ORACLE Stroke Study

Honeybul, Stephen; Ho, Kwok M.; Blacker, David

doi:10.1227/neu.0000000000001115

Cited by 40 publications

(8 citation statements)

References 29 publications

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“…These findings are in concordance with a similar investigation performed amongst Australian healthcare workers in which only 8.7% of participants regarded an mRS of 4–5 as acceptable [ 14 ]. There were similar finding in a survey that assessed opinion in an online survey amongst North American and Asian neurologists, neurosurgeons and neurointensivists [ 22 ], and in a study that investigated opinion in patients who had previously suffered a stroke (and presumably thereby has first-hand experience of the consequences of stroke).…”

Section: Discussionsupporting

confidence: 92%

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A study of the opinions of Swedish healthcare personnel regarding acceptable outcome following decompressive hemicraniectomy for ischaemic stroke

Olivecrona

Honeybul

2017

Acta Neurochir

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BackgroundDecompressive hemicraniectomy (DC) is an established lifesaving treatment for malignant infarction of the middle cerebral artery (mMCAI). However, surgical decompression will not reverse the effects of the stroke and many survivors will be left severely disabled. The objective of this study was to assess what neurological outcome would be considered acceptable in these circumstances amongst Swedish healthcare workers.MethodHealthcare workers were invited to participate in a presentation that outlined the pathophysiology of mMCAI, the rationale behind DC and outcome data from randomised controlled trials that have investigated efficacy of the procedure. They were then asked which neurological outcome would they feel to be acceptable based on the modified Rankin Score (mRS) and the Aphasia Handicap Scale (AHS). Information regarding sex, age, marital status, relatives, religion, earlier experience of stroke and occupation was also collected.ResultsSix hundred and nine persons participated. The median accepted mRS was 3. An mRS of 4 or 5 was perceived to be acceptable by only 30.5% of participants. Therefore the most likely outcome, based on the results of the randomised controlled trials, would be unacceptable to most of the participants [OR 0.39 (CI, 0.22–0.69)]. The median accepted AHS was 3. A worst language outcome of restricted autonomy of verbal communication (AHS 3) or better would be accepted by 44.6%.ConclusionsThis study has highlighted the ethical problems when obtaining consent for DC following mMCAI, because for many of the participants the most likely neurological outcome would be deemed unacceptable. These issues need to be considered prior to surgical intervention and the time may have come for a broader societal discussion regarding the value of a procedure that converts death into survival with severe disability given the attendant financial and healthcare resource implications.

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Section: Discussionsupporting

confidence: 92%

“…The questionnaire was similar to that used by Honeybul et al [ 14 ] in a previous study. (Questionnaire available as supplemental data.)…”

Section: Methodsmentioning

confidence: 99%

A study of the opinions of Swedish healthcare personnel regarding acceptable outcome following decompressive hemicraniectomy for ischaemic stroke

Olivecrona

Honeybul

2017

Acta Neurochir

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“…Although DHC has proven to significantly reduce mortality, the degree of disability of its survivors has provoked an intense discussion in the literature [22, 23, 24]. This important question has been overlooked because most studies evaluated disability based exclusively on the Rankin scale.…”

Section: Discussionmentioning

confidence: 99%

High Risk of Seizures and Epilepsy after Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke

Brondani

Almeida

Cherubini

et al. 2017

Cerebrovasc Dis Extra

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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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“…Although the indications and efficacy of DC remain controversial, a large number of DC procedures are now performed worldwide and so many patients undergo subsequent CP. 1,27–31 …”

Section: Discussionmentioning

confidence: 99%

Early or late cranioplasty following decompressive craniotomy for traumatic brain injury: A systematic review and meta-analysis

Zheng

Spreckelsen

et al. 2018

J Int Med Res

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ObjectiveTo evaluate the effectiveness of early (<3 months) cranioplasty (CP) and late CP (>3 months) on post-operative complications in patients receiving decompressive craniotomy (DC) for traumatic brain injury (TBI).MethodsThe Cochrane Library, PubMed and EMBASE databases were systematically searched for studies published prior to May 21, 2017. A meta-analysis examined post-operative overall complication rates, infection rates, subdural fluid collection and operating times according to early and late CP.ResultsOf the initial 1675 references, five studies, all cohort, involving a total of 413 patients, were selected for the review. There was no difference between early and late CP in post-operative overall complication rate (RR=0.68, 95%CI [0.36, 1.29]) and the post-operative infection rate (RR=0.50, 95%CI [0.20, 1.24]) in patients receiving DC for TBI. However, there was a significant difference in post-operative subdural effusion (RR=0.24, 95%CI [0.07, 0.78]) and mean operative time (mean difference = −33.02 min, 95%CI [−48.19, −17.84]) both in favour of early CP.ConclusionsNo differences were found between early and late CP in post-operative overall complications and procedural related infections in patients receiving DC for TBI, but early CP reduced the complication of subdural effusion and the mean operating time. These findings need to be confirmed by large, randomised controlled trials.

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ORACLE Stroke Study

Abstract: DESTINY, Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral ArterymRS, modified Rankin Scale.

Cited by 40 publications

References 29 publications

A study of the opinions of Swedish healthcare personnel regarding acceptable outcome following decompressive hemicraniectomy for ischaemic stroke

A study of the opinions of Swedish healthcare personnel regarding acceptable outcome following decompressive hemicraniectomy for ischaemic stroke

High Risk of Seizures and Epilepsy after Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke

Early or late cranioplasty following decompressive craniotomy for traumatic brain injury: A systematic review and meta-analysis

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