Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial

Hofmeijer, Jeannette; Kappelle, L. Jaap; Algra, Ale; Amelink, G. J.; Gijn, J. van; Worp, H. Bart van der

doi:10.1016/s1474-4422(09)70047-x

Cited by 799 publications

(735 citation statements)

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“…Cerebral edema in the neurointensive care setting can occur with a heterogenous group of neurological diseases, which typically fall under the categories of metabolic [1, 2], infectious [3], neoplastic [4], cerebrovascular [5][6][7], and traumatic [8,9] brain injury. Irrespective of the inciting process, cerebral edema results in the pathological accumulation of fluid in the brain's intracellular and extracellular spaces.…”

Section: Overview Of Perturbations In Brain Fluid Homeostasismentioning

confidence: 99%

“…Until recently, only case series and nonrandomized case-control studies suggested any benefit of decompressive craniectomy [39][40][41][42][43]. Several recent randomized controlled trials have demonstrated improved survival after decompressive craniectomy in certain stroke populations [6,[44][45][46]. These findings may have been influenced by the "early" timing of craniectomy in their protocols, potentially averting secondary brain damage associated with cerebral edema [47], although the inclusion of patients who may not have truly needed decompression also may have favorably influenced outcome.…”

Section: Osmotherapymentioning

confidence: 99%

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Novel Treatment Targets for Cerebral Edema

2012

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Cerebral edema is a common finding in a variety of neurological conditions, including ischemic stroke, traumatic brain injury, ruptured cerebral aneurysm, and neoplasia. With the possible exception of neoplasia, most pathological processes leading to edema seem to share similar molecular mechanisms of edema formation. Challenges to brain-cell volume homeostasis can have dramatic consequences, given the fixed volume of the rigid skull and the effect of swelling on secondary neuronal injury. With even small changes in cellular and extracellular volume, cerebral edema can compromise regional or global cerebral blood flow and metabolism or result in compression of vital brain structures. Osmotherapy has been the mainstay of pharmacologic therapy and is typically administered as part of an escalating medical treatment algorithm that can include corticosteroids, diuretics, and pharmacological cerebral metabolic suppression. Novel treatment targets for cerebral edema include the Na(+)-K(+)-2Cl(−) co-transporter (NKCC1) and the SUR1-regulated NC Ca-ATP (SUR1/TRPM4) channel. These two ion channels have been demonstrated to be critical mediators of edema formation in brain-injured states. Their specific inhibitors, bumetanide and glibenclamide, respectively, are well-characterized Food and Drug Administration-approved drugs with excellent safety profiles. Directed inhibition of these ion transporters has the potential to reduce the development of cerebral edema and is currently being investigated in human clinical trials. Another class of treatment agents for cerebral edema is vasopressin receptor antagonists. Euvolemic hyponatremia is present in a myriad of neurological conditions resulting in cerebral edema. A specific antagonist of the vasopressin V1A-and V2-receptor, conivaptan, promotes water excretion while sparing electrolytes through a process known as aquaresis.Keywords Cerebral edema . Hyponatraemia . Osmotherapy . NKCC1 . SUR1/TRPM4 . Vaptan . Glyburide Overview of Perturbations in Brain Fluid HomeostasisCerebral edema in the neurointensive care setting can occur with a heterogenous group of neurological diseases, which typically fall under the categories of metabolic [1, 2], infectious [3], neoplastic [4], cerebrovascular [5][6][7], and traumatic [8,9] brain injury. Irrespective of the inciting process, cerebral edema results in the pathological accumulation of fluid in the brain's intracellular and extracellular spaces. This occurs secondary to alterations in the complex interplay between 4 distinct fluid compartments within the cranium; fluid is present within: 1) the blood in the cerebral blood vessels, 2) the cerebrospinal fluid in the ventricular system and subarachnoid space, 3) the interstitial fluid of the brain parenchyma, and 4) the intracellular fluid of the neurons and glia. These fluid compartments are not isolated, and specific movements of solutes and water from one compartment to another occur under normal conditions. When dysregulation of this normally tightly controlled fluid balance...

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Section: Overview Of Perturbations In Brain Fluid Homeostasismentioning

confidence: 99%

Section: Osmotherapymentioning

confidence: 99%

Novel Treatment Targets for Cerebral Edema

2012

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“…There were 64 patients who were randomized, and in this study surgical decompression was not superior to best medical treatment with mRS at 1 year. The authors suggested a longer time to randomization and increase in stroke severity (based on median National Institutes of Health Stroke Scale of 24 in the HAMLET vs 21.5 in the DECIMAL study, and 22 in the DESTINY study of the medically treated patients), which may have explained their findings [67].…”

Section: Surgical Therapiesmentioning

confidence: 98%

“…Long-term safety and the role for hemicraniectomy was studied by the recent French DECIMAL [65], German DESTINY [66] and Dutch HAMLET [67] trials; and collectively evaluated by a pooled analysis [68]. The DECIMAL study [65] enrolled 38 patients with malignant middle cerebral artery infarction from 7 stroke centers and randomized them to receive standard medical therapy or hemicraniectomy plus standard medical therapy.…”

Section: Surgical Therapiesmentioning

confidence: 99%

Care of the Stroke Patient: Routine Management to Lifesaving Treatment Options

2011

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The management of the acute ischemic stroke patient spans the time course from the emergency evaluation and treatment period through to the eventual discharge planning phase of stroke care. In this article we evaluate the literature and describe what have become standard treatments in the care of the stroke patient. We will review the literature that supports the use of a dedicated stroke unit for routine stroke care which has demonstrated reduced rates of morbidity and mortality. Also reviewed is the use of glycemic control in the initial setting along with data supporting the use of prophylactic treatments options in order to aide in the prevention of life threatening medical complications. In addition, lifesaving treatments will be discussed in light of new literature demonstrating reduced mortality in large hemispheric stroke patients undergoing surgical decompressive surgery. Both medical and surgical treatment options are discussed and compared.

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“…In order to clearly define the indication for the surgical treatment and to decrease complications derived from DC in a university hospital in southern Brazil, a specific protocol for DC in the treatment of intracranial hypertension derived from ischemia of the MCA region has been implemented since 2007, in conjunction with the neurology department. Even though studies have demonstrated the efficacy of DC in patients presenting with malignant MCA infarction 5,6,7,8,9,10 , some resistance to its application still exists, particularly regarding the functionality of the patients who survive the acute event.The goals of the present study were to assess the mortality rates from the use of DC in the treatment of patients …”

mentioning

confidence: 99%

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

Bongiorni

Hockmuller

Klein

et al. 2017

Arq. Neuro-Psiquiatr.

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Objective: To assess, by Rankin scale, the functional disability of patients who had a malignant middle cerebral artery (MCA) ischemic stroke, who underwent decompressive craniotomy (DC) within the first 30 days. Methods: A cross-sectional study in a University hospital. Between June 2007 and December 2014, we retrospectively analyzed the records of all patients submitted to DC due to a malignant MCA infarction. The mortality rate was defined during the hospitalization period. The modified outcome Rankin score (mRS) was measured 30 days after the procedure, for stratification of the quality of life. Results: The DC mortality rate was 30% (95% CI 14.5 to 51.9) for the 20 patients reported. The mRS 30 days postoperatively was ≥ 4 [3.3 to 6] for all patients thereafter. Conclusion: DC is to be considered a real alternative for the treatment of patients with a malignant ischemic MCA infarction.Keywords: craniotomy; cerebral infarction; intracranial hypertension. RESUMOObjetivo: Avaliar a capacidade funcional de pacientes com acidente vascular cerebral isquêmico no território da artéria cerebral média (ACM) submetidos à craniotomia descompressiva (CD) no período de 30 dias pela escala de Rankin. Métodos: Estudo transversal em um hospital universitário. Entre junho de 2007 e dezembro de 2014, analisados retrospectivamente os registros de todos os pacientes submetidos a CD devido a enfarte maligno na ACM. A taxa de mortalidade foi definida durante o período de internação. O resultado da estratificação da qualidade de vida foi através da escala Rankin modificado (mRS) mensurado em 30 dias após o procedimento. Resultados: A taxa de mortalidade CD foi de 30% (IC 95% 14,5-51,9) para os 20 pacientes relatados. A mRS 30 dias de pós-operatório foi => 4 [3,3-6] para todos os pacientes. Conclusão: CD deve ser considerada uma alternativa real para o tratamento de pacientes com enfarte isquêmico no território da ACM.Palavras-chave: craniotomia; infarto cerebral; hipertensão intracraniana.A decompressive craniotomy (DC) has been a therapeutic option for an infarction of the middle cerebral artery (MCA) region. The goal of the surgical treatment is the reduction of the intracranial hypertension. The procedure is based on a fronto-parieto-temporal craniotomy, ipsilateral to the lesion, followed by plastic reconstruction of the dura mater, allowing immediate decompression of the brain 1,2,3,4,5 .Some complications, such as infection of the surgical area, temporal muscle hematoma with cerebral compression, intracerebral hemorrhage, or worsening of the neurological condition may follow DC 2,3,4 . In order to clearly define the indication for the surgical treatment and to decrease complications derived from DC in a university hospital in southern Brazil, a specific protocol for DC in the treatment of intracranial hypertension derived from ischemia of the MCA region has been implemented since 2007, in conjunction with the neurology department. Even though studies have demonstrated the efficacy of DC in patients presenting with ma...

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Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial

Cited by 799 publications

References 20 publications

Novel Treatment Targets for Cerebral Edema

Novel Treatment Targets for Cerebral Edema

Care of the Stroke Patient: Routine Management to Lifesaving Treatment Options

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

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