Normothermia after decompressive surgery for space-occupying middle cerebral artery infarction: a protocol-based approach

Abstract

BackgroundModerate hypothermia after decompressive surgery might not be beneficial for stroke patients. However, normothermia may prove to be an effective method of enhancing neurological outcomes. The study aims were to evaluate the application of a pre-specified normothermia protocol in stroke patients after decompressive surgery and its impact on temperature load, and to describe the functional outcome of patients at 12 months after treatment.MethodsWe analysed patients with space-occupying middle cerebral artery (MCA) infarction treated with decompressive surgery and a pre-specified temperature management protocol. Patients treated primarily with device-controlled normothermia or hypothermia were excluded. The individual temperature load above 36.5 °C was calculated for the first 96 h after hemicraniectomy as the Area Under the Curve, using °C x hours. The effect of temperature load on functional outcome at 12 months was analysed by logistic regression.ResultsWe included 40 stroke patients treated with decompressive surgery (mean [SD] age: 58.9 [10.1] years; mean [SD] time to surgery: 30.5 [16.7] hours). Fever (temperature > 37.5 °C) developed in 26 patients during the first 96 h after surgery and mean (SD) temperature load above 36.5 °C in this time period was 62,3 (+/− 47,6) °C*hours. At one year after stroke onset, a moderate to moderately severe disability (modified Rankin Scale score of 3 or 4) was observed in 32% of patients, and a severe disability (score of 5) in 37% of patients, respectively. The lethality in the cohort at 12 months was 32%. The temperature load during the first 96 h was not an independent predictor for 12 month lethality (OR 0.986 [95%-CI:0.967–1.002]; p < 0.12).ConclusionsTemperature control in surgically treated patients with space-occupying MCA infarction using a pre-specified protocol excluding temperature management systems resulted in mild hyperthermia between 36.8 °C and 37.2 °C and a low overall temperature load. Future prospective studies on larger cohorts comparing different strategies for normothermia treatment including temperature management devices are needed.Electronic supplementary materialThe online version of this article (10.1186/s12883-017-0988-x) contains supplementary material, which is available to authorized users.

Hypothermia on the first day of ICU admission leads to increased in-hospital mortality in patients with subarachnoid hemorrhage

“…Another study reported that hypothermia within 6 h of onset was associated with severe neurological dysfunction in the early stages of cerebral infarction 37 . Other studies have also demonstrated that hypothermia therapy may not be beneficial for patients with malignant middle cerebral artery occlusion cerebral infarction, in part because of the higher incidence of adverse events in patients treated with hypothermia 38 , 39 . Importantly, DCI after the rupture of an intracranial aneurysm is a significant cause of mortality 40 .…”

Lower Body Temperature Independently Predicts Delayed Cerebral Infarction in the Elderly With Ruptured Intracranial Aneurysm

“…However, the detailed mechanism by which hypothermia exerts its protective effects on brain tissues remains unclear. Conversely, recent studies showed that moderate hypothermia might not be beneficial for stroke patients (19), as it did not reduce the likelihood of death or disability in patients with neonatal encephalopathy, but rather, it significantly increased the risk of death (20). Rahmig et al (19) found that, in surgically treated patients with middle carotid artery (MCA) infarction, the risk of death was lower for individuals with high body temperature than for those with low body temperature.…”

“…Conversely, recent studies showed that moderate hypothermia might not be beneficial for stroke patients (19), as it did not reduce the likelihood of death or disability in patients with neonatal encephalopathy, but rather, it significantly increased the risk of death (20). Rahmig et al (19) found that, in surgically treated patients with middle carotid artery (MCA) infarction, the risk of death was lower for individuals with high body temperature than for those with low body temperature. The discrepancies observed in the abovementioned findings may be explained by the fact that low body temperature and therapeutic hypothermia may be different conditions.…”

Hyperthermia is a predictor of high mortality in patients with sepsis

“…Thus, focusing on a single BT record may increase the bias risk. Temperature load (TL) [ 5 ] may be a method to this limitation, defined as the sum of BT above/below the targeted temperature level multiplied by the duration (hours). For instance, the TL of hyperthermia (> 38.3 °C) within 72 h should be calculated as follows—step 1: ; step 2: .…”