Factors affecting the outcome of decompressive craniectomy for large hemispheric infarctions: a prospective cohort study

Kılınçer, Cumhur; Asıl, Talip; Utku, Ufuk; Hamamcıoğlu, Mustafa Kemal; Turgut, Nilda; Hiçdönmez, Tufan; Şimşek, Osman; Ekuklu, Galip; Çobanoğlu, Sebahattin

doi:10.1007/s00701-005-0493-7

Cited by 98 publications

(91 citation statements)

References 20 publications

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“…Several studies failed to find a significant improvement in outcome after DH in patients with such infarctions. 17,32,34 Our results show that functional outcome is unlikely to improve in these patients even after DH, but the survival of these patients should be highlighted, suggesting decompression's positive effect on mortality in patients with malignant ICA infarction. At 90 days following presentation, 75.9% of patients with a dominant-hemisphere infarction had poor outcome compared to 53.2% of patients with nondominanthemisphere involvement.…”

Section: Discussionmentioning

confidence: 71%

“…This is related to an increased mass effect and risk of brain herniation with compression of vital structures and hemodynamically, higher impairment of autoregulation. 1,17 Decompressive hemicraniectomies for MCA-and ICA-territory infarcts were included in this study. Acute ICA-territory infarctions usually have a poorer prognosis than MCA-territory infarction, and cerebral edema is more severe.…”

Section: Discussionmentioning

confidence: 99%

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

Daou

Kent

Montaño

et al. 2016

JNS

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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...

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Section: Discussionmentioning

confidence: 71%

Section: Discussionmentioning

confidence: 99%

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

Daou

Kent

Montaño

et al. 2016

JNS

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“…Additional prognostic considerations should include preexisting radiographic and neurologic signs of herniation and total infarct volume. 7,23 There is no evidence that laterality (dominant vs nondominant hemispheric infarction) affects long-term outcome, although severe language deficits may be considered unacceptable quality of life. 30,31 This meta-analysis has multiple limitations.…”

Section: Discussionmentioning

confidence: 99%

“…[2][3][4] Both nonrandomized and randomized controlled trials (RCTs) suggest that DC is most effective within 48 hours of stroke onset (early DC), 2,3,5,6 but despite decreased mortality, survivors often have poor functional outcomes secondary to stroke severity. 2,7 In 2007, a landmark interim pooled analysis of 3 RCTs demonstrated improved functional outcomes, defined as modified Rankin Scale (mRS) scores 0-3, for MCI patients treated with early DC. 6 However, this morbidity benefit was not present upon completion of the trials 5,8,9 ; nor has it been demonstrated in subsequent RCTs, 10,11 which employed a less stringent definition of acceptable functional outcome (mRS 0-4) with poor generalizability.…”

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confidence: 99%

Early decompressive craniectomy for malignant cerebral infarction

2016

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Background: Decompressive craniectomy (DC) is an aggressive life-saving surgical intervention for patients with malignant cerebral infarction (MCI). However, DC remains inconsistently and infrequently utilized, primarily due to enduring concern that increased survival occurs only at the cost of poor functional outcome. Our aim was to clarify the role of DC performed within 48 hours (early DC) for patients with MCI, including patients aged .60 years. Methods: We performed a meta-analysis of all available randomized controlled trials comparing early DC to best medical care for MCI. Studies were identified through literature searches of electronic databases including PubMed, EMBASE, and Scopus. We employed a Mantel-Haenszel fixed effects model to assess treatment effect on dichotomized modified Rankin Scale (mRS) outcomes at 12 months. Results: A total of 289 patients from 6 randomized controlled trials comparing early DC to best medical care were included. Early DC resulted in an increased rate of excellent outcomes, defined as mRS #2 (relative risk [RR] 2.81, 95% confidence interval [CI] 1.01-7.82, p 5 0.047), and favorable outcomes, defined as mRS #3 (RR 2.06, 95% CI 1.25-3.40, p 5 0.005). Early DC also increased the rate of survival with unfavorable outcomes, defined as mRS 4-5 (RR 3.03, 95% CI 1.98-4.65, p , 0.001). Conclusions: Early DC increases the rate of excellent outcomes, i.e., functional independence, in addition to favorable and unfavorable outcomes; however, these findings must be interpreted within the context of patients' goals of care. We have developed a clinical decision algorithm that incorporates goals of care, which may guide consideration of early DC for MCI in clinical practice. Neurol Clin Pract 2016;6:433-443 M alignant cerebral infarction (MCI) refers to large-volume ischemic strokes involving the middle cerebral artery territory, which are complicated by lifethreatening cerebral edema. 1 Managed medically, MCI carries a mortality rate of 80%. 1,2 Decompressive craniectomy (DC), the surgical removal of a portion Editorial, page 381

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“…Supratentorial yerleşimli beyin damar hastalıklarından (malign orta serebral arter (OSA) infarktı, geniş kortikal ve lober hematomlar) sonra gelişen beyin ödemi unkal ve transtentorial herniasyona, infratentorial yerleşimli beyin damar hastalıklarından (serebellar infarkt, serebellum ve beyin sapı hematomları) hidrosefali, beyin sapı basısı, transforaminal tonsiller herniasyon gibi mortaliteyi arttırıcı klinik tablolara neden olurlar (3). Hangi hastaların dekompresyon cerrahisinden daha fazla fayda göreceğini inmenin başlangıcında tahmin etmek oldukça zor olmasına rağmen genel olarak kabul edilen radyolojik ve klinik olarak malign ödem için yüksek riskli olan hastalarda medikal tedaviye rağmen kitle etkisinde artış devam etmekteyse, dekompresyon cerrahisi yaşam kurtarıcı bir tedavi seçeneği olmaktadır (4,5). Bu yazıda, merkezimizde dekompresyon cerrahisi uygulanan akut inme olguları sunularak, operasyondan sonraki izlem süreleri, sağ kalım oranları ve dizabilite skorları son literatür bilgileriyle birlikte karşılaştırıldı ve tartışıldı.…”

Section: ) Intraserebral Hemoraji (İh) %15 (%10-15)unclassified

Decompressive surgery in stroke

Kunt¹,

Yaka²,

Öztürk³

et al. 2014

Türk Beyin Damar Hast Derg

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ÖZETAMAÇ: Merkezimizde dekompresyon cerrahisi uygulanan akut inme olgularını sunmak ve sonuçları son literatür bilgileriyle birlikte tartışmak. GEREÇ ve YÖNTEM: Ağustos 2010 -Şubat 2012 tarihleri arasında Dokuz Eylül Üniversite Hastanesi Nöroloji servisinde izlenen ve 1-11 gün içinde medikal tedaviye rağmen klinik progresyon gelişen 4 kadın, 4 erkek toplam 8 hastaya dekompresyon cerrahisi uygulandı. Hastaların altısına geniş hemikraniektomi + duraplasti, ikisine suboksipital kraniektomi operasyonu yapıldı. BULGULAR: Orta serebral arter enfarktı olan bir olgu, gelişen yaygın arka sistem enfarktı nedeniyle, bir olgu ise operasyon sonrası gelişen enfeksiyon nedeniyle kaybedildi. Postoperatif izlem süresi 35-95 gün olan diğer hastalarda mRS; iki hastada 2, iki hastada 4 ve birer hastada 3 ve 5 olarak değişiklik gösterdi. SONUÇ: Olgu sayımız sınırlı olsa da, sonuçlarımız, cerrahi tedavinin hem mortaliteyi azalttığı, hem de bazı hastalarda fonksiyonel iyileşmeyi sağladığını göstermektedir. Anahtar Sözcükler: İnme, cerrahi. DECOMPRESSIVE SURGERY IN STROKEABSTRACT OBJECTIVE: Our aim was to present the acute stroke cases carried out decompression surgery and to discuss our results with literature. MATERIAL and METHODS: Decompression surgery was carried out in 8 patients including 4 women and 4 men who followed and clinically progressed despite the medical treatment within 1-11 days in Dokuz Eylül University Hospital Neurology Clinic between August 2010 and February 2012. Extensive hemicraniectomy+duraplasty were performed in 6 patients and suboccipital craniectomy was performed in 2 patients. RESULTS: One patient with middle cerebral artery infarction died because of widespread posterior system infarction and additionally one patient died due to infection following operation. In remaining patients followed for 35 to 95 days postoperatively, mRS was change 2 points in 2 patients, 4 points in 2 patients, 3 points in 1 patient and 5 points in 1 patient. CONCLUSION: Although sample size was limited, our results were showed that surgical treatment reduces mortality and helps to provide the functional recovery in some patients.

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Factors affecting the outcome of decompressive craniectomy for large hemispheric infarctions: a prospective cohort study

Cited by 98 publications

References 20 publications

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

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

Early decompressive craniectomy for malignant cerebral infarction

Decompressive surgery in stroke

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