Background: Decompressive craniectomy (DC) significantly reduces mortality in large territory ischemic strokes that develop intractable cerebral edema. However, evidence for functional benefit remains sparse and contradictory. Objective: This study aimed to assess cut-off value for predictor outcomes of early DC. Methods: We conducted a prospective, observational cohort study from December 2016 to June 2021. Patients were screened for ischemic stroke involving the middle cerebral, internal carotid artery or both using the National Institutes of Health Stroke Scale score. All patients underwent DC. Multivariate analysis was performed for an array of clinical variables in relation to functional outcomes according to the modified Rankin Scale (mRS) and Pearson’s correlation coefficient analysis. Clinical outcome was assessed after 3- and 6-month follow-up. Results: In total, 243 patients were included in this study. Age ≤71 years (AUC=0.955, p <0.001 accuracy 89.7%), onset to DC ≤9 hours (AUC=0.824, p <0.001 accuracy 78.8%), volume of infarction ≤155 cm3 (AUC=0.939, p <0.001 accuracy 93.6%) and the Alberta Stroke Program Early CT Score or ASPECT score ≥6 (AUC = 1, p <0.001 accuracy 100%) were significantly associated with good clinical outcomes in early DC (mRS 0 to 3). Conclusion: Among patients with large territory ischemic strokes undergoing early DC, age ≤71 years, onset to DC ≤9 hours, volume of infarction ≤155 cm3 and ASPECT score ≥6 was significantly associated with good clinical outcomes. All prognostic factors in early DC correlated well with functional outcomes at 6 months which could be used to predict outcome, and consider clinical indications and informed postoperative complications among patients with large territory ischemic stroke.
Background: Burst suppression are widely used in case of refractory increased intracranial pressure for deep state of brain inactivation. Inhaled sevoflurane via the anesthetic conserving device could be useful for the sedation of patients in the intensive care unit (ICU), but prospective studies have been small study. Case report: A 53-year-old male patient with confusion, not follow to command and status epilepticus had been hospitalized and diagnosed glioblastoma multiforme at left temporal lobe. By the time initial therapy had begun with dexamethasone and anti-epileptic drug, the symptoms had improved. The patient was performed craniotomy with tumor removal during intra-operative found intractable cerebral edema and changed operation to decompressive craniectomy, in post-operative period after increased dosage of propofol and midazolam to control intracranial pressure, patient developed hypotension, then norepinephrine was titrated to maintain mean arterial pressure more than 65 mmHg and used inhaled sevoflurane to decrease dose propofol for maintain hemodynamics then during 5 day usage inhaled sevoflurane, norepinephrine could wean off and Glasgow coma scale was improve. Follow up brain EEG at 1st week showed no epileptiform discharge, antiepileptic drug could de-escalated and CT scan showed no refractory cerebral edema or hemorrhage. Ventilator was weaned off and the patient was transfer to step down ward. Conclusion: When managing intractable cerebral edema patient with inhaled sevoflurane showed that lower opioid dose intensity, promote resolving from seizures or status epilepticus, decrease dose of vasopressor to maintain hemodynamics and no adverse events supported the use of inhaled sevoflurane via the anesthetic conserving device in this patient who have clinical need for burst suppression.
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