Functional impairment, disability, and quality of life outcome after decompressive hemicraniectomy in malignant middle cerebral artery infarction

Foerch, Christian; Lang, Josef; Krause, Jochen; Raabe, Andreas; Sitzer, Matthias; Seifert, Volker; Steinmetz, Helmuth; Kessler, Kirn R.

doi:10.3171/jns.2004.101.2.0248

Cited by 120 publications

(149 citation statements)

References 35 publications

(42 reference statements)

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“…Out of 30 enrolled patients 14 showed signs of herniation (dilated pupil), and the time point of surgery varied broadly from 13 to 235 h after stroke [25]. Likewise, these results are supported by a prospective study of Kilincer et al identifying sings of herniation as a prognostic factor for poor outcome [31], and by several retrospective trials [32,33,34]. Furthermore, in the studies of Skoglund et al (n = 18) and Chung et al (n = 24) 67 and 100% of patients, respectively, showed signs of herniation, leading to worse neurological outcomes compared to the results of the DECIMAL and DESTINY trials [8,9,35,36].…”

Section: Surgical Treatmentsupporting

confidence: 67%

Surgical Aspects of Decompression Craniectomy in Malignant Stroke: Review

Zweckberger¹,

Jüettler

Bösel

et al. 2014

Cerebrovasc Dis

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Background: Space-occupying malignant stroke of the middle cerebral artery (MCA) is associated with a high mortality rate of up to 80% under conservative treatment. Although there is convincing evidence that decompression craniectomy can significantly reduce mortality rate and improve neurological outcome in young patients (<60 years), many surgeons are still hesitant to recommend hemicraniectomy for stroke patients. Summary: This review addresses some major issues that appear to be an obstacle to decompression craniectomy, in particular, indicating surgery for patients >60 years or with infarcts of the dominant hemisphere. Furthermore, it emphasizes technical issues such as timing and size of the craniectomy, additional temporal lobectomy, and resection of the temporal muscle, as well as duraplasty and cranioplasty. According to the current literature, decompression craniectomy in older patients can increase survival without most severe disabilities, although, most survivors need assistance in most bodily needs. Involvement of the dominant hemisphere results in aphasia that might partly recover in younger patients, although, considering the neuropsychological deficits caused by infarctions of the nondominant hemisphere, involvement of the dominant hemisphere does not pose as a contraindication for decompression craniectomy. Furthermore, there is convincing evidence that surgery should be performed within 48 h after the onset of symptoms and the size of the craniectomy should be at least 12 cm as a minimum. An additional lobectomy or the resection of the temporal muscle, however, can only be part of individual treatment options. Conceding the weak evidence, it is recommended to close the dura by some form of a duraplasty avoiding cerebrospinal fluid leakages or scarring between the cortex and the scalp leading to injuries during reimplantation of the bone-flap. Complications associated with decompression surgery (hemorrhages, infections, ‘sinking skin-flap syndrome', cerebrospinal fluid leakages, hydrocephalus, seizures), with the infarction itself, or with those that occur during the ICU course (cardiac and pulmonary complications) appear acceptable and are mostly treatable, especially considering the fatal course of conservative treatment. Key Message: This review summarizes the current state of the literature about decompression craniectomy of patients with malignant stroke addressing, in particular, critical surgical issues, and thus, help surgeons to make decisions confidently for/or against performing surgery.

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Section: Surgical Treatmentsupporting

confidence: 67%

Surgical Aspects of Decompression Craniectomy in Malignant Stroke: Review

Zweckberger¹,

Jüettler

Bösel

et al. 2014

Cerebrovasc Dis

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“…Age impacted outcome, with older patients having worse outcomes. 986 The authors stressed, "The decision to perform decompressive surgery should, however, be made on an individual basis in every case". [987][988][989] Although the surgery may be recommended for treatment of seriously affected patients, the physician should advise the patient's family about the potential outcomes, including survival with severe disability.…”

Section: Decompressive Surgerymentioning

confidence: 99%

Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Jauch¹,

Saver²,

Adams³

et al. 2013

Stroke

5,370

1,801

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Background and Purpose-The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. Methods-Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. Results-The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. Guidelines for the Early Management of PatientsThis statement was approved by the American Heart Association Science Advisory and Coordinating Committee on December 12, 2012. A copy of the document is available at http://my.americanheart.org/statements by selecting either the "By Topic" link or the "By Publication Date" link. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.The Executive Summary is available as an online-only Data Supplement with this article at http://stroke.ahajournals.org/lookup/suppl/ doi:10.1161/STR.0b013e318284056a/-/DC1.The American Heart Association requests that this document be cited as follows: Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H; on behalf of the American Heart Association Stroke Council, Council on Cardio...

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“…As an alternative therapy, surgical decompression techniques (large hemicraniectomy with durotomy) have been proposed to relieve the high intracranial pressure, but this strategy remains controversial in the absence of randomized, controlled trials and the fear of severe and "unacceptable" residual disability. [3][4][5][6][7][8][9][10][11][12] This controversy in the medical literature was also apparent in the national survey that we performed in 47 French Neurology Departments in 2000, showing that only 2 centers were convinced of the efficacy of decompressive craniectomy. The majority of centers (77%) approved the concept of a randomized trial evaluating the benefit of decompressive craniectomy in patients with malignant MCA infarction (K. Vahedi, unpublished data, 2000).…”

mentioning

confidence: 99%

Sequential-Design, Multicenter, Randomized, Controlled Trial of Early Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarction (DECIMAL Trial)

Vahedi

Vicaut²,

Matéo³

et al. 2007

Stroke

735

578

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on behalf of the DECIMAL InvestigatorsBackground and Purpose-There is no effective medical treatment of malignant middle cerebral artery (MCA) infarction.The purpose of this clinical trial was to assess the efficacy of early decompressive craniectomy in patients with malignant MCA infarction. Methods-We conducted in France a multicenter, randomized trial involving patients between 18 and 55 years of age with malignant MCA infarction to compare functional outcomes with or without decompressive craniectomy. A sequential, single-blind, triangular design was used to compare the rate of development of moderate disability (modified Rankin scale score Յ3) at 6 months' follow-up (primary outcome) between the 2 treatment groups. Results-After randomization of 38 patients, the data safety monitoring committee recommended stopping the trial because of slow recruitment and organizing a pooled analysis of individual data from this trial and the 2 other ongoing European trials of decompressive craniectomy in malignant MCA infarction. Among the 38 patients randomized, the proportion of patients with a modified Rankin scale score Յ3 at the 6-month and 1-year follow-up was 25% and 50%, respectively, in the surgery group compared with 5.6% and 22.2%, respectively, in the no-surgery group (Pϭ0.18 and Pϭ0.10, respectively). There was a 52.8% absolute reduction of death after craniectomy compared with medical therapy only (PϽ0.0001). Conclusions-In this trial, early decompressive craniectomy increased by more than half the number of patients with moderate disability and very significantly reduced (by more than half) the mortality rate compared with that after medical therapy.

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Functional impairment, disability, and quality of life outcome after decompressive hemicraniectomy in malignant middle cerebral artery infarction

Cited by 120 publications

References 35 publications

Surgical Aspects of Decompression Craniectomy in Malignant Stroke: Review

Surgical Aspects of Decompression Craniectomy in Malignant Stroke: Review

Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Sequential-Design, Multicenter, Randomized, Controlled Trial of Early Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarction (DECIMAL Trial)

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