Outcome Following Decompressive Hemicraniectomy for Malignant Cerebral Infarction

Honeybul, Stephen; Ho, Kwok M.; Gillett, Grant

doi:10.1161/strokeaha.115.010078

Cited by 29 publications

(13 citation statements)

References 26 publications

(25 reference statements)

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“…Being able to identify those patients at highest risk for MBE and therefore those who may particularly benefit from early DC is important. Previous studies have identified several risk factors for the development of MBE such as: initial National Institutes of Health Stroke Scale (NIHSS) score, Alberta Stroke Program Early CT Score (ASPECTS), collateral score (CS), clot burden score (CBS) and diffusion/perfusion parameters in magnetic resonance image (MRI) [ 8 – 12 ].That being said, no simple prediction score for the development of MBE has yet been developed. The aim of this study was to identify independent risk factors for the development of MBE in order to generate a simple, reliable prediction score based on strength of association of each independent risk factor.…”

Section: Introductionmentioning

confidence: 99%

A simple prediction score system for malignant brain edema progression in large hemispheric infarction

Bajgur

Kim

et al. 2017

PLoS ONE

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Malignant brain edema (MBE) due to hemispheric infarction can result in brain herniation, poor outcomes, and death; outcome may be improved if certain interventions, such as decompressive craniectomy, are performed early. We sought to generate a prediction score to easily identify those patients at high risk for MBE. 121 patients with large hemispheric infarction (LHI) (2011 to 2014) were included. Patients were divided into two groups: those who developed MBE and those who did not. Independent predictors of MBE were identified by logistic regression and a score was developed. Four factors were independently associated with MBE: baseline National Institutes of Health Stroke Scale (NIHSS) score (p = 0.048), Alberta Stroke Program Early Computed Tomography Score (ASPECTS) (p = 0.007), collateral score (CS) (p<0.001) and revascularization failure (p = 0.013). Points were assigned for each factor as follows: NIHSS ≤ 8 (= 0), 9–17 (= 1), ≥ 18 (= 2); ASPECTS≤ 7 (= 1), >8 (= 0); CS<2 (= 1), ≥2 (= 0); revascularization failure (= 1),success (= 0). The MBE Score (MBES) represents the sum of these individual points. Of 26 patients with a MBES of 0 to 1, none developed MBE. All patients with a MBES of 6 developed MBE. Both MBE development and functional outcomes were strongly associated with the MBES (p = 0.007 and 0.002, respectively). The MBE score is a simple reliable tool for the prediction of MBE.

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Section: Introductionmentioning

confidence: 99%

A simple prediction score system for malignant brain edema progression in large hemispheric infarction

Bajgur

Kim

et al. 2017

PLoS ONE

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“…1 The value of the procedure and appropriate indications are debated because of concerns regarding reducing mortality but increasing severe disability among those who undergo the procedure. [2][3][4] The utilization of the procedure has increased in United States over the years 5 ; however, no major change has been observed in response to publication of randomized clinical trials that demonstrate superiority of hemicraniectomy over conservative management in patients with ischemic stroke. 6 Although several trials have been completed, the small number of subjects recruited prevents conclusive assessment of the magnitude of benefits associated with hemicraniectomy in ischemic stroke patients.…”

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confidence: 99%

Hemicraniectomy versus Conservative Treatment in Large Hemispheric Ischemic Stroke Patients: A Meta-analysis of Randomized Controlled Trials

Qureshi

Ishfaq

Rahman

et al. 2016

Journal of Stroke and Cerebrovascular Diseases

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“…The senior author of the Australian study (S.H.) has frequently expressed a view that survival with an mRS of 4 should be categorised as unfavourable and this may (even unintentionally) have influenced the participants to give a negative response regarding this outcome [ 12 , 15 ]. Alternatively, the higher response in the current study may reflect cultural values intrinsic to the Swedish society where survival at any cost may be felt to be important.…”

Section: Discussionmentioning

confidence: 99%

“…The rationale for surgical decompression is that death due to tonsillar herniation is prevented and the reduction in mortality has been clearly demonstrated by recent randomised controlled trials [ 10 , 17 , 18 , 25 , 26 ]. However, unlike the endovascular techniques, surgical decompression will not reverse the effects of what is by definition a very extensive infarct and many patients will be left with significant neurological deficits [ 15 , 24 ]. Indeed, in the pooled analysis of the three European stroke trials, it was only possible to conclude that surgery improved clinical outcome by redefining the favourable category such that it included patients with a modified Rankin Scale (mRS) of 4 [ 25 ].…”

Section: Introductionmentioning

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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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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Outcome Following Decompressive Hemicraniectomy for Malignant Cerebral Infarction

Cited by 29 publications

References 26 publications

A simple prediction score system for malignant brain edema progression in large hemispheric infarction

A simple prediction score system for malignant brain edema progression in large hemispheric infarction

Hemicraniectomy versus Conservative Treatment in Large Hemispheric Ischemic Stroke Patients: A Meta-analysis of Randomized Controlled Trials

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

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