Surgical decompression for cerebral oedema in acute ischaemic stroke

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

doi:10.1002/14651858.cd003435.pub2

Cited by 72 publications

(63 citation statements)

References 34 publications

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“…154 This benefit was demonstrated in a pooled analysis of 3 randomized controlled trials in which early decompressive surgery (within 48 hours of stroke onset) decreased the mortality of these massive strokes (from 71% with conservative treatment to 22% with surgery) and also significantly increased the chances of survival with only moderate disability (from 21% with conservative treatment to 43% with surgery). 155 On the basis of the available data, decompressive craniectomy results in improved quality-adjusted life years 156 ; however, the benefit of decompressive surgery has only been shown for patients aged ≤60 years.…”

Section: Surgical Options For Severe Strokementioning

confidence: 98%

Palliative and End-of-Life Care in Stroke

Holloway¹,

Arnold²,

Creutzfeldt³

et al. 2014

Stroke

243

120

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Background and Purpose-The purpose of this statement is to delineate basic expectations regarding primary palliative care competencies and skills to be considered, learned, and practiced by providers and healthcare services across hospitals and community settings when caring for patients and families with stroke. Methods-Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were chosen to reflect the diversity and expertise of professional roles in delivering optimal palliative care. Writing group members were assigned topics relevant to their areas of expertise, reviewed the appropriate literature, and drafted manuscript content and recommendations in accordance with the American Heart Association's framework for defining classes and level of evidence and recommendations. Results-The palliative care needs of patients with serious or life-threatening stroke and their families are enormous: complex decision making, aligning treatment with goals, and symptom control. Primary palliative care should be available to all patients with serious or life-threatening stroke and their families throughout the entire course of illness. To optimally deliver primary palliative care, stroke systems of care and provider teams should (1) promote and practice patient-and family-centered care; (2) effectively estimate prognosis; (3) develop appropriate goals of care; (4) be familiar with the evidence for common stroke decisions with end-of-life implications; (5) assess and effectively manage emerging stroke symptoms; (6) possess experience with palliative treatments at the end of life; (7) assist with care coordination, including referral to a palliative care specialist or hospice if necessary; (8) provide the patient and family the opportunity for personal growth and make bereavement resources available if death is anticipated; and (9) actively participate in continuous quality improvement and research. Conclusions-Addressing the palliative care needs of patients and families throughout the course of illness can complement

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Section: Surgical Options For Severe Strokementioning

confidence: 98%

Palliative and End-of-Life Care in Stroke

Holloway¹,

Arnold²,

Creutzfeldt³

et al. 2014

Stroke

243

120

View full text Add to dashboard Cite

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“…Unlike previous publications, we address the effect of early DC on achieving functional independence and also include the largest reported cohort of randomized MCI patients older than 60 years. Most importantly, despite multiple RCTs and previously published meta-analyses, 8,37,38 early DC for MCI remains inconsistently and infrequently utilized. 12,13,[18][19][20] Our specific aim was to generate outcome data with direct clinical applicability.…”

Section: Figurementioning

confidence: 99%

“…2,7 In 2007, a landmark interim pooled analysis of 3 RCTs demonstrated improved functional outcomes, defined as modified Rankin Scale (mRS) scores 0-3, for MCI patients treated with early DC. 6 However, this morbidity benefit was not present upon completion of the trials 5,8,9 ; nor has it been demonstrated in subsequent RCTs, 10,11 which employed a less stringent definition of acceptable functional outcome (mRS 0-4) with poor generalizability. [12][13][14][15][16][17] Consequently, there is enduring concern that early DC increases survival only at the cost of poor quality of life.…”

mentioning

confidence: 99%

“…[12][13][14][15][16][17] Consequently, there is enduring concern that early DC increases survival only at the cost of poor quality of life. 8,9,12,15 Lack of clarity is evidenced by wide variations in clinical practice with infrequent and inconsistent utilization of early DC for MCI patients in the United States and other countries. 15,[18][19][20] In light of these considerations, we performed a meta-analysis of all available RCTs comparing 12-month functional outcomes in adult MCI patients treated with early DC vs best medical care.…”

mentioning

confidence: 99%

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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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“…However, in addition to complications associated with the surgical procedure [5], its impact on functional outcome is equivocal. A large proportion of individuals undergoing DHC, particularly older patients, survive with moderately severe or severe disability [4,6]. Furthermore, DHC is most beneficial within the first 48 h after stroke, after which clear benefit has not been shown.…”

Section: Introductionmentioning

confidence: 99%

The Role of Osmotic Therapy in Hemispheric Stroke

2015

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Our results suggest that patients with moderate size hemispheric infarcts on presentation and those who do not require OT within the first 24 h of stroke may survive until discharge with medical management alone. Black race was also associated with conservative management failure, a finding that may reflect a cultural preference toward aggressive management. Further prospective studies are needed to better establish the utility of medical management of hemispheric edema in the setting of moderate size hemispheric infarcts.

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Surgical decompression for cerebral oedema in acute ischaemic stroke

Cited by 72 publications

References 34 publications

Palliative and End-of-Life Care in Stroke

Palliative and End-of-Life Care in Stroke

Early decompressive craniectomy for malignant cerebral infarction

The Role of Osmotic Therapy in Hemispheric Stroke

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