Intracranial pressure following decompressive hemicraniectomy for malignant cerebral infarction: clinical and treatment correlations

Funchal, Bruno Ferreira; Alves, Maramélia Miranda; Suriano, Ítalo Capraro; Chaddad-Neto, Feres; Ferraz, Maria Elizabeth; Silva, Gisele Sampaio

doi:10.1590/0004-282x20180132

Cited by 12 publications

(7 citation statements)

References 7 publications

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“…Indeed, DC performed before clinical signs of herniation is shown to improve functional outcomes however surgery performed after onset of clinical deterioration may be too late to yield beneficial outcomes (Shah et al, 2019). Furthermore, although DC is the most powerful tool currently available to combat elevated ICP, the procedure is highly invasive, benefits remain controversial and the long-term implications of the procedure on ICP dynamics are not well understood (Funchal et al, 2018; Lilja-Cyron et al, 2019; Shah et al, 2019). A pooled analysis of the randomized control trials DECIMAL, HAMLET, and DESTINY, compared early DC with best available conventional medical management in patients with evidence of MCA territory hypersensitivity and a National Institute of Health Stroke Scale (NIHSS) > 15/20 (Jüttler et al, 2007; Vahedi et al, 2007a,b; Hofmeijer et al, 2009; Geurts et al, 2013).…”

Section: Discussionmentioning

confidence: 99%

NK1-r Antagonist Treatment Comparable to Decompressive Craniectomy in Reducing Intracranial Pressure Following Stroke

et al. 2019

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Background and Purpose: The morbidity and early mortality associated with stroke is largely attributable to cerebral edema and elevated intracranial pressure (ICP). Existing pharmacotherapies do not target the underlying pathophysiology and are often ineffective in sustainably lowering ICP, whilst decompressive craniectomy (DC) surgery is life-saving yet with surgical/peri-operative risk and increased morbidity in the elderly. Accordingly, there is an urgent need for therapies that directly target the mechanisms of edema genesis. Neurogenic inflammation, mediated by substance P (SP) binding to the tachykinin NK1 receptor (NK1-r), is associated with blood-brain barrier (BBB) disruption, cerebral edema and poor outcome post-stroke. NK1-r antagonist treatment ameliorates BBB dysfunction and cerebral edema in rodent stroke models. However, treatment has not been investigated in a large animal model, an important step toward clinical translation. Consequently, the current study compared the efficacy of NK1-r antagonist treatment to DC surgery in reducing ICP post-stroke in a clinically relevant ovine model. Methods: Anesthetized female Merino sheep (65 ± 6 kg, 18–24 months) underwent sham surgery ( n = 4) or permanent middle cerebral artery occlusion ( n = 22). Stroke animals were randomized into one of 5 treatments: 1×NK1 bolus (4 h), 2×NK1 bolus (4 h;9 h), 3×NK1 bolus (4 h;9 h;14 h), DC surgery (performed at 4 h) or saline vehicle. ICP, blood pressure and blood gasses were monitored for 24 h post-stroke. At 24 h post-stroke anesthetized animals underwent MRI followed by perfusion and brains removed and processed for histological assessment. Results: 2×NK1, 3×NK1 administration or DC surgery significantly ( p < 0.05) reduced ICP compared to vehicle. 1×NK1 was ineffective in sustainably lowering ICP. On MRI, midline shift and cerebral edema were more marked in vehicles compared to NK1-r treatment groups. Conclusion: Two or three boluses of NK1-r antagonist treatment reduced ICP comparable to DC surgery, suggesting it may provide a novel alternative to invasive surgery for the management of elevated ICP.

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Section: Discussionmentioning

confidence: 99%

NK1-r Antagonist Treatment Comparable to Decompressive Craniectomy in Reducing Intracranial Pressure Following Stroke

et al. 2019

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“…A verbal response is scored as 5 (oriented), 4 (confused conversation), 3 (inappropriate words), 2 (incomprehensible speech), and 1 (no response). Motor response is scored as 6 (obey command), 5 (purposeful movement to painful stimulus), 4 (withdraws to pain), 3 (decorticate posturing), 2 (decerebrate posturing), and 1 (no response) [ 23 ]. A high GCS score indicates that the patient's consciousness is weak.…”

Section: Methodsmentioning

confidence: 99%

Stereotactic Aspiration Acts as an Effective Treatment for Malignant Middle Cerebral Artery Infarction

Wang

Chen

Wang

et al. 2022

Journal of Healthcare Engineering

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Objective. This study seeks to explore the efficacy and prognosis of stereotactic aspiration for malignant middle cerebral artery infarction (mMCAI). Methods. A total of 50 mMCAI patients who were diagnosed and treated in our hospital from January 2018 to June 2020 were collected and then randomly divided into control group (decompressive craniectomy, n = 24) and study group (stereotactic aspiration, n = 26). After 1 and 6 months of treatment, the scores of the National Institutes of Health Stroke Scale (NIHSS), Glasgow Coma Scale (GCS), Barthel Index, and modified Rankin Scale (mRS) were used to evaluate the therapeutic effect. Additionally, the mortality and survival rates after treatment were recorded to compare the prognostic effect between the two groups. Results. One month after treatment, the GCS scores and Barthel Index score increased in both the control and study groups and were significantly higher in the study group. The follow-up results at 1 and 6 months after treatment showed that in comparison with the control group, stereotactic aspiration led to a higher survival rate and lower mortality rate; the latter had superior NIHSS score and mRS score and better prognosis. Conclusion. In comparison with decompressive craniectomy, stereotactic aspiration shows outstanding clinical efficacy and more advantages in the treatment of mMCAI. Therefore, stereotactic aspiration is more worthy of clinical application.

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“…Two small case series comprising 12 and 16 patients after DC for MCI, respectively, showed a higher incidence of IHTN and maximum ICP >10 mm Hg in deceased patients, without statistical significance. 7,8 In another series of 25 patients undergoing ICP monitoring after DC for MCI, 9 IHTN was associated with mortality at 6 months.…”

Section: Discussionmentioning

confidence: 96%

Invasive Monitoring of Intracranial Pressure After Decompressive Craniectomy in Malignant Stroke

Hernández-Durán

Meinen

Rohde

2021

Stroke

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Background and Purpose: The role of decompressive hemicraniectomy (DC) in malignant cerebral infarction (MCI) has clearly been established, but little is known about the course of intracranial pressure (ICP) in patients undergoing this surgical measure. In this study, we investigated the role of invasive ICP monitoring in patients after DC for MCI, postulating that postoperative ICP predicts mortality. Methods: In this retrospective observational study of MCI patients undergoing DC, ICP were recorded continuously in hourly intervals for the first 72 hours after DC. For every hour, mean ICP was calculated, pooling ICP of every patient. A receiver operating characteristic analysis was performed for hourly mean ICP. A subgroup analysis by age (≥60 years and <60 years) was also performed. Results: A total of 111 patients were analyzed, with 29% mortality rate in patients <60 years, and 41% in patients ≥60 years. A threshold of 10 mm Hg within the first 72 postoperative hours was a reliable predictor of mortality in MCI, with an acceptable sensitivity of 70% and high specificity of 97%. Established predictors of mortality failed to predict mortality. Conclusions: Our study suggests the need to reevaluate postoperative ICP after DC in MCI and calls for a redefinition of ICP thresholds in these patients to indicate further therapy.

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Intracranial pressure following decompressive hemicraniectomy for malignant cerebral infarction: clinical and treatment correlations

Cited by 12 publications

References 7 publications

NK1-r Antagonist Treatment Comparable to Decompressive Craniectomy in Reducing Intracranial Pressure Following Stroke

NK1-r Antagonist Treatment Comparable to Decompressive Craniectomy in Reducing Intracranial Pressure Following Stroke

Stereotactic Aspiration Acts as an Effective Treatment for Malignant Middle Cerebral Artery Infarction

Invasive Monitoring of Intracranial Pressure After Decompressive Craniectomy in Malignant Stroke

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