Decompressive hemicraniectomy: predictors of functional outcome in patients with ischemic stroke

Abstract

P atients presenting with large ischemic strokes may develop uncontrollable, progressive brain edema that puts them at risk for compression of brain parenchyma and cerebral herniation. 23 There are a limited number of therapeutic options, but research has shown that operative procedures, such as decompressive hemicraniectomy (DH), decrease patient mortality.32 Malignant infarction treated only by conservative approaches results in a mortality rate of 80% within the 1st week of the stroke. 15Edema that does not respond to medical treatment necessitates DH as a life-saving procedure. Studies have demonstrated that DH surgery can result in a reduction of mortality rate to 30% and, if decompression is performed within 24 hours of stroke onset, to 10%. 7,12,18,24,32 While DH imabbreviatioNs BMI = body mass index; DH = decompressive hemicraniectomy; DVT = deep vein thrombosis; ICA = internal carotid artery; IVC = inferior vena cava; MCA = middle cerebral artery; MI = myocardial infarction; MLS = midline shift; mRS = modified Rankin Scale; NIHSS = National Institutes of Health Stroke Scale; tPA = tissue plasminogen activator. obJective Patients presenting with large-territory ischemic strokes may develop intractable cerebral edema that puts them at risk of death unless intervention is performed. The purpose of this study was to identify predictors of outcome for decompressive hemicraniectomy (DH) in ischemic stroke. methods The authors conducted a retrospective electronic medical record review of 1624 patients from 2006 to 2014. Subjects were screened for DH secondary to ischemic stroke involving the middle cerebral artery, internal carotid artery, or both. Ninety-five individuals were identified. Univariate and multivariate analyses were performed for an array of clinical variables in relationship to functional outcome according to the modified Rankin Scale (mRS). Clinical outcome was assessed at 90 days and at the latest follow-up (mean duration 16.5 months). results The mean mRS score at 90 days and at the latest follow-up post-DH was 4. Good functional outcome was observed in 40% of patients at 90 days and in 48% of patient at the latest follow-up. The mortality rate at 90 days was 18% and at the last follow-up 20%. Univariate analysis identified a greater likelihood of poor functional outcome (mRS scores of 4-6) in patients with a history of stroke .66]; p = 0.017), peak midline shift (MLS) > 10 mm ]; p = 0.011), or a history of myocardial infarction ]; p = 0.04). Multivariate analysis demonstrated elevated odds of poor functional outcome associated with a history of stroke .05]; p = 0.008), MLS > 10 mm ; p = 0.007), a history of diabetes .88]; p = 0.01), delayed time from onset of stroke to DH (OR 1.32 [95% CI 1.02-1.72]; p = 0.037), and evidence of pupillary dilation prior to DH .51]; p = 0.04). Patients with infarction involving the dominant hemisphere had higher odds of unfavorable functional outcome at 90 days ]; p = 0.014), but at the latest follow-up, cerebral dominance was not significantly related to outc...

Efficacy of Occupational Therapy Task‐oriented Approach in Upper Extremity Post‐stroke Rehabilitation

“…Studies demonstrated that having a stroke affecting the dominant hand might be associated with unfavourable functional outcomes at the acute stage. However, in subacute and chronic phases, it is suggested that there is no significant difference in functional improvement among individuals with dominant or non‐dominant paralyses post‐stroke (Lima et al, ; Nam et al, ; Daou et al, ). Using client‐centred tools such as Canadian occupational performance measure (COPM), individuals post‐stroke tend to setup rehabilitation goals influenced by their stroke severity more than their handedness (Waddell et al, ).…”

Pupillary abnormalities in non-selected critically ill patients: an observational study

“…To the best of our knowledge, no previous study has reported the prevalence of PAs in this population. Our findings should be cautiously compared with those from previous studies that almost uniquely included neurosurgical patients (4)(5)(6)(7)(8)(9). The prevalence of PAs may vary according to the quality of the pupillary evaluation, which can be challenging at the bedside (2,(10)(11)(12)(13)(14).…”

“…This is probably mainly due to the high price of this technology. However, the high frequency of clinical PAs we detected in our study may help to justify the purchase of [9] Data are expressed as number [%].…”

Decompressive craniotomy for the treatment of malignant infarction of the middle cerebral artery: mortality and outcome

“…A Chinese study evaluated the effectiveness of DC in patients over 80 years of age, concluding that DC, even in patients in this age group, may increase the survival rate without severe compromise of functionality 18 . In a recent American study, involving more than 1,600 patients, the authors reported the results according to age as uni-and multivariate analysis, not taking into account this variable as a significant predictor of clinical outcome 20 .…”