Functional outcomes of decompressive hemicraniectomy following malignant middle cerebral artery infarctions: a systematic review

McKenna, Alison; Wilson, Colin; Caldwell, Sheena B.; Curran, David

doi:10.3109/02688697.2012.654835

Cited by 30 publications

(25 citation statements)

References 27 publications

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“…Among the patients undergoing DHC in this study, the median NIHSS score on admission was 18 (IQR [14][15][16][17][18][19][20][21][22], the condition exhibited a right-side predominance (73.0%) and the presence of ipsilateral ICA occlusion was detected in 57.2% of patients, although these were not found to be independent factors affecting the 30-day mortality. Interestingly, the occurrence of atrial fibrillation (60.0%) was found to be inversely correlated with mortality, although this finding did not reach statistical significance in the multivariate analysis.…”

Section: Characteristics Of Patients Undergoing Decompressive Hemicramentioning

confidence: 91%

“…Published reports suggest that a poor outcome may be attributable to the presence of herniation, a low preoperative level of consciousness and the involvement of multiple vascular territories in ischemic stroke patients (6,10,15,20). In a meta-analysis of three RCTs, DHC performed within 48 hours of ictus reduced the mortality rate from 71% to 22% and doubled the probability of a favorable functional outcome (mRS ≤3) at one year after surgery (22).…”

Section: Characteristics Of Patients Undergoing Decompressive Hemicramentioning

confidence: 99%

“…As to in-hospital mortality, the rate observed among elderly patients after this procedure may be higher (24), while other studies have reported that age as well as sex, thrombolysis, and the occurrence of stroke-related complications, such as aspiration pneumonia, do not affect in-hospital mortality, although the patients undergoing DHC (mean age: 55.6 years) in these studies exhibited a higher rate (32.1%) of mortality than conservatively treated acute ischemic stroke patients (4). In a systematic review incorporating a wide range in age and hours from ictus to surgery, an age over 60 years (P<0.05) as well as additional cerebral artery involvement and a greater midline shift preoperatively were found to be independent factors affecting 30-day mortality after DHC (15). In the present study, it is interesting to note that the most frequent reason for not performing DHC, as indicated by family members, was an advanced age, while patients ≥60 years of age comprised 80.2% of all DHC patients (median: 69, IQR: 61-75).…”

Section: Age Limitationsmentioning

confidence: 99%

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Nationwide Survey of Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction in Japan

et al. 2014

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OBJECTIVE:Decompressive hemicraniectomy (DHC) for malignant middle cerebral artery (MCA) infarction has been shown to reduce mortality and improve functional outcomes in young adults; however, there is currently debate regarding how routinely such surgery should be performed in the clinical setting, considering the very high rate of disability and functional dependence among survivors. We herein report the current status of the frequency of and indications for DHC for malignant MCA infarction in Japan. METHODS:We retrospectively studied of cohort cases of DHC for malignant MCA infarction treated at pivotal teaching neurosurgical departments in Japan between January 2011 and December 2011. Information was obtained regarding patient characteristics, radiological features and outcomes during follow-up. The endpoints included 30-day mortality rate and functional outcomes, as measured according to the modified Rankin scale (mRS) score at three months. RESULTS:Three hundred and fifty-five patients underwent DHC at 259 neurosurgical departments who replied to the survey, corresponding to a rate of 8.7% of the 4,092 candidates with malignant MCA infarction, the latter being equivalent to 8.5% of patients with acute ischemic stroke identified during the same period. Among the patients undergoing DHC, the mean age was 67.0 years, and those ≥60 years of age comprised 80.2% of all DHC patients. The most frequently used modality for vascular imaging was magnetic resonance angiography (77.2%). DHC was generally performed between 24-48 hours after onset (38.9%), with 36.9% of patients undergoing surgery at ≥48 hours. At the time of surgery, 26.1% of the patients had a Glasgow coma scale (GCS) score of ≤6. Pre-surgical 2 midbrain compression was noted in 52.1% of the patients. The 30-day mortality after DHC was 18.6%, and factors affecting death were a GCS score of ≤6 (OR 1.88, 95%CI 1.05-3.32, P=0.03) and midbrain compression (OR 2.28, 95%CI 1.31-4.09, P=0.005). According to the multivariate analysis, only midbrain compression was an independent risk factor (OR 2.12, 95% CI 1.16-3.95, P=0.01) for 30-day mortality. Modified Rankin scale scores at three months were available in 175 patients (49.3%), only 5.2% of whom exhibited a favorable functional outcome (mRS score ≤3). Meanwhile, 22.9% of the patients had an mRS score of 4, 26.9% had an mRS score of 5 and 45.1% were found to have died. CONCLUSIONS:In the present study, less than one-tenth of candidates with malignant MCA infarction in Japan underwent decompressive surgery, and the vast majority of patients were elderly. Age was not found to be an independent factor for immediate mortality in this study, and performing surgery in the elderly may be justified based on additional evidence of functional improvements. INTRODUCTIONMalignant middle cerebral artery (MCA) infarction is characterized by the development of life-threatening space-occupying cerebral edema complicating large MCA infarction and is widely used as a category for subgrouping stroke patients (6,11,14,20,25). D...

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Section: Characteristics Of Patients Undergoing Decompressive Hemicramentioning

confidence: 91%

Section: Characteristics Of Patients Undergoing Decompressive Hemicramentioning

confidence: 99%

Section: Age Limitationsmentioning

confidence: 99%

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Nationwide Survey of Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction in Japan

et al. 2014

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“…4,6 For treatment, decompressive hemicraniectomy surgery may be employed to normalize intracranial pressure and increase survival rate but it provides limited improvement in infarct volume and functional outcomes. 7 Opportunities to identify new directions that may enable treatment of acute stroke, especially in severe cases in which reperfusion has not occurred, must therefore be explored as a matter of urgency.…”

Section: Introductionmentioning

confidence: 99%

Immune Cell Infiltration in Malignant Middle Cerebral Artery Infarction: Comparison with Transient Cerebral Ischemia

Chu

Kim

Lee

et al. 2013

J Cereb Blood Flow Metab

187

175

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We tested whether significant leukocyte infiltration occurs in a mouse model of permanent cerebral ischemia. C57BL6/J male mice underwent either permanent (3 or 24 hours) or transient (1 or 2 hours þ 22-to 23-hour reperfusion) middle cerebral artery occlusion (MCAO). Using flow cytometry, we observed B15,000 leukocytes (CD45 þ high cells) in the ischemic hemisphere as early as 3 hours after permanent MCAO (pMCAO), comprising B40% lymphoid cells and B60% myeloid cells. Neutrophils were the predominant cell type entering the brain, and were increased to B5,000 as early as 3 hours after pMCAO. Several cell types (monocytes, macrophages, B lymphocytes, CD8þ T lymphocytes, and natural killer cells) were also increased at 3 hours to levels sustained for 24 hours, whereas others (CD4 þ T cells, natural killer T cells, and dendritic cells) were unchanged at 3 hours, but were increased by 24 hours after pMCAO. Immunohistochemical analysis revealed that leukocytes typically had entered and widely dispersed throughout the parenchyma of the infarct within 3 hours. Moreover, compared with pMCAO, there were B50% fewer infiltrating leukocytes at 24 hours after transient MCAO (tMCAO), independent of infarct size. Microglial cell numbers were bilaterally increased in both models. These findings indicate that a profound infiltration of inflammatory cells occurs in the brain early after focal ischemia, especially without reperfusion.

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“…In this series, 74% of patients had very good outcomes (modified Rankin Scale [mRS] score, 0 or 1). 135 have studied patients with supratentorial infarctions treated with decompressive craniectomy, usually within 48 hours of stroke onset. Three prospective trials showed reduced mortality with hemicraniectomy compared with medical management (22% versus 71% mortality, pooled analysis) in patients <60 years of age, but no individual study showed an improvement in the percentage of survivors with good outcomes (mRS score, 0-3), although this improvement (43% versus 21%) was noted in a pooled analysis.…”

Section: Neurosurgical Options In a Deteriorated Patientmentioning

confidence: 99%

Recommendations for the Management of Cerebral and Cerebellar Infarction With Swelling

Wijdicks¹,

Sheth²,

Carter³

et al. 2014

Stroke

432

204

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Functional outcomes of decompressive hemicraniectomy following malignant middle cerebral artery infarctions: a systematic review

Cited by 30 publications

References 27 publications

Nationwide Survey of Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction in Japan

Nationwide Survey of Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction in Japan

Immune Cell Infiltration in Malignant Middle Cerebral Artery Infarction: Comparison with Transient Cerebral Ischemia

Recommendations for the Management of Cerebral and Cerebellar Infarction With Swelling

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