Decompressive Hemicraniectomy in Malignant Middle Cerebral Artery Infarction: The ‘Real World' Beyond Studies

Abstract

Background: Decompressive hemicraniectomy (DHC) is life-saving in patients with malignant middle cerebral artery infarction (MMI), but outcome, perspectives and complications after DHC in daily practice are largely unknown. Methods: From 2008 until 2014, we extracted patient's characteristics as well as complications from our database for patients with MMI who underwent DHC. Additionally, we analysed medical records from the different rehabilitation steps. Results: We identified 48 consecutive patients (mean 57 years, 21 male, 41.7% >60 years) with MMI who underwent DHC. The decision for DHC was made on an individual basis, including patients without impaired consciousness or stroke onset >48 h. In-hospital patients achieved only marginal clinical improvement. Seventy-five percent attended an early-rehabilitation, 44% achieved post-stroke rehabilitation and 6% carried on late-stage rehabilitation. In all, 45.5% returned home after rehabilitation. In-hospital mortality was 14.6%, overall mortality was 16.7%. Surviving patients (78.9%) had a modified Rankin Scale of 4-5. Frequent neurologic complications were symptomatic epilepsy and delirium. Following DHC/bone-flap-reimplantation, wound-healing disorders, epidural hematoma and wound infections were major surgery-related complications. Pulmonary infections were frequent in the acute-phase and urinary tract infections were predominant in the late-phase. Conclusions: DHC is a life-saving technique in patients with MMI, but complications are frequent, were underestimated in randomized clinical trials and may worsen the functional outcome.

A Scoping Review of the Incidence, Predictors, and Outcomes of Delirium Among Critically Ill Stroke Patients

“…Only 3 studies reported anatomic stroke subtypes 18,30,31. Only 4 reported stroke severity 18,22,32,33. These 4 used the National Institutes of Health Stroke Scale (NIHSS), with scores ranging from 9 to 19 and mean NIHSS scores reported as 9,22 11,18 14,32 and 19 33…”

Delirium in neurosurgery: a systematic review and meta-analysis

“…A total of 4290 studies were screened on the title/abstract. Eventually, 47 studies were assessed full text, of which 27 excluded: delirium diagnosis not reproducible (n s (number of studies) = 9), [20][21][22][23][24][25][26][27][28] full text not found (n s = 3), [29][30][31] duplicate (n s = 3), [18,32] paediatric patients (n s = 1) [33], overlapping populations (n s = 3), [4,34,35] no delirium assessment (n s = 1), [36] no original data (n s = 2) [37,38] and an unclear number of patients undergoing intracranial surgery (n s = 5) [39][40][41][42][43]. Finally, 20 paper were included in the qualitative analysis and 18 papers in the quantitative analysis (n p (number of patients) = 5083).…”

Cerebral Edema in Patients with severe Hemispheric Syndrome: Incidence, Risk Factors, and Outcomes—Data from SITS-ISTR

“…However, in a real-world setting, patients who undergo hemicraniectomy present frequently with complications that were underestimated in randomized clinical trials and may worsen the functional outcome, with 80% of survivors completely dependent (mRS 4-5). 20 Recently, new guidelines on CED management in neurocritical care patients have been published. 21 For acute treatment, they suggest using either hypertonic sodium solutions or mannitol for the initial management of CED in patients with acute ischemic stroke (conditional recommendation, low-quality evidence), although neurological outcomes appear to be not affected.…”

“…There is continued uncertainty about the benefit and risks of surgical decompression in patients with space-occupying hemispheric infarction if performed after the first 48hours. However, in a real-world setting, patients who undergo hemicraniectomy present frequently with complications that were underestimated in randomized clinical trials and may worsen the functional outcome, with 80% of survivors completely dependent (mRS 4–5) [ 20 ].…”