Recovery From Aphasia After Hemicraniectomy for Infarction of the Speech-Dominant Hemisphere

Kastrau, Frank; Wolter, Marcus; Huber, Walter; Block, Frank E.

doi:10.1161/01.str.0000157595.93115.70

Cited by 77 publications

(62 citation statements)

References 21 publications

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“…24,27 A significant improvement in aphasia and a better overall outcome, however, have been observed with longer follow-ups. 5,16 Involvement of the dominant cerebral hemisphere should not preclude surgical decompression because long-term differences in clinical outcome after DH are not significantly different from those seen in patients with nondominant-hemisphere infarctions. 9,27,29 Intravenous tPA administration was not a significant predictor of poor outcome after DH.…”

Section: Discussionmentioning

confidence: 99%

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%

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

Daou

Kent

Montaño

et al. 2016

JNS

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“…Assessment of quality of life is complicated by inability of patients with severe dysphasia to reliably complete questionnaires for themselves. 34 The opinions of relatives or carers may not necessarily be a true reflection of the patients' own perceptions, however the magnitude of such bias is likely to be small to moderate. 35 Although some evidence suggests there may not be a substantial difference in the presence and severity of emotional and cognitive changes between survivors of rightand left-hemisphere stroke overall, those with righthemisphere stroke underestimate these changes compared with their partners' observations.…”

Section: Discussionmentioning

confidence: 99%

Does Hemispheric Lateralization Influence Functional and Cardiovascular Outcomes After Stroke?

Fink

Frampton

Lyden

et al. 2008

Stroke

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Background and Purpose— The influence of stroke lateralization on functional and cardiovascular outcome after stroke is not well established. We evaluated the influence of hemispheric lateralization among patients enrolled in prospective acute stroke trials. Methods— We obtained data from the VISTA database for acute stroke trials which reported lateralization. Baseline data, cardiac adverse events, and 90-day outcomes were compared between right and left hemisphere stroke patients. A “hemisphere unbiased” subscore of the NIHSS which omitted items strongly associated with lateralized cognitive deficits was also compared for trials which reported individual NIHSS item scores. A multivariable analysis of outcome predictors was performed. Results— Three acute stroke trials met the prespecified inclusion criteria. 1644 placebo-treated patients with documented hemispheric lateralization were included in the analysis. Baseline NIHSS was higher for left hemisphere patients (mean 16.2, versus 12.8 right, P <0.001); there was no difference in the “hemisphere unbiased” NIHSS subscore (10.88 left, 11.08 right, n=687, P =0.49). There was no difference between hemispheres in 90-day modified Rankin Score (3.43 left, 3.29 right, P =0.13), mortality (22.1% left, 19.5% right, P =0.20), or cardiac adverse events ( P =0.71). Hemispheric lateralization was not an independent predictor of outcome in the multivariable analysis after controlling for the hemispheric bias intrinsic to the NIHSS. Conclusions— There is no difference in functional outcome between patients with right or left hemisphere stroke. Use of the baseline NIHSS score to predict stroke outcome must take hemispheric lateralization into account. Stroke lateralization is not an important predictor of cardiac adverse events or 90-day mortality.

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“…Patients nevertheless have a chance for language recovery. Young age and early decompression surgery in patients with malignant dominant stroke have been identified as predictors for language recovery, conceding that this might take several months or even years and might be incomplete [67]. While the recovery of language is modulated by several factors including type, intensity, and timing of the intervention or the severity of the initial presentation, the anatomical regions for recovery are less clear [68,69,70,71].…”

Section: Surgical Treatmentmentioning

confidence: 99%

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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Recovery From Aphasia After Hemicraniectomy for Infarction of the Speech-Dominant Hemisphere

Cited by 77 publications

References 21 publications

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

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

Does Hemispheric Lateralization Influence Functional and Cardiovascular Outcomes After Stroke?

Surgical Aspects of Decompression Craniectomy in Malignant Stroke: Review

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