Surgical decompression for cerebral oedema in acute ischaemic stroke

Morley, Nicholas CD; Berge, Eivind; Cruz‐Flores, Salvador; Whittle, Ian R.

doi:10.1002/14651858.cd003435

Cited by 38 publications

(35 citation statements)

References 31 publications

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“…190 -192 Surgical evacuation may be done in patients with large hemispheric infarcts, but survivors have severe residual neurological deficits. [193][194][195][196][197][198][199][200] Subsequent to a 2002 Cochrane review that found some evidence for benefit from surgical decompression, 201 larger nonrandomized prospective trials have shown a reduction in the mortality rate of patients who have hemicraniectomy of large lesions involving the middle cerebral artery territory. 193 …”

Section: Summers Et Al Nursing Care Of the Acute Ischemic Stroke Patimentioning

confidence: 99%

Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient

Summers¹,

Leonard²,

Wentworth³

et al. 2009

Stroke

219

208

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Section: Summers Et Al Nursing Care Of the Acute Ischemic Stroke Patimentioning

confidence: 99%

Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient

Summers¹,

Leonard²,

Wentworth³

et al. 2009

Stroke

219

208

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“…The idea of edema as the primary cause of ICP elevation after stroke appears to have become a self-fulfilling prophecy, as ICP rise seems only to have been investigated in subjects with large volumes of edema. [2][3][4] Little is known about the levels of ICP in patients with smaller strokes and volumes of edema, because of the invasiveness of available methods for ICP monitoring in patients. Our group has recently shown that ICP is dramatically elevated 24 hours after relatively minor stroke in rats, 5 raising doubts about the association between ICP and edema.…”

Section: Introductionmentioning

confidence: 99%

Intracranial Pressure Elevation after Ischemic Stroke in Rats: Cerebral Edema is Not the Only Cause, and Short-Duration Mild Hypothermia is a Highly Effective Preventive Therapy

Murtha

McLeod

Pepperall

et al. 2014

J Cereb Blood Flow Metab

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In both the human and animal literature, it has largely been assumed that edema is the primary cause of intracranial pressure (ICP) elevation after stroke and that more edema equates to higher ICP. We recently demonstrated a dramatic ICP elevation 24 hours after small ischemic strokes in rats, with minimal edema. This ICP elevation was completely prevented by short-duration moderate hypothermia soon after stroke. Here, our aims were to determine the importance of edema in ICP elevation after stroke and whether mild hypothermia could prevent the ICP rise. Experimental stroke was performed in rats. ICP was monitored and shortduration mild (35°C) or moderate (32.5°C) hypothermia, or normothermia (37°C) was induced after stroke onset. Edema was measured in three studies, using wet-dry weight calculations, T 2 -weighted magnetic resonance imaging, or histology. ICP increased 24 hours after stroke onset in all normothermic animals. Short-duration mild or moderate hypothermia prevented this rise. No correlation was seen between ΔICP and edema or infarct volumes. Calculated rates of edema growth were orders of magnitude less than normal cerebrospinal fluid production rates. These data challenge current concepts and suggest that factors other than cerebral edema are the primary cause of the ICP elevation 24 hours after stroke onset.

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“…11 Findings from animal studies and numerous case reports are supported by a number of uncontrolled, nonrandomized, prospective case series suggesting a substantial benefit of decompressive surgery on mortality, from 67% to 88%, to 0% to 34% compared with historical controls. 12 This effect may even be more pronounced if treatment is started earlier, before signs of herniation appear. 13,14 These studies also suggest that hemicraniectomy may reduce poor functional outcome (modified Rankin Scale [mRS] score 4 to 6, Barthel Index 0 to 25, or Glasgow Outcome Scale score 1 to 3) from 95% in conservatively treated patients to 8% to 50% in surgically treated patients.…”

mentioning

confidence: 99%

“…13,14 These studies also suggest that hemicraniectomy may reduce poor functional outcome (modified Rankin Scale [mRS] score 4 to 6, Barthel Index 0 to 25, or Glasgow Outcome Scale score 1 to 3) from 95% in conservatively treated patients to 8% to 50% in surgically treated patients. 3,12,13,15 None of those reports, however, was a randomized clinical trial. In addition, most of the control groups consisted of patients who were significantly older, had more comorbidity, and more often had lesions of the dominant hemisphere.…”

mentioning

confidence: 99%

Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY)

Jüttler

Schwab

Schmiedek

et al. 2007

Stroke

800

585

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Background and Purpose-Decompressive surgery (hemicraniectomy) for life-threatening massive cerebral infarction represents a controversial issue in neurocritical care medicine. We report here the 30-day mortality and 6-and 12-month functional outcomes from the DESTINY trial. Methods-DESTINY (ISRCTN01258591) is a prospective, multicenter, randomized, controlled, clinical trial based on a sequential design that used mortality after 30 days as the first end point. When this end point was reached, patient enrollment was interrupted as per protocol until recalculation of the projected sample size was performed on the basis of the 6-month outcome (primary end pointϭmodified Rankin Scale score, dichotomized to 0 to 3 versus 4 to 6). All analyses were based on intention to treat. Results-A statistically significant reduction in mortality was reached after 32 patients had been included: 15 of 17 (88%) patients randomized to hemicraniectomy versus 7 of 15 (47%) patients randomized to conservative therapy survived after 30 days (Pϭ0.02). After 6 and 12 months, 47% of patients in the surgical arm versus 27% of patients in the conservative treatment arm had a modified Rankin Scale score of 0 to 3 (Pϭ0.23). Conclusions-DESTINY showed that hemicraniectomy reduces mortality in large hemispheric stroke. With 32 patients included, the primary end point failed to demonstrate statistical superiority of hemicraniectomy, and the projected sample size was calculated to 188 patients. Despite this failure to meet the primary end point, the steering committee decided to terminate the trial in light of the results of the joint analysis of the 3 European hemicraniectomy trials.

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Surgical decompression for cerebral oedema in acute ischaemic stroke

Cited by 38 publications

References 31 publications

Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient

Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient

Intracranial Pressure Elevation after Ischemic Stroke in Rats: Cerebral Edema is Not the Only Cause, and Short-Duration Mild Hypothermia is a Highly Effective Preventive Therapy

Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY)

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