Craniectomy For Malignant Cerebral Infarction Research Articles

Long-Term Survival After Decompressive Craniectomy for Malignant Brain Infarction: A 10-Year Nationwide Study.

Decompressive craniectomy (DC) has been shown to be an effective treatment for malignant cerebral infarction (MCI). There are limited nationwide studies evaluating outcome after craniectomy for MCI. To describe the evolution in DC practices for MCI, long-term survival, and associated prognostic factors. We searched the French medico-administrative national database to retrieve patients who underwent DC between 2008 and 2017. A total of 1841 cases of DC were performed over 10years in 51 centers. Mean age at procedure was 50.9years, 18% were above 60years, and 64.4% were male. There was a significant increase in DC for MCI over the 10years (p < 0.001), and the annual volume of procedures more than doubled (95/year vs. 243/year). Early survival at one week and one month was 86%, 95%CI (84.5, 87.6) and 79.7%, 95%CI (77.8, 81.5), respectively. Long-term survival at 1 and 5years were 73.6%, 95%CI (71.6, 75.7) and 68.9%, 95%CI (66.5, 71.4), respectively. Patients below 60years at the time of DC (HR = 0.5; 95%CI [0.4, 0.7], p < 0.001), DC being performed in a center with a high surgical activity (HR = 0.8; 95%CI [0.6, 0.9], p = 0.002), and the patients having unimpaired consciousness (HR = 0.6; 95%CI [0.5, 0.8], p < 0.001) were associated with increased survival in both univariate and adjusted Cox regressions.18.7% of the survivors had a cranioplasty inserted within 3months and 57.8% within 6months. The probability of having a cranioplasty at one year was 75.6%, 95%CI (77.9, 73.1). Over the past 10years in France, DC has been increasingly performed for MCI regardless of age. However, in-hospital mortality remains considerable, as about one quarter of patients died within the first weeks. For those who survive beyond 6months, the risk of death significantly decreases. Early mortality is especially high for comatose patients above 60years operated in inexperienced centers. Most of those who remain in good functional status tend to undergo a cranioplasty within the year following DC.

Risk-benefit Analysis of Barbiturate Coma Therapy in Patients Who Received Decompressive Craniectomy for Malignant Cerebral Infarction

Risk-benefit Analysis of Barbiturate Coma Therapy in Patients Who Received Decompressive Craniectomy for Malignant Cerebral Infarction

Therapeutic Hypothermia after Decompressive Craniectomy in Malignant Cerebral Infarction

†‡ * † ‡ Decompressive hemicraniectomy followed by subsequent therapeutic hypothermia can reduce mortality in patients with malignant cerebral infarction without significantly increasing risk. We report three cases of malignant cerebral infarction treated with hemicraniectomy followed by hypothermia. Case 1 received elective decompressive surgery and hypothermia. Case 2 developed subsequent cerebral infarction with uncal herniation. Therefore, emergent decompressive surgery and hypothermia was performed in this case. Despite surgery and hyperosmolar therapy, case 3 received hypothermia treatment for refractory increased intracranial pressure. All patients survived with a score of 4 or 5 on the modified Rankin scale. Therefore, we suggest that application of hypothermia after hemicraniectomy is safe and feasible. Several possible modifications can be made to improve the management strategy in order to increase the benefits of hypothermia treatment.

Craniectomy for Malignant Cerebral Infarction: Prevalence and Outcomes in US Hospitals

ObjectRandomized trials have demonstrated the efficacy of craniectomy for the treatment of malignant cerebral edema following ischemic stroke. We sought to determine the prevalence and outcomes related to this by using a national database.MethodsPatient discharges with ischemic stroke as the primary diagnosis undergoing craniectomy were queried from the US Nationwide Inpatient Sample from 1999 to 2008. A subpopulation of patients was identified that underwent thrombolysis. Two primary end points were examined: in-hospital mortality and discharge to home/routine care. To facilitate interpretations, adjusted prevalence was calculated from the overall prevalence and two age-specific logistic regression models. The predictive margin was then generated using a multivariate logistic regression model to estimate the probability of in-hospital mortality after adjustment for admission type, admission source, length of stay, total hospital charges, chronic comorbidities, and medical complications.ResultsAfter excluding 71,996 patients with the diagnosis of intracranial hemorrhage and posterior intracranial circulation occlusion, we identified 4,248,955 adult hospitalizations with ischemic stroke as a primary diagnosis. The estimated rates of hospitalizations in craniectomy per 10,000 hospitalizations with ischemic stroke increased from 3.9 in 1999–2000 to 14.46 in 2007–2008 (p for linear trend<0.001). Patients 60+ years of age had in-hospital mortality of 44% while the 18–59 year old group was found to be 24%(p = 0.14). Outcomes were comparable if recombinant tissue plasminogen activator had been administered.ConclusionsCraniectomy is being increasingly performed for malignant cerebral edema following large territory cerebral ischemia. We suspect that the increase in the annual incidence of DC for malignant cerebral edema is directly related to the expanding collection of evidence in randomized trials that the operation is efficacious when performed in the correct patient population. In hospital mortality is high for all patients undergoing this procedure.

Serious Cardiac Adverse Events After Decompressive Craniectomy for Malignant Cerebral Infarction

There is a significant association between cardiac dysfunction and ischemic stroke. The serious cardiac adverse events (SCAEs) after decompressive craniectomy for malignant cerebral infarction from ischemic stroke were studied retrospectively. Retrospective data were collected for preexisting cardiac risk factors, baseline clinical measures, and perioperative SCAEs including life-threatening arrhythmias, myocardial ischemia, cardiac failure, and cardiac arrest. The association between perioperative SCAEs and mortality was assessed using the χ(2) test. Data from 42 patients were analyzed. Mortality occurred in 19 (45.2%) patients. Eleven (57.9% of deaths) suffered mortality because of neurological causes, 7 patients (36.8% of mortality) because of cardiac causes, and 1 because of other causes. Mortality in patients who developed SCAEs was significantly higher than in those without SCAEs [75% mortality with SCAEs vs. 18.2% without SCAEs (P<0.0001)]. The odds ratio for mortality with SCAEs was 13.5 (3.1 to 59.5). There was a significant correlation between the number of SCAEs and mortality (Spearmans ρ=0.738 (P<0.0001). Serious cardiac events are common in the acute period after stroke and decompressive craniectomy, and are important contributors to mortality.

Do patients have any special medical or rehabilitation difficulties after a craniectomy for malignant cerebral infarction during their hospitalization in a physical medicine and rehabilitation department?

ObjectivesTo observe whether medical complications, the evolution of neurological disorders and dependence and/or the discharge destinations are different for patients treated by craniectomy for malignant cerebral infarction in the middle cerebral artery compared to patients treated medically for severe or malignant cerebral infarction in the same cerebral territory, during their hospitalization in a physical medicine and rehabilitation department. Patients and methodsThis retrospective study compared patients treated by craniectomy for malignant cerebral infarction in the middle cerebral artery and patients treated medically for severe or malignant cerebral infarction in the same cerebral territory. Patients were paired according to age, lesion side and hospitalization period. ResultsTwelve patients treated by craniectomy (age 43±10.44) were paired with 12 patients treated medically (age 49±7.66). The two groups were comparable in terms of general undesirable medical events. The medical events related to craniectomy are described. The evolution of patient deficiencies, the length of the hospital stay (194±118.93 days vs 152±94.64 days), the Functional Independence Measure at discharge (87±21.28 vs 95±22.19) and the number of direct home discharges (7 vs 9) did not significantly differ between groups. Discussion and conclusionNo more medical problems were observed in the patients treated by craniectomy than in the patients treated medically, except for the medical events specifically related to craniectomy, which extended the hospital stay but had no major repercussions.

Assessment of outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 60 years of age

Decompressive surgery can be life saving after malignant cerebral infarction. However, severe residual disability occurs in a significant number of surviving patients. Most discussion about the benefits of surgery is based on studies performed in patients who are < or = 60 years of age. Less is known about the benefits of the procedure in the elderly population. The authors undertook a review of the literature on decompressive craniectomy for malignant cerebral infarction and compared the mortality and outcome data published in patients older and younger than 60 years of age. The authors discuss their analysis, with specific reference to the limitations of the studies analyzed, the outcome measures used, and the special considerations required when discussing stroke recovery in the elderly. Studies on decompressive craniectomy for malignant middle cerebral artery infarction reported in the English literature were analyzed. A cutoff point for age of > 60 or < or = 60 years was set, and the study population was segregated. No studies specifically analyzed patients > 60 years old. A total of 19 studies was identified, 10 of which included patients who were > 60 years of age. A comparison between the 2 age groups was made within the 10 studies and also among all the patients in the 19 studies. Mortality rates and outcome scores were assessed for each study, and a Barthel Index (BI) score of < 60 or a modified Rankin Scale (mRS) score of > 3 was considered to represent a poor outcome. Rates were compared using the Fisher exact test, and p values < 0.05 were considered statistically significant. Nineteen studies were found, which included 273 patients undergoing decompressive craniectomy for malignant cerebral infarcts. Ten of these studies included 73 patients (26.7%) who were > 60 years of age. The mean follow-up times ranged from 5.75 to 12.3 months in the > 60-years group and 4.2 to 28 months in the < or = 60-years group. The mortality rate was significantly higher, at 51.3% in the > 60-years group (37 of 72 patients) compared with 20.8% (41 of 197 patients) in the < or = 60-years group (p < 0.0001). Similarly, patients who survived in the > 60-years group had significantly higher rates of poor outcomes, at 81.8% (27 of 33), compared with 33.1% (47 of 142) in the < or = 60-year-old group (p < 0.0001). The BI was the most commonly used primary outcome measure (15 out of 19 studies), followed by the mRS score, which was used in 4 studies. The mortality rate and functional outcome, as measured by the BI and mRS, were significantly worse in patients > 60 years of age following decompressive craniectomy for malignant infarction. Age is an important factor to consider in patient selection for surgery. However, cautious interpretation of the results is required because the outcome scores that were used only measure physical disability, whereas other factors, including psychosocial, financial, and caregiver burden, should be considered in addition to age alone.