conservative therapy at 12-month follow-up in the three prospective trials (Figure 1). Conclusion: DHC in patient cohorts with significant comorbid data is associated with reduced mortality but a worsened functional outcome in survivors. The treating practitioner should consider this procedure only in the context of a lengthy discussion regarding the patient’s baseline functional and health status as well as competing benefits and risks associated with this procedure.
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Truckenmueller, Peter, Anton Früh, Stefan Wolf, Katharina Faust, Nils Hecht, Julia Onken, Robert Ahlborn, Peter Vajkoczy, and Anna Zdunczyk. "Reduction in wound healing complications and infection rate by lumbar CSF drainage after decompressive hemicraniectomy." Journal of Neurosurgery, December 1, 2022, 1–9. http://dx.doi.org/10.3171/2022.10.jns221589.
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OBJECTIVE Wound healing disorders and surgical site infections are the most frequently encountered complications after decompressive hemicraniectomy (DHC). Subgaleal CSF accumulation causes additional tension of the scalp flap and increases the risk of wound dehiscence, CSF fistula, and infection. Lumbar CSF drainage might relieve subgaleal CSF accumulation and is often used when a CSF fistula through the surgical wound appears. The aim of this study was to investigate if early prophylactic lumbar drainage might reduce the rate of postoperative wound revisions and infections after DHC. METHODS The authors retrospectively analyzed 104 consecutive patients who underwent DHC from January 2019 to May 2021. Before January 2020, patients did not receive lumbar drainage, whereas after January 2020, patients received lumbar drainage within 3 days after DHC for a median total of 4 (IQR 2–5) days if the first postoperative CT scan confirmed open basal cisterns. The primary endpoint was the rate of severe wound healing complications requiring surgical revision. Secondary endpoints were the rate of subgaleal CSF accumulations and hygromas as well as the rate of purulent wound infections and subdural empyema. RESULTS A total of 31 patients died during the acute phase; 34 patients with and 39 patients without lumbar drainage were included for the analysis of endpoints. The predominant underlying pathology was malignant hemispheric stroke (58.8% vs 66.7%) followed by traumatic brain injury (20.6% vs 23.1%). The rate of surgical wound revisions was significantly lower in the lumbar drainage group (5 [14.7%] vs 14 [35.9%], p = 0.04). A stepwise linear regression analysis was used to identify potential covariates associated with wound healing disorder and reduced them to lumbar drainage and BMI. One patient was subject to paradoxical herniation. However, the patient’s symptoms rapidly resolved after lumbar drainage was discontinued, and he survived with only moderate deficits related to the primary disease. There was no significant difference in the rate of radiological herniation signs. The median lengths of stay in the ICU were similar, with 12 (IQR 9–23) days in the drainage group compared with 13 (IQR 11–23) days in the control group (p = 0.21). CONCLUSIONS In patients after DHC and open basal cisterns on postoperative CT, lumbar drainage appears to be safe and reduces the rate of surgical wound revisions and intracranial infection after DHC while the risk for provoking paradoxical herniation is low early after surgery.
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Wei, Heng, Fu-Min Jia, Hong-Xiang Yin, and Zhen-Li Guo. "Decompressive hemicraniectomy versus medical treatment of malignant middle cerebral artery infarction: a systematic review and meta-analysis." Bioscience Reports 40, no. 1 (January 2020). http://dx.doi.org/10.1042/bsr20191448.
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Abstract Objectives: To estimate evidence for decompressive hemicraniectomy (DHC) versus medical treatment effects on survival rate and favorable functional recovery among patients of malignant middle cerebral artery infarction (MMCAI) in randomized controlled trials (RCTs). Design: The present study is a systematic review and meta-analysis of RCTs. Setting: The MEDLINE/PubMed, EMBASE, Springer, Cochrane Collaboration database, China National Knowledge Infrastructure (CNKI) database, and Wanfang database were comprehensively searched for RCTs regarding the effects of DHC versus medical treatment among patients of MMCAI in these English and Chinese electronic databases from inception to 1 June 2019. Two reviewers independently retrieved RCTs and extracted relevant information. The methodological quality of the included trials was estimated using the Cochrane risk of bias tool. Review Manager5.3.5 software was used for statistical analyses. The statistical power of meta-analysis was estimated by Power and Precision, version 4 software. Participants: Nine RCTs with a total of 425 patients with MMCAI, containing 210 cases in the DHC group and 215 cases in the medical treatment group, met the inclusion criteria were included. Primary outcomes were measured by survival rate, defined as modified Rankin scale (mRS) score 0–5 and favorable functional recovery as mRS score 0–3. The follow-up time of all studies was at 6–12months. Results: First, compared with the medical treatment group, DHC was associated with a statistically significant increase survival rate (RR: 1.96, 95%CI 1.61–2.38, P < 0.00001) and favorable functional recovery (RR: 1.62, 95%CI 1.11–2.37, P = 0.01). Second, subgroup analysis: (1) Compared with the medical treatment group among patients age ≤60 years, DHC was associated with a statistically significant increase survival rate (RR = 2.20, 95%CI 1.60–3.04, P < 0.00001); (2) Compared with the medical treatment group among patients of age >60 years, DHC was also associated with a statistically significant increase survival rate (RR: 1.93, 95%CI 1.45–2.59, P < 0.00001); (3) Compared with the medical treatment group, the time of DHC was preformed within 48 h from the onset of stroke that could statistically significant increase survival rate (RR: 2.16, 95%CI 1.69–2.75, P < 0.00001). Third, sensitivity analyses that measured the results were consistent, indicating that the results were stable. Fourth, the results of statistical power analysis were ≥80%. Finally, the funnel plot of the survival rate included nine RCTs showed no remarkable publication bias. Conclusions: Our study results indicated that DHC could increase survival rate and favorable functional recovery among patients age ≤60 or >60 years. The optimal time for DHC might be no more than 48 h from the onset of symptoms. However, due to the limitations of this research, it is necessary to design high quality, large-scale RCTs to further evaluate these findings.
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AbdeleRahman, Kader, Maria Carissa Pineda, Fred Rincon, William Young, Matthew Vibbert, Rodney Bell, and Michael Moussouttas. "Abstract T P120: Clinical Demographic Effects on Functional Outcome in Patients Following Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction." Stroke 45, suppl_1 (February 2014). http://dx.doi.org/10.1161/str.45.suppl_1.tp120.
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Background: Malignant MCA infarction is a devastating disease representing 1-10% of strokes. Evidence from recent randomized controlled trials show improved survival and functional outcomes following decompressive hemicraniectomy (DHC) compared with optimal medical. Ideal patient selection remains somewhat controversial. The current study examines the effects of demographic and clinical variables on functional outcomes in patients surviving one or more years following DHC. Methods: We retrospectively reviewed patients who underwent DHC for malignant MCA infarction at our institution from 03/2006 to 04/2012. We collected and compared demographic and clinical variables including age, gender, race, timing of DHC, side of infarction, IV TPA administration, and additional cerebral territorial involvement (ACA or PCA). The mean mRs was calculated for each group and the Wilcoxon-Mann-Whitney two tailed test was used to calculate statistical significance. Results: A total of 32 patients met inclusion/exclusion criteria. There was no statistical difference in functional outcomes between patients ≤60 years of age and those >60 years (p=0.51). No statistical difference was observed between males and females (p=0.84)). Patients who received their DHC within 48 hours of their stroke were more likely to have a better outcome than patients who received DHC after 48 hours (p=0.024). Other variables including race, cerebral dominance involvement, IV TPA administration, or additional cerebral territory involvement did not show statistical significance with respect to functional outcomes (p=0.22, p=0.462, p=0.597, and p=0.614 respectively). Conclusion: In this retrospective study, early DHC done within 48 hours of stroke was the only clinical variable shown to improve functional outcomes 1 year or more later among survivors of patients receiving DHC for malignant MCA infarction. No difference in functional outcome was seen based on age, gender, race, IV TPA administration, dominant MCA involvement, and additional cerebral territorial co infarction. Patient selection should be individualized and larger studies are needed to better assess this patient population, especially in the elderly.
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Ojeda, Chris, Nitya Chitravanshi, Patrick C. Reid, Charles J. Prestigiacomo, Ennis J. Duffis, and Chirag D. Gandhi. "Abstract TP132: Decompressive Hemicraniectomy Improves Survival in Malignant Middle Cerebral Artery Stroke Patients with Hemorhagic Conversion Admitted with a High Glasgow Coma Scale." Stroke 44, suppl_1 (February 2013). http://dx.doi.org/10.1161/str.44.suppl_1.atp132.
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Decompressive hemicraniectomy (DHC) has been shown to improve clinical outcome in cases of malignant infarct but its indications have not been well classified. This study focuses on patients who suffered malignant middle cerebral artery (MMCA) infarct with subsequent hemorrhagic conversion and were admitted with mild brain injury (initial Glasgow Coma Scale≥13). Survival rates of MMCA infarct patients with hemorrhagic conversion who underwent DHC were compared with those treated with medical management only. Hypothesis: Patients admitted for MMCA infarct with a Glasgow Coma Scale ≥13 who develop hemorrhagic conversion have improved survivability when DHC is performed. Methods: Retrospective review was performed on all cases consulted for neurological surgery from 2007-2012 at University Hospital. Patients were selected on the criteria of MMCA infarct on admission with subsequent development of hemorrhage conversion. Patients who underwent DHC had to have the hemorrhagic conversion prior to surgery for inclusion. The primary endpoint was mortality. Fisher’s Exact Test and odds ratio were performed on patients with MMCA infarct and hemorrhagic conversion comparing patient mortality with DHC to that without. Results: In total, 91 MMCA infarct patients were referred to neurological surgery, 33 with an initial Glasgow Coma Scale >13. Of those, 36% (12/33) had hemorrhagic conversion. Six patients underwent DHC with a survival rate of 6/6. Patients treated medically had a survival rate of 33%. The Fisher’s Exact Test showed statistical significance (p<0.05) for improved survival rate and Odds ratio confirmed reduced mortality within a 95% confidence interval of hemorrhagic conversion following MMCA infarct when DHC was performed using GraphPad InStat 3.10. Conclusion: A statistically significant increase in survival has been found with use of DHC for MMCA infarct with subsequent hemorrhagic conversion in patients with a high admission Glasgow Coma Scale.
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Ojeda, Chris, Nitya Chitravanshi, Patrick C. Reid, Ennis J. Duffis, Charles J. Prestigiacomo, and Chirag D. Gandhi. "Abstract TP137: Increased Survival of Malignant Middle Cerebral Artery Stroke Patients with Midline Shift and High Glasgow Coma Scale Undergoing Decompressive Hemicraniectomy." Stroke 44, suppl_1 (February 2013). http://dx.doi.org/10.1161/str.44.suppl_1.atp137.
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Intro: Ischemic stroke of the middle cerebral artery often results in malignant cerebral edema leading to rapid clinical decline and midline shift. Decompressive hemicraniectomy (DHC) has been shown to improve clinical outcome in cases of malignant infarct but indications of when to perform it have not been well classified. This study focuses on patients who suffered malignant middle cerebral artery (MMCA) infarct and entered with mild brain injury (initial Glasgow Coma Scale≥13). Survival rates were compared among patients who received DHC versus medical treatment with a focus on midline shift. Hypothesis: Patients entering for MMCA with a Glascow Coma Scale ≥13who develop midline shift will have reduced mortality due to DHC relative to those with an entirely medical treatment. Methods: Retrospective review was performed on all cases consulted for neurological surgery from 2007-2012 at University Hospital. Patients were selected on the criteria of MMCA infarct. Midline shifts used were recorded prior to surgery or in the absence of surgery, 2-4 days post infarct. The primary endpoint was mortality at discharge. Multiple regression analysis was performed comparing the patient outcome to the degree of midline shift and if DHC occurred. Results: In total, 91 patients were referred to neurological surgery and 34 qualified with an initial Glasgow Coma Scale ≥13. Of those, 10 received a DHC, all with a midline shift and a survival rate of 70% (7/10). Exclusively medical treatment was done on 24 patients, 7 had midline shift reported with a survival rate of 29% (2/7) and 17 with no shift had a survival rate of 100% (17/17).The total medical survival rate was 79% (19/24). Regression analysis showed statistical significance (p<0.05) with mortality as the dependent variable and degree of midline shift (mm) and if DHC occurred as independent variables with GraphPad InStat 3.10. Conclusion: A statistically significant increase in survival has been found with use of DHC for MMCA infarct patients with a high Glasgow Coma Scale who have midline shift.
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Veldeman, Michael, Lorina Daleiden, Hussam Hamou, Anke Höllig, and Hans Clusmann. "An altered posterior question-mark incision is associated with a reduced infection rate of cranioplasty after decompressive hemicraniectomy." Journal of Neurosurgery, April 2020, 1–9. http://dx.doi.org/10.3171/2020.2.jns193335.
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OBJECTIVEPerforming a cranioplasty (CP) after decompressive craniotomy is a straightforward neurosurgical procedure, but it remains associated with a high complication rate. Surgical site infection (SSI), aseptic bone resorption (aBR), and need for a secondary CP are the most common complications. This observational study aimed to identify modifiable risk factors to prevent CP failure.METHODSA retrospective analysis was performed of all patients who underwent CP following decompressive hemicraniectomy (DHC) between 2010 and 2018 at a single institution. Predictors of SSI, aBR, and need for allograft CP were evaluated in a univariate analysis and multivariate logistic regression model.RESULTSOne hundred eighty-six patients treated with CP after DHC were included. The diagnoses leading to a DHC were as follows: stroke (83 patients, 44.6%), traumatic brain injury (55 patients, 29.6%), subarachnoid hemorrhage (33 patients, 17.7%), and intracerebral hemorrhage (15 patients, 8.1%). Post-CP SSI occurred in 25 patients (13.4%), whereas aBR occurred in 32 cases (17.2%). An altered posterior question-mark incision, ending behind the ear, was associated with a significantly lower infection rate and CP failure, compared to the classic question-mark incision (6.3% vs 18.4%; p = 0.021). The only significant predictor of aBR was patient age, in which those developing resorption were on average 16 years younger than those without aBR (p < 0.001).CONCLUSIONSThe primary goal of this retrospective cohort analysis was to identify adjustable risk factors to prevent post-CP complications. In this analysis, a posterior question-mark incision proved beneficial regarding infection and CP failure. The authors believe that these findings are caused by the better vascularized skin flap due to preservation of the superficial temporal artery and partial preservation of the occipital artery. In this trial, the posterior question-mark incision was identified as an easily and costless adaptable technique to reduce CP failure rates.
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Xu, Jindong, Sonisha A. Warren, and Anna Y. Khanna. "Abstract T P289: Long-term Outcome Analysis in Patients With Malignant Middle Cerebral Artery Stroke Who Underwent Decompressive Hemicraniectomy." Stroke 46, suppl_1 (February 2015). http://dx.doi.org/10.1161/str.46.suppl_1.tp289.
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Background and Purpose: Decompressive hemicraniectomy (DHC) reduces mortality and improves physical outcome in selected patients with malignant middle cerebral artery (mMCA) stroke. In this study, we performed comprehensive functional evaluation in mMCA stroke patients who underwent DHC, and attempted to identify the pre-surgical factors that correlated with long-term physical outcome. Methods: We identified mMCA stroke patients treated with DHC in our institution between January 2007 and April 2013. Functional outcome was assessed in survivors through clinic visit or telephone interview using modified Rankin Scale (mRS), Barthel Index, Geriatric Depression Scale, Stroke Impact Scale, Satisfaction of Life Scale, and retrospective consent. In addition, all patients including survivors and deceased were classified into acceptable outcome (mRS<=4) and bad outcome (mRS>4) groups. Pre-surgical factors including age, gender, stroke risk factors, time to surgery, cerebral vessel involvement, cause of stroke, use of intravenous tPA or endovascular intervention were compared between two groups. Results: 37 patients were identified meeting our study criteria. 11 out of 16 survivors were enrolled for functional assessment (mean age 54.7 years, 73% male, 27% left hemisphere stroke, and mean time after stroke 3.4 years). Psychosocial aspect scored much higher than physical outcome in comprehensive functional evaluation. The majority of participants were satisfied with life and agreed for the retrospective consent. Comparing two groups with acceptable (n=9) and bad (n=23) outcomes, pre-surgical characteristics including age>60, anterior cerebral artery involvement, hemorrhagic transformation, history of diabetes and coronary artery diseases were potentially associated with worse long-term outcome. Conclusions: A better psychological recovery suggests that appropriate mMCA stroke patients should not be deprived a DHC only based on a presumed unfavorable physical outcome. Some pre-surgical factors may be predictive for a worse outcome, which will assist physicians and families making critical decisions.
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Kamran, Saadat, Naveed Akhtar, Abdul Salam, Ayman Alboudi, Kainat Kamran, Yahiya Bashir Imam, Numan Amir, et al. "CT pattern of Infarct location and not infarct volume determines outcome after decompressive hemicraniectomy for Malignant Middle Cerebral Artery Stroke." Scientific Reports 9, no. 1 (November 19, 2019). http://dx.doi.org/10.1038/s41598-019-53556-w.
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AbstractMalignant middle cerebral artery [MMCA] infarction has a different topographic distribution that might confound the relationship between lesion volume and outcome. Retrospective study to determine the multivariable relationship between computerized tomographic [CT] infarct location, volume and outcomes in decompressive hemicraniectomy [DHC] for MMCA infarction. The MCA infarctions were classified into four subgroups by CT, subtotal, complete MCA [co-MCA], Subtotal MCA with additional infarction [Subtotal MCAAI] and co-MCA with additional infarction [Co-MCAAI]. Maximum infarct volume [MIV] was measured on the pre-operative CT. Functional outcome was measured by the modified Rankin Scale [mRS] dichotomized as favourable 0–3 and unfavourable ≥4, at three months. In 137 patients, from least favourable to favourable outcome were co-MCAAI, subtotal MCAAI, co-MCA and subtotal MCA infarction. Co-MCAAI had the worst outcome, 56/57 patients with additional infarction had mRS ≥ 4. Multiple comparisons Scheffe test showed no significant difference in MIV of subtotal infarction, co-MCA, Subtotal MCAAI but the outcome was significantly different. Multivariate analysis confirmed MCAAI [7.027 (2.56–19.28), p = 0.000] as the most significant predictor of poor outcomes whereas MIV was not significant [OR, 0.99 (0.99–01.00), p = 0.594]. Other significant independent predictors were age ≥ 55 years 12.14 (2.60–56.02), p = 0.001 and uncal herniation 4.98(1.53–16.19), p = 0.007]. Our data shows the contribution of CT infarction location in determining the functional outcome after DHC. Subgroups of patients undergoing DHC had different outcomes despite comparable infarction volumes.
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Maali, Laith, and Khader Abdelerahaman. "Abstract W P133: Combined Malignant MCA Plus ACA or PCA Infarcts Do Not Have a Worse Outcome Than Isolated Malignant MCA Infarcts in Patients One Year Following Decompressive Hemicraniectomy." Stroke 46, suppl_1 (February 2015). http://dx.doi.org/10.1161/str.46.suppl_1.wp133.
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Background: Malignant MCA infarction is a devastating disease associated with up to 80% mortality due to edema and herniation. Evidence from three European randomized trials show that decompressive hemicraniectomy (DHC) may improve functional outcomes in select patients. Adjacent cerebral territorial infarction often coincides with malignant MCA infarcts. This study compares the effects of isolated malignant MCA infarcts versus combined malignant MCA plus ipsilateral (ACA or PCA) infarcts on functional outcomes in patients surviving one or more years following DHC. We hypothesized that patients with no additional territorial involvement would have a better functional outcome. Methods: Retrospective analysis was performed on patients who underwent DHC for malignant MCA infarction from 03/2006 to 03/2012. Inclusion criteria include: Age 18-60, clinical and radiographical diagnosis of acute unilateral MCA stroke involving at least 50% of MCA territory, and DHC performed primarily to treat space occupying edema . Exclusion criteria include: Prestroke mRs of >2, life expectancy < 3 years, and death < 1 year after DHC. Patients were divided into two groups: (a) those with isolated MCA infarcts and (b) those with MCA combined with significant adjacent ipsilateral ACA or PCA involvement. Functional outcomes were calculated using the modified Rankin scale (mRs). The mean mRs was calculated for each group and the Wilcoxon-Mann-Whitney two tailed test was used to calculate statistical significance. Alpha level was set at p< 0.05. Results: A total of 26 patients met criteria. 20 patients had isolated MCA infarcts while 6 had combined MCA plus ACA or PCA infarcts. No statistical difference in functional outcome was observed between the isolated MCA group (x - =3.6) and the combined MCA group (x - =3.83) (p value=0.614). Conclusion: In this retrospective study, patients surviving one year after their DHC did not demonstrate a worse functional outcome due to additional cerebral territorial co-infarction. These findings argue against a major negative influence of combined infarctions on functional outcome compared to previous limited studies. Larger studies are needed to verify these results and to better assess criteria for ideal patient selection for DHC.
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Ahmadvand, Ardavan, Hamidreza Seifmanesh, Maryam Ghandali, Ali Afrasiabi, Vida Tajiknia, and Mahtab Amoujani. "A review on covid-19 and acute ischemic stroke, malignant cerebral edema & decompressive hemicraniectomy: A perfect storm; tackling this crisis by understanding it." Journal of Clinical Images and Medical Case Reports 2, no. 5 (October 29, 2021). http://dx.doi.org/10.52768/2766-7820/1388.
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Since the world was hit by novel coronavirus pandemic, so many challenges for all healthcare providers have been arisen. It is safe to say that no specialty was singled out in the matter of different complication from this viscous covid-19 situation and neurologists and neurosurgeon were no different. There are some studied reporting neurological complication associated with coronavirus infections but when it comes to life threatening and acute neurological complications such as strokes and malignant cerebral edema the data is scant. Here we are going to review the possible pathophysiology of this phenomenon, the relationship between covid-19 and acute ischemic stroke and malignant cerebral edema by taking a closer look at current data regarding this matter. Keywords: covid-19; acute ischemic stroke; malignant cerebral edema; covid-19 associated neurological complications. Abbreviations: DHC: Decompressive Hemicraniectomy; ELVO: Emergent Large Vessel Occlusion; MCE: Malignant Cerebral Edema.
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Topiwala, Karan K., Margy E. McCullough-Hicks, Soren Christensen, and Gregory W. Albers. "Abstract 127: Anatomical Predictors Of Malignant Cerebral Edema Using Voxel-based Lesion Symptom Mapping." Stroke 53, Suppl_1 (February 2022). http://dx.doi.org/10.1161/str.53.suppl_1.127.
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Introduction: Prior publications indicate an increased risk of developing malignant cerebral edema in acute ischemic stroke patients with temporal lobe involvement. We examined on a voxel-by-voxel basis whether topographic locations of baseline diffusion and perfusion weighted MRI lesions could predict subsequent need for treatment of malignant cerebral edema with either decompressive hemicraniectomy (DHC) or hyperosmolar therapy (HT). Methods: We used a registry of 898 patients evaluated for acute treatment for suspected large vessel occlusion (LVO) stroke. Fifty-nine cases, receiving either DHC and/or HT and having sufficient data for evaluation, were manually matched with 59 controls for age, lesion size, and Thrombolysis in Cerebral Infarction (TICI) score. Binary masks of ADC + Tmax >6s lesions generated from automated RAPID software output were created. Lesions were co-registered to standard MNI atlas space. Voxel-based lesion symptom mapping (Version 2.55) was used to generate statistical maps of lesion contribution to malignant cerebral edema formation. Maps were thresholded to P<0.01 on basis of cluster size and permutation method. Hemispheres were combined to increase statistical power. Results and Conclusions: 118 patients were analyzed. After controlling for age, TICI score, and lesion volume, only punctate regions of the parieto-occipital lobe were found to be mildly predictive of the need for either DHC or HT (T-scores 2.5-3, p<0.01). There does not appear to be any significant topographic region of the brain involved on baseline diffusion-perfusion MRI that predicts subsequent need for treatment of malignant cerebral edema in patients with LVO stroke.
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Sulakvelidze, Nika, Adam G. Kelly, Thanh G. Ton, Kyra J. Becker, and Claire J. Creutzfeldt. "Abstract T MP87: Information Framing And Decision-making After Malignant Middle Cerebral Artery Stroke." Stroke 46, suppl_1 (February 2015). http://dx.doi.org/10.1161/str.46.suppl_1.tmp87.
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Background and Objective: In patients with malignant infarction of the middle cerebral artery (MCA), decompressive hemicraniectomy (DHC) reduces mortality and improves outcome but leaves many survivors severely disabled. In deciding whether to undergo this surgery, patients and surrogates look to providers for relevant prognostic information to help make treatment decisions based on their personal values. The goal of this study is to explore whether the way treatment information is framed influences decision-making regarding DHC. Methods: Ambulatory patients and their family members in hospital outpatient waiting rooms were recruited for this voluntary survey. Subjects were randomized to 1 of 5 different videos of a physician discussing treatment options for their loved one with a hypothetical acute malignant MCA ischemic stroke, each video with a different presentation format (positive or negative framing, reporting results in absolute or relative proportions, graphical display). Subjects were then asked to indicate their treatment decisions and to provide basic demographic data. Results: Fifty-three subjects were enrolled in the study, the majority of whom were insured (47; 88.7%), white (40; 78.4%) and independent (33; 64.7%). Half were 51 years or older (27; 50.9%) and had an income less than $50,000 annually (50.9%). Randomization arms did not differ according to age (p=0.5), functional status (p=0.3), income (p=0.9), insurance type (p=0.4) or race (p=0.8). Marital status differed slightly between arms (p=0.06). Controlling for marital status, subjects were most likely to choose surgery for their loved one (OR 6.9, 95% CI: 0.6, 77.8) after viewing video B (positive framing, relative risk reduction) and least likely (OR 0.8, 95% CI: 0.1-5.5) after viewing video C (negative framing, relative risk reduction) compared to those in the graphical group. Conclusions: Information framing may influence surrogate decision-making for DHC after malignant MCA ischemic stroke. Clinicians should consider this influence when counseling patients; formal decision aids or other methods to present results in a more standardized fashion may help mitigate these effects.
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Abburi, Nandini, Andrea Sterenstein, Hannah Breit, Sarah Song, Sayona John, Lauren Koffman, and Ivan Da Silva. "Abstract TP123: Automated Pupillometry In Large Hemispheric Infarctions And Effects On Therapeutic Interventions - A Retrospective Analysis." Stroke 53, Suppl_1 (February 2022). http://dx.doi.org/10.1161/str.53.suppl_1.tp123.
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Background: Cerebral edema is a complication of large hemispheric infarctions (LHI), and automated pupillometry (AP) may be used to monitor for worsening cerebral edema. We hypothesized that AP may recognize earlier clinical deterioration and lead to earlier interventions, ultimately improving outcomes. Methods: This is a retrospective study of acute ischemic stroke patients admitted to a tertiary care hospital from 1/2012-12/2019, with admission imaging of ≥2/3 MCA territory with or without other territory involvement. Patients with AP documented every 4 hours were compared to patients admitted before AP was utilized (2012-2015). Neurologic pupil index (NPi) value <3 and a difference of >0.7 between eyes were recorded along with clinical change, defined as Glasgow coma scale (GCS) decrease of >2. Demographics and hospitalization data were recorded; including mechanical ventilation (MV), hyperosmolar therapy, decompressive hemicraniectomy (DHC), and mortality. Logistic regression was used for association measures. Results: Total of 77 patients were in the AP group (mean age 60, 55% females, mean admission NIHSS was 22, and mean admission GCS 9) and 169 patients in the non-AP group (mean age 64, 55% females, mean admission NIHSS 21, and mean GCS 10.4). Admission GCS was significantly lower in the AP group (p=0.04). There was higher use of MV in the AP group (54 patients, 70%), vs 88 (52%) in the non-AP group (p=0.0084). Hyperosmolar therapy was used more in AP patients (79%), vs 55% in the non-AP group (p=0.0004). There was a trend towards higher rates of DHC in the AP group (35%) compared to the non-AP group (24%), but not significant. Mortality rate was 37% in both groups, and there was no difference in mean discharge modified Rankin scale (mRS). Conclusion: More patients in the AP group were treated with hyperosmolar therapy and underwent DHC, suggesting use of AP may have triggered more therapeutic interventions. The patients in which AP was utilized seemed more critically ill on admission, based on GCS and need for MV; however, the mortality rate and discharge mRS were not significantly different. Prospective studies may determine if using AP in LHI patients would lead to earlier intervention, ultimately improving mortality and morbidity.
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Sun, Wenzhe, Guo Li, Yang Song, Zhou Zhu, Zhaoxia Yang, Yuxi Chen, Jinfeng Miao, et al. "A web based dynamic MANA Nomogram for predicting the malignant cerebral edema in patients with large hemispheric infarction." BMC Neurology 20, no. 1 (September 29, 2020). http://dx.doi.org/10.1186/s12883-020-01935-6.
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Abstract Background For large hemispheric infarction (LHI), malignant cerebral edema (MCE) is a life-threatening complication with a mortality rate approaching 80%. Establishing a convenient prediction model of MCE after LHI is vital for the rapid identification of high-risk patients as well as for a better understanding of the potential mechanism underlying MCE. Methods One hundred forty-two consecutive patients with LHI within 24 h of onset between January 1, 2016 and August 31, 2019 were retrospectively reviewed. MCE was defined as patient death or received decompressive hemicraniectomy (DHC) with obvious mass effect (≥ 5 mm midline shift or Basal cistern effacement). Binary logistic regression was performed to identify independent predictors of MCE. Independent prognostic factors were incorporated to build a dynamic nomogram for MCE prediction. Results After adjusting for confounders, four independent factors were identified, including previously known atrial fibrillation (KAF), midline shift (MLS), National Institutes of Health Stroke Scale (NIHSS) and anterior cerebral artery (ACA) territory involvement. To facilitate the nomogram use for clinicians, we used the “Dynnom” package to build a dynamic MANA (acronym for MLS, ACA territory involvement, NIHSS and KAF) nomogram on web (http://www.MANA-nom.com) to calculate the exact probability of developing MCE. The MANA nomogram’s C-statistic was up to 0.887 ± 0.041 and the AUC-ROC value in this cohort was 0.887 (95%CI, 0.828 ~ 0.934). Conclusions Independent MCE predictors included KAF, MLS, NIHSS, and ACA territory involvement. The dynamic MANA nomogram is a convenient, practical and effective clinical decision-making tool for predicting MCE after LHI in Chinese patients.
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Creutzfeldt, Claire J., Glenn B. Schubert, David L. Tirschwell, WT Longstreth, and Kyra J. Becker. "Abstract 155: Risk of Seizures after Malignant MCA Stroke and Decompressive Hemicraniectomy." Stroke 43, suppl_1 (February 2012). http://dx.doi.org/10.1161/str.43.suppl_1.a155.
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Background Post-stroke seizures (PSS) have a devastating effect on morale and may further impair an already compromised quality of life. The reported incidence of PSS is 5-12%, but may be higher in patients with malignant MCA stroke requiring decompressive hemicraniectomy. Seizure prophylaxis for stroke survivors is not recommended, and little guidance exists about the use of prophylactic antiepileptic drugs (AEDs) after neurosurgical procedures. We aimed to determine the incidence of seizures after hemicraniectomy in stroke survivors and to identify risk factors for development of seizures after stroke. Via telephone interview, we explored patients own experience after their stroke. Methods We reviewed charts of patients aged 18-99 with malignant MCA infarction who underwent decompressive hemicraniectomy from Jan 1, 2002 to Dec 31, 2008. We looked for seizures that occurred after their stroke and for clinical and imaging factors related to those. All patients who consented to a telephone interview were contacted to inquire about seizure history. Seizure-free survival analysis was used, with log rank testing for associations. Results We identified 38 patients, mean follow-up time was 504 days (IQR 140-857). Nearly half of patients suffered a seizure (18/38) and the seizures were difficult to control in 9/18. Four patients suffered their first seizure during initial hospitalization. For 14/18, the first seizure occurred after or around cranioplasty and mostly at home. Perioperative seizure prophylaxis was variable and did not influence seizure occurrence. Older age showed a trend towards increased seizure risk (log rank p=.09). Neither gender, race, severity, location or hemorrhagic transformation were associated with development of post-stroke seizures. Modified Rankin Scale score (mRS) at discharge was 4 or above in all patients. By last follow-up, 17/38 patients had a mRS of 3 or better. Patients who suffered a seizure did not feel well prepared for the possibility of PSS, and for some the seizures were considered a major setback. Among those who responded to the questionnaire (n=14, 12 had seizures), all would have wanted to know whether or not they were at high risk for developing PSS, and would have opted to take anti-epileptic medications for seizure prophylaxis. Conclusions The frequency of seizures after malignant MCA stroke requiring decompressive hemicraniectomy is higher than expected, and the seizures often difficult to control.