Improved Hemodynamic Parameters in Middle Cerebral Artery Infarction After Decompressive Craniectomy

Amorim, Robson Luís Oliveira de; Andrade, Almir Ferreira de; Gattás, Gabriel; Paiva, Wellingson Silva; Menezes, Marcos Roberto de; Teixeira, Manoel Jacobsen; Bor‐Seng‐Shu, Edson

doi:10.1161/strokeaha.113.003670

Cited by 25 publications

(17 citation statements)

References 33 publications

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“…This is related to an increased mass effect and risk of brain herniation with compression of vital structures and hemodynamically, higher impairment of autoregulation. 1,17 Decompressive hemicraniectomies for MCA-and ICA-territory infarcts were included in this study. Acute ICA-territory infarctions usually have a poorer prognosis than MCA-territory infarction, and cerebral edema is more severe.…”

Section: Discussionmentioning

confidence: 99%

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Decompressive hemicraniectomy: predictors of functional outcome in patients with ischemic stroke

Daou

Kent

Montaño

et al. 2016

JNS

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P atients presenting with large ischemic strokes may develop uncontrollable, progressive brain edema that puts them at risk for compression of brain parenchyma and cerebral herniation. 23 There are a limited number of therapeutic options, but research has shown that operative procedures, such as decompressive hemicraniectomy (DH), decrease patient mortality.32 Malignant infarction treated only by conservative approaches results in a mortality rate of 80% within the 1st week of the stroke. 15Edema that does not respond to medical treatment necessitates DH as a life-saving procedure. Studies have demonstrated that DH surgery can result in a reduction of mortality rate to 30% and, if decompression is performed within 24 hours of stroke onset, to 10%. 7,12,18,24,32 While DH imabbreviatioNs BMI = body mass index; DH = decompressive hemicraniectomy; DVT = deep vein thrombosis; ICA = internal carotid artery; IVC = inferior vena cava; MCA = middle cerebral artery; MI = myocardial infarction; MLS = midline shift; mRS = modified Rankin Scale; NIHSS = National Institutes of Health Stroke Scale; tPA = tissue plasminogen activator. obJective Patients presenting with large-territory ischemic strokes may develop intractable cerebral edema that puts them at risk of death unless intervention is performed. The purpose of this study was to identify predictors of outcome for decompressive hemicraniectomy (DH) in ischemic stroke. methods The authors conducted a retrospective electronic medical record review of 1624 patients from 2006 to 2014. Subjects were screened for DH secondary to ischemic stroke involving the middle cerebral artery, internal carotid artery, or both. Ninety-five individuals were identified. Univariate and multivariate analyses were performed for an array of clinical variables in relationship to functional outcome according to the modified Rankin Scale (mRS). Clinical outcome was assessed at 90 days and at the latest follow-up (mean duration 16.5 months). results The mean mRS score at 90 days and at the latest follow-up post-DH was 4. Good functional outcome was observed in 40% of patients at 90 days and in 48% of patient at the latest follow-up. The mortality rate at 90 days was 18% and at the last follow-up 20%. Univariate analysis identified a greater likelihood of poor functional outcome (mRS scores of 4-6) in patients with a history of stroke .66]; p = 0.017), peak midline shift (MLS) > 10 mm ]; p = 0.011), or a history of myocardial infarction ]; p = 0.04). Multivariate analysis demonstrated elevated odds of poor functional outcome associated with a history of stroke .05]; p = 0.008), MLS > 10 mm ; p = 0.007), a history of diabetes .88]; p = 0.01), delayed time from onset of stroke to DH (OR 1.32 [95% CI 1.02-1.72]; p = 0.037), and evidence of pupillary dilation prior to DH .51]; p = 0.04). Patients with infarction involving the dominant hemisphere had higher odds of unfavorable functional outcome at 90 days ]; p = 0.014), but at the latest follow-up, cerebral dominance was not significantly related to outc...

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Section: Discussionmentioning

confidence: 99%

“…The mRS ranges from 0 (no symptoms) to 6 (death), with intermediate values (1)(2)(3)(4)(5) representing increasing functional and cognitive disability. Poor functional outcome was defined as an mRS score of 4 (moderately severe disability), 5 (severe disability), or 6 (death).…”

Section: Outcomementioning

confidence: 99%

Decompressive hemicraniectomy: predictors of functional outcome in patients with ischemic stroke

Daou

Kent

Montaño

et al. 2016

JNS

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“…Additionally, the size of the hemicraniectomy is important and a diameter of DHC of at least 12 cm is recommended in most studies. Pre-and postoperative perfusion CT hemodynamic parameters were associated with mortality and the improvement of PCT parameters after DHC was related to favorable outcome [52] . Recent metaanalyses including newer controlled trials [51,53,54] confirmed the results of previous studies: DHC significantly decreases mortality and improves functional outcome for malignant infarction in patients aged 18-80, although with a nonsignificant increase in the proportion of major disability especially among aged survivors.…”

Section: Dhcmentioning

confidence: 93%

“…Improved imaging procedures -perfusion and angio CT, PW and DW-MRI, PET -early after stroke may help to select patients who will develop malignant infarction and therefore will especially benefit from early DHC. Controlled studies to prove this concept and the effect on hemodynamic parameters [52] are urgently needed.…”

Section: Dhcmentioning

confidence: 99%

Malignant MCA Infarction: Pathophysiology and Imaging for Early Diagnosis and Management Decisions

Heiss

2015

Cerebrovasc Dis

114

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Background: Malignant middle cerebral artery infarction is a devastating condition, with up to 80% mortality in conservatively treated patients. The pathophysiology of this stroke is characterized by a large core of severe ischemia and only a relatively small rim of penumbra. Due to the fast development of irreversible morphological damage, cytotoxic edema occurs immediately in a large portion of the ischemic territory. The subsequent damage of the tight junctions leads to the breakdown of the blood brain barrier and vasogenic brain edema, resulting in space-occupying brain swelling. The progressive vasogenic edema reaches its maximum after 1 to several days and exerts a mechanical force on surrounding tissue structures leading to midline shift and transtentorial herniation and finally brain stem compression and death. Summary: Early severe neurological symptoms - hemiparesis, gaze deviation, higher cortical signs - followed by headache, vomiting, papillo edema and reduced consciousness may predict the deleterious course. Imaging supports the suspected diagnosis with hypodense changes on CT extending beyond 50% of the MCA territory. The size of the probably infarcted tissue and a midline shift on CT as well as the size of the lesion on diffusion-weighted MRI are predictive of a malignant course. Reduction of cerebral blood flow below a critical value and volume of irreversible tissue damage detected by positron emission tomography in the early hours after the stroke are indicative of progression to malignant infarction with increased intracranial pressure (ICP) and decreased tissue oxygen tension observed by multimodal neuromonitoring in the later course. Treatment options of malignant infarction include general measures to limit the extent of space-occupying edema, but these therapies have not been efficacious. Only surgical intervention with decompressive hemicraniectomy (DHC) was successful in relieving the effects of increased ICP and of the deleterious shifts of brain tissue. Several controlled clinical trials have proven the efficacy of DHC with a significant decrease in mortality and improved functional outcome. However, DHC must be performed early and with a large diameter, regardless of the age of patients, but in patients beyond 60 years, the higher likelihood of resulting severe disability should be taken into consideration. Key Messages: Malignant MCA infarction can be predicted early with a high sensitivity by neuroimaging. The early diagnosis is mandatory for DHC, which was shown to reduce mortality and improve functional outcome in several controlled clinical trials.

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“…Better functional outcomes in early DC patients are likely not only due to preventing lethal brain herniation, but also improving cerebral hemodynamics, thereby limiting secondary injury and increasing potential for long-term recovery. 28,29 However, we also found that early DC in MCI increases the risk of survival with unfavorable functional outcome (mRS 4-5). These somewhat paradoxical findings, in which both favorable and unfavorable functional outcomes are increased, are driven by the large reduction in MCI-related mortality in patients treated with early DC.…”

Section: Discussionmentioning

confidence: 54%

Early decompressive craniectomy for malignant cerebral infarction

2016

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Background: Decompressive craniectomy (DC) is an aggressive life-saving surgical intervention for patients with malignant cerebral infarction (MCI). However, DC remains inconsistently and infrequently utilized, primarily due to enduring concern that increased survival occurs only at the cost of poor functional outcome. Our aim was to clarify the role of DC performed within 48 hours (early DC) for patients with MCI, including patients aged .60 years. Methods: We performed a meta-analysis of all available randomized controlled trials comparing early DC to best medical care for MCI. Studies were identified through literature searches of electronic databases including PubMed, EMBASE, and Scopus. We employed a Mantel-Haenszel fixed effects model to assess treatment effect on dichotomized modified Rankin Scale (mRS) outcomes at 12 months. Results: A total of 289 patients from 6 randomized controlled trials comparing early DC to best medical care were included. Early DC resulted in an increased rate of excellent outcomes, defined as mRS #2 (relative risk [RR] 2.81, 95% confidence interval [CI] 1.01-7.82, p 5 0.047), and favorable outcomes, defined as mRS #3 (RR 2.06, 95% CI 1.25-3.40, p 5 0.005). Early DC also increased the rate of survival with unfavorable outcomes, defined as mRS 4-5 (RR 3.03, 95% CI 1.98-4.65, p , 0.001). Conclusions: Early DC increases the rate of excellent outcomes, i.e., functional independence, in addition to favorable and unfavorable outcomes; however, these findings must be interpreted within the context of patients' goals of care. We have developed a clinical decision algorithm that incorporates goals of care, which may guide consideration of early DC for MCI in clinical practice. Neurol Clin Pract 2016;6:433-443 M alignant cerebral infarction (MCI) refers to large-volume ischemic strokes involving the middle cerebral artery territory, which are complicated by lifethreatening cerebral edema. 1 Managed medically, MCI carries a mortality rate of 80%. 1,2 Decompressive craniectomy (DC), the surgical removal of a portion Editorial, page 381

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Improved Hemodynamic Parameters in Middle Cerebral Artery Infarction After Decompressive Craniectomy

Cited by 25 publications

References 33 publications

Decompressive hemicraniectomy: predictors of functional outcome in patients with ischemic stroke

Decompressive hemicraniectomy: predictors of functional outcome in patients with ischemic stroke

Malignant MCA Infarction: Pathophysiology and Imaging for Early Diagnosis and Management Decisions

Early decompressive craniectomy for malignant cerebral infarction

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