Malignant Hemispheric Infarction Research Articles

Predicting Functional Outcome After Decompressive Craniectomy for Malignant Hemispheric Infarction: Clinical and Novel Imaging Factors

Decompressive craniectomy (DC) is an established optional treatment for malignant hemispheric infarction (MHI). We analyzed relevant clinical factors and computed tomography (CT) measurements in patients with DC for MHI to identify predictors of functional outcome 3-6 months after stroke. This study was performed at 2 comprehensive stroke centers. The inclusion criteria required DC for MHI, no additional intraoperative procedures (strokectomy or cerebral ventricular drain placement), and documented functional status 3-6 months after the stroke. We classified functional outcome as acceptable if the modified Rankin Scale score was <5, or as unacceptable if it was 5 or 6 (bedbound and totally dependent on others or death). Multiple logistic regression analyzed relevant clinical factors and multiple perioperative CT measurements to identify predictors of acceptable functional outcome. Of 87 identified consecutive patients, 66 met the inclusion criteria. Acceptable functional outcome occurred in 35 of 66 (53%) patients. Likelihood of acceptable functional outcome decreased significantly with increasing age (OR 0.92, 95% CI 0.82-0.97, P= 0.004) and with increasing post-DC midline brain shift (OR 0.78, 95% CI 0.64-0.96, P= 0.016), and decreased non-significantly with left-sided stroke (OR 0.30, 95% CI 0.08-1.10, P= 0.069) and with increasing craniectomy barrier thickness (OR 0.92, 95% CI 0.85-1.01, P= 0.076). Patient age and the post-DC midline shift may be useful in prognosticating functional outcome after DC for MHI. Stroke side and craniectomy barrier thickness merit further ideally prospective outcome prediction testing.

MALIGNANT HEMISPHERIC INFARCTION AFTER SUBTLE TRACHEAL RUPTURE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Tracheal rupture after endotracheal intubation is a rare but life-threatening complication with an incidence of approximately 0.005%. Predisposing factor can be a weakness of the membranous trachea secondary to chronic illness or steroid use. Herein we present a case of a young woman who developed a distal tracheal rupture after emergent endotracheal intubation with devastating consequences. CASE PRESENTATION: A 48-year-old female with a medical history of hypertension, epilepsy, and panhypopituitarism secondary to a respected craniopharyngioma was admitted to the intensive care unit with a diagnostic impression of obstructive uropathy with septic shock and multiorgan failure. Supportive management with aggressive fluids resuscitation, antibiotics, dual vasopressor therapy, and endotracheal intubation was given. Hours later, the patient became hemodynamically unstable requiring increased vasopressor therapy with increased demand in ventilation parameters. Physical examination was positive for massive subcutaneous emphysema from her chest tracking through facial and neck planes. A chest computerized tomography (CT) scan was performed and showed a distal tracheal rupture as the most likely cause of the massive pneumothorax that progressed to tension subcutaneous emphysema. Upon acute neurological deterioration, a head CT scan was performed, revealing a left pan-hemispheric malignant ischemic stroke involving the left anterior, middle, and posterior cerebral arteries suggestive of a left internal carotid artery (ICA) complete occlusion. The patient had a National Institutes of Health Stroke Scale score above 20, a left hemisphere infarction, and a GCS 3/11, conferring a poor clinical outcome. As poor prognosis and poor quality of life were expected, the family members opted to withdraw life support. DISCUSSION: Malignant hemispheric infarction has a mortality rate as high as 80 percent with catastrophic neurologic sequelae. Its incidence is less than ten percent of all ischemic infarcts and it's generally caused by embolic occlusion of the ICA. CONCLUSIONS: To our knowledge, there are no malignant hemorrhagic strokes provoked by traumatic intubation resulted from tracheal rupture documented to this day. We presume the etiology of this event to be subcutaneous air that exerted enough pressure between the fascial and cervical planes to result in significant vascular compression. Tracheal rupture is one of the most feared immediate complications of intubation as it could result in increased morbidity and mortality. There is no established consensus for the treatment yet, but early surgical repair has been the mainstay of treatment. However, conservative management has been chosen in cases of small ruptures with similar outcomes. REFERENCE #1: JOSEPH, M. M., & LEWIS, S. (2002). Stroke after penetrating trauma of the oropharynx. Pediatric Emergency Care, 18(3), 179–181.doi:10.1097/00006565-200206000-00007 DISCLOSURES: No relevant relationships by Ian Da Silva Lugo, source=Web Response No relevant relationships by Juan Feliciano-FIgueroa, source=Web Response No relevant relationships by Hector Nunez Medina, source=Web Response No relevant relationships by Héctor Oliveras-Cordero, source=Web Response No relevant relationships by Juan Santiago, source=Web Response

Limiting Brain Shift in Malignant Hemispheric Infarction by Decompressive Craniectomy

ObjectiveDecompressive craniectomy (DC) improves functional outcomes in selected patients with malignant hemispheric infarction (MHI), but variability in the surgical technique and occasional complications may be limiting the effectiveness of this procedure. Our aim was to evaluate predefined perioperative CT measurements for association with post-DC midline brain shift in patients with MHI. MethodsAt two medical centers we identified 87 consecutive patients with MHI and DC between January 2007 and December 2019. We used our previously tested methods to measure the craniectomy surface area, extent of transcalvarial brain herniation, thickness of tissues overlying the craniectomy, diameter of the cerebral ventricle atrium contralateral to the stroke, extension of infarction beyond the craniectomy edges, and the pre and post-DC midline brain shifts. To avoid potential confounding from medical treatments and additional surgical procedures, we excluded patients with the first CT delayed >30 hours post-DC, resection of infarcted brain, or insertion of an external ventricular drain during DC. The primary outcome in multiple linear regression analysis was the postoperative midline brain shift. ResultsWe analyzed 72 qualified patients. The average midline brain shift decreased from 8.7 mm pre-DC to 5.4 post-DC. The only factors significantly associated with post-DC midline brain shift at the p<0.01 level were preoperative midline shift (coefficient 0.32, standard error 0.10, p=0.002) and extent of transcalvarial brain herniation (coefficient -0.20, standard error 0.05, p <0.001). ConclusionsIn patients with MHI and DC, smaller post-DC midline shift is associated with smaller pre-DC midline brain shift and greater transcalvarial brain herniation. This knowledge may prove helpful in assessing DC candidacy and surgical success. Additional studies to enhance the surgical success of DC are warranted.

New CT measurements to assess decompression after hemicraniectomy: A two-center reliability study

ObjectivesTo test the reliability of three simplified measurements made after decompressive hemicraniectomy (DHC) for malignant hemispheric infarction on computed tomography (CT) scan. Patients and methodsWe defined new simple methods to measure the thickness of the soft tissues overlying the craniectomy defect and the extent of infarction beyond the anterior and posterior craniectomy edges on post-DHC CT. Multiple raters independently made the three new CT measurements in 49 patients from two institutions. The Intraclass Correlation Coefficient (ICC) compared the raters for interrater agreements (reliability). ResultsBetween two raters at Augusta University Medical Center, each measuring 21 CT scans, the ICC coefficient point estimates were good to excellent (0.83 – 0.92). Among four raters at University of Virginia Medical Center, with three raters measuring each of 28 CT scans, the ICC coefficient point estimates were good to excellent (0.87 – 0.95). ConclusionsThe proposed simple methods to obtain three additional CT measurements after DHC in malignant hemispheric infarction have good to excellent reliability in two independent patient samples. The clinical usefulness of these measurements should be investigated.

Radiological Parameters Predicting Clinical Outcome After Decompressive Hemicraniectomy in Malignant Ischemic Stroke

Abstract INTRODUCTION Decompressive Hemicraniectomy (DH) is advocated as a lifesaving procedure in the management of patients with raised intracranial pressure due to malignant hemispheric infarction. The purpose of this study was to identify radiological parameters predicting the clinical outcome in patients with DH in large-territory ischemic stroke. METHODS Patients undergoing DH for malignant ischemic stroke were identified from electronic data base search (2011-2018). Logistic regression analysis evaluated the association of radiological variables with clinical outcome according to modified Rankin Scale (mRS) and Glasgow Outcome Scale Extended (GOSE) at 180 d. RESULTS Among 98 patients, 59 (60.2%) underwent CT scan post DH within 24 h. The median age of the included patients was 54 yr (29-80 yr), with males being predominant (89.8%). The mean NIHSS score for the included patients was 18.64 ± 6.8 (3-33), and majority of the patients (88.1%) had Middle Cerebral Artery Infarction (MCA). The mean mRS and GOSE at 180 d were 3.88 ± 1.39 and 4.12 ± 1.8, respectively. Univariate analysis identified a greater likelihood of good functional outcome in patients with ischemic stroke post DH on CT scan if there was absence of effacement of cortical sulci [OR 1.31: 95% CI: 1.28-1.39; P = .05], absence of effacement of basal cisterns [OR 3.4: 95% CI:1.36-8.5; P = .03], absence of hemorrhagic transformation in the infarct core [OR 2.3: 95% CI: 2.00-2.65; P = .03], or absence of compression of lateral ventricle [OR 1.25: 95% CI: 1.20-1.27; P = .05]. Furthermore, multivariate analysis found significant association in predicting good functional outcome with absence of effacement of cortical sulci [OR 2.01: 95% CI: 1.22-20.71; P = .02], absence of hemorrhagic transformation [OR 2.09: 95% CI: 1.01-27.30; P = .02], and absence of compression of lateral ventricles [OR 1.35: 95% CI: 1.28-18.4; P = .05], but absence of effacement of basal cisterns was not statistically significant (P = .36). CONCLUSION The radiographic features post DH in ischemic stroke predict the clinical outcome, thus stratify our management plan.

Decompressive craniectomy in malignant hemispheric infarction: favorable outcome and disability

ContextPatients with malignant middle cerebral artery (MCA) infarction are prone to a mortality rate of 70–80%. Decompressive craniectomy (DC) has been used as an important treatment modality to control refractory intracranial hypertension.AimIn this study, we aimed to evaluate the impact of DC in reducing mortality rate and improving the functional outcome in the patients who underwent DC surgery for malignant MCA infarctionSettings and designThe prospective clinical case study included 24 patients with refractory intracranial hypertension due to malignant MCA infarctionPatients and methodsAll patients enrolled in the study have refractory intracranial hypertension due to malignant MCA infarction; they were allocated to undergo decompressive craniectomy between 2014 and 2017. Each patient was evaluated clinically using the Glasgow Coma Scale (GCS) and the modified Rankin Scale (mRS).ResultsAll patients on admission have the GCS of 5–12 score (mean 8). Fourteen patients underwent DC in the first 48 h while 10 patients were operated upon after 48 h. Postoperatively, two patients (9%) had a score of 3 on the modified Rankin Scale, six patients (25%) had a score of 4, and eight patients (33%) had a score of 5. Mortality occurred in eight patients (33%) with the worst score of 6. Similar unfavorable outcome was reported at 6- and 12-month follow-up with different degrees of disability.ConclusionDecompressive craniectomy for malignant MCA infarction has an effective role in decreasing the mean intracranial pressure, reducing the mortality rate, and increasing the number of patients with a favorable outcome.

Maximum Decompressive Hemicraniectomy for Patients with Malignant Hemispheric Infarction.

ObjectiveThe authors applied maximum external decompression for malignant hemispheric infarction and investigated the functional outcome according to the patient age.MethodsTwenty-five patients with malignant hemispheric infarction were treated using a hemicraniectomy with maximum external decompression, comprising a larger (>14cm) hemicraniectomy, resection of the temporalis muscle and its fascia, spaciously expansive duraplasty, and approximation of the skin flap. The medical and diagnostic imaging records for the patients were reviewed, and 1-year functional outcome data obtained for the younger group (aged ≤ 60 years) and elderly group (aged > 60 years).ResultsThe patients (n=25) who underwent maximum surgical decompression revealed a minimal mortality rate (n=2, 8.0%). The patients (n=14) in the younger group all survived with mRS scores of 2 (n=1, 7.1%), 3 (n=7, 50.0%), 4 (n=3, 21.4%), or 5 (n=3, 21.4%). A majority of the younger patients (57.1% with mRS ≤3) lived with functional independence. When the 1-year mRS scores were dichotomized between favorable (mRS ≤3) and unfavorable (mRS ≥4) outcomes, the younger group had significantly more patients with a favorable outcome than the elderly group (57.1% versus 9.1%, p=0.033). In contrast, in the elderly group, most patients showed unfavorable outcomes with the mRS scores of 4 (n=5, 45.5%), 5 (n=3, 27.3%), or 6 (n=2, 18.2%), whereas only one patient showed favorable outcome (mRS 3). A majority of the elderly patients (45.5% with mRS 4) survived with moderately severe disability.ConclusionFor malignant hemispheric infarction, a hemicraniectomy with maximum external decompression was found to considerably increase survival with a favorable outcome in functional independence (mRS ≤3) for younger patients aged ≤60 years. It can be optimal surgical treatment for younger patients.

Refractory Intracranial Hypertension: The Role of Decompressive Craniectomy.

Raised intracranial pressure (ICP) is associated with worse outcomes after acute brain injury, and clinical guidelines advocate early treatment of intracranial hypertension. ICP-lowering therapies are usually administered in a stepwise manner, starting with safer first-line interventions, while reserving higher-risk options for patients with intractable intracranial hypertension. Decompressive craniectomy is a surgical procedure in which part of the skull is removed and the underlying dura opened to reduce brain swelling-related raised ICP; it can be performed as a primary or secondary procedure. After traumatic brain injury, secondary decompressive craniectomy is most commonly undertaken as a last-tier intervention in a patient with severe intracranial hypertension refractory to tiered escalation of ICP-lowering therapies. Although decompressive craniectomy has been used in a number of conditions, it has only been evaluated in randomized controlled trials after traumatic brain injury and acute ischemic stroke. After traumatic brain injury, decompressive craniectomy is associated with lower mortality compared to medical management but with higher rates of vegetative state or severe disability. In patients with stroke-related malignant hemispheric infarction, hemicraniectomy significantly decreases mortality and improves functional outcome in adults <60 years of age. Surgery also reduces mortality in those >60 years, but results in a higher proportion of severely disabled survivors compared to medical therapy in this age group. Decisions to recommend decompressive craniectomy must always be made not only in the context of its clinical indications but also after consideration of an individual patient's preferences and quality of life expectations. This narrative review discusses the management of intractable intracranial hypertension in adults, focusing on the role of decompressive craniectomy in patients with traumatic brain injury and acute ischemic stroke.

Herniation despite Decompressive Hemicraniectomy in Large Hemispherical Ischemic Strokes

Despite decompressive hemicraniectomy (DHC), progressive herniation resulting in death has been reported following middle cerebral artery (MCA) strokes. We aimed to determine the surgical parameters measured on brain computed tomography (CT) scan that are associated with progressive herniation despite DHC in large MCA strokes. Retrospective chart review of medical records of patients with malignant hemispheric infarction who underwent DHC for cerebral edema was performed. Infarct volume was calculated on CT scans obtained within 24 hours of ictus. Radiological parameters of craniectomy bone flap size, brain volume protruding out of the skull, adequate centering of the craniectomy over the stroke bed, and the infarct volume outside the craniectomy bed (volume not centered [VNC]) were measured on the postoperative brain CT. Of 41 patients who underwent DHC, 7 had progressive herniation leading to death. Radiographic parameters significantly associated with progressive herniation included insufficient centering of craniectomy bed on the stroke bed (P = .03), VNC (P = .011), additional anterior cerebral artery infarction (P = .047), and smaller craniectomy length (P = .05). Multivariate logistic regression analysis for progressive herniation using craniectomy length and VNC as independent variables demonstrated that a higher VNC was significantly associated with progressive herniation despite surgery (P = .029). In large MCA strokes, identification of large infarct volume outside the craniectomy bed was associated with progressive herniation despite surgery. These results will need to be verified in larger prospective studies.

Abstract WP339: Herniation Despite Decompressive Hemicraniectomy in Large Hemispherical Ischemic Stroke Patients

Background: Despite timely decompressive hemicraniectomy (DHC), clinical failure or progressive herniation requiring a second decompression procedure and mortality has been reported in acute middle cerebral artery (MCA) strokes. Hypothesis: Our objective was to determine the stroke and surgical parameters measured on head CT scan that are associated with progressive herniation despite DHC in patients with large hemispheric MCA strokes. Methods: Retrospective chart review of all medical records and imaging features of patients with malignant hemispheric infarction who underwent DHC for cerebral edema from July 2010 to June 2015, was performed. Patients who died from postoperative hemorrhagic complications were excluded. Infarct volume was calculated using ABC/2 method on CT scans within 48 hours of symptom onset (Kostov et al, 2012, World Neurosurg). Radiologic parameters of the craniectomy bone flap (length, width, area) and brain volume protruding out of the skull (height and volume) were measured (Chung et al, 2011, Neurologist). Images were reviewed by a board certified neuroradiologist to determine whether the craniectomy bed was sufficiently centered on the stroke bed (Zweckberger et al, 2014, Cerebrovasc Dis) and the brain volume not included in the craniectomy bed. Groups were compared using Fisher exact test for categorical variables and T-test or Mann-Whitney U test for continuous variables, as appropriate. Results: Out of 41 patients who underwent DHC for cerebral edema (mean age 53.1 ±12, 48.7% females, 36.5% African Americans) 7 had progressive herniation leading to mortality. Radiographic parameters that were significantly different between both groups were presence of malignant edema (p=0.047), insufficient centering of the craniectomy bed on the stroke bed (p=0.03), large infarct volume not centered on the craniectomy bed (p=0.011), presence of anterior cerebral artery infarction (p=0.047), and smaller craniectomy length (p=0.05). There was a trend in protruding brain volume (p=0.056). Conclusion: Besides the craniectomy length, sufficient centering of the craniectomy over the stroke bed may be required to prevent progressive herniation.

Challenges in the Anesthetic and Intensive Care Management of Acute Ischemic Stroke.

Acute ischemic stroke (AIS) is a devastating condition with high morbidity and mortality. In the past 2 decades, the treatment of AIS has been revolutionized by the introduction of several interventions supported by class I evidence-care on a stroke unit, intravenous tissue plasminogen activator within 4.5 hours of stroke onset, aspirin commenced within 48 hours of stroke onset, and decompressive craniectomy for supratentorial malignant hemispheric cerebral infarction. There is new class I evidence also demonstrating benefits of endovascular therapy on functional outcomes in those with anterior circulation stroke. In addition, the importance of the careful management of key systemic physiological variables, including oxygenation, blood pressure, temperature, and serum glucose, has been appreciated. In line with this, the role of anesthesiologists and intensivists in managing AIS has increased. This review highlights the main challenges in the endovascular and intensive care management of AIS that, in part, result from the paucity of research focused on these areas. It also provides guidelines for the management of AIS based upon current evidence, and identifies areas for further research.

Critical Age Affecting Functional Outcome after Decompressive Hemicraniectomy for Malignant Hemispheric Infarction

Although age already is known as a crucial factor affecting the functional outcome after a hemicraniectomy for malignant hemispheric infarction, previous studies have used arbitrary age cut-offs of 50, 60, or 70 years. Therefore, this study investigated predictors of the functional outcome after a hemicraniectomy and attempted to determine the critical age for an unfavorable functional outcome. A total of 38 patients with large hemispheric infarction were treated with a decompressive hemicraniectomy and the corresponding 1-year modified Rankin Scale (mRS) data obtained. An array of clinical variables was then investigated in relation to the functional outcomes. A multivariate analysis that used binary multiple logistic regression revealed that advanced age was a statistically significant predictor of an unfavorable 1-year functional outcome. In a receiver operating characteristic curve analysis for age, a patient age >58 years was determined as an appropriate cut-off value for predicting an unfavorable outcome. The patients aged >58 years showed an 82% positive predictive value (PPV) for an unfavorable outcome with mRS ≥4, and a 50% PPV for mRS ≥5. Moreover, a patient age cutoff value of >67 years exhibited a 100% PPV for predicting an unfavorable functional outcome with mRS ≥4. Advanced age was identified as a significant predictor of an unfavorable outcome and functional dependency. The PPV of a patient age >58 years and >67 years for predicting an unfavorable outcome with functional dependency was 82% and 100%, respectively.

Malignant hemispheric infarction of the middle cerebral artery. Diagnostic considerations and treatment options

IntroductionMalignant hemispheric infarction (MHI) is a specific and devastating type of ischaemic stroke. It usually affects all or part of the territory of the middle cerebral artery although its effects may extend to other territories as well. Its clinical outcome is frequently catastrophic when only conventional medical treatment is applied. ObjectiveThe purpose of this review is to analyse the available scientific evidence on the treatment of this entity. DevelopmentMHI is associated with high morbidity and mortality. Its clinical characteristics are early neurological deterioration and severe hemispheric syndrome. Its hallmark is the development of space-occupying cerebral oedema between day 1 and day 3 after symptom onset. The mass effect causes displacement, distortion, and herniation of brain structures even when intracranial hypertension is initially absent. Until recently, MHI was thought to be fatal and untreatable because mortality rates with conventional medical treatment could exceed 80%. In this unfavourable context, decompressive hemicraniectomy (DHC) has re-emerged as a therapeutic alternative for selected cases, with reported decreases in mortality ranging between 15% and 40%. ConclusionsIn recent years, several randomised clinical trials have demonstrated the benefit of DHC in patients with MHI. This treatment reduces mortality in addition to improving functional outcomes.

Safety and outcomes of decompressive craniectomy after intravenous tissue plasminogen activator administration for malignant cerebral infarction

Objective: The aim of this study was to evaluate the safety and outcomes of decompressive craniectomy (DC) after intravenous tissue plasminogen activator (IV tPA) administration for malignant cerebral infarction. Methods: We retrospectively reviewed patients who underwent DC for malignant cerebral infarction. We compared fourteen patients who underwent DC after IV tPA administration with another nine patients who underwent DC without prior IV tPA administration. Results: Twenty-three patients underwent DC for malignant hemispheric cerebral infarction in our hospital for five years. Fibrinolysis was performed prior to the DC in fourteen patients (60,9%). The patients characteristics did not differ between the DC patients with and without prior IV tPA administration. The complications that developed after DC were similar in both groups: in patients who underwent DC after IV tPA administration, 9 (64.3%) developed haemorrhagic transformation and 6 (42.9%) developed hydrocephalus. The functional outcome, as the 6-month GOS, was similar in both groups (p = 0.762). ICU mortality (p = 0.329) and hospital mortality after ICU (p= 0.634) were also similar between the two groups. Conclusion: Although the main limitation is that the number of patients in our serie was small, which reduced the statistical power, our study suggest that DC after failure of IV tPA administration for malignant cerebral infarction is safe and did not cause an excess of complications arising from the use of fibrinolytic.

Hydrocephalus after decompressive craniectomy for malignant hemispheric cerebral infarction

Purpose: Several studies have investigated the incidence and risk factors of hydrocephalus after decompressive craniectomy (DC) for malignant hemispheric cerebral infarction. However, the results are controversial. Therefore, the following is a retrospective cohort study to determine the incidence and risk factors of hydrocephalus after DC for malignant hemispheric cerebral infarction. Materials and methods: From January 2004 to June 2014, patients at two medical centres in south-west China, who underwent DC for malignant hemispheric cerebral infarction, were included. The patients’ clinical and radiologic findings were retrospectively reviewed. A chi-square test, Mann–Whitney U-test and logistic regression model were used to identify the risk factors. Results: A total of 128 patients were included in the study. The incidence of ventriculomegaly and shunt-dependent hydrocephalus were 42.2% (54/128) and 14.8% (19/128), respectively. Lower preoperative Glasgow Coma Scale (GCS) score and presence of subarachnoid haemorrhage (SAH) were factors significantly associated with the development of post-operative hydrocephalus after DC. Conclusions: Cerebral infarction patients receiving DC have a moderate tendency to suffer from post-operative hydrocephalus. A poor GCS score and the presence of SAH were significantly associated with the development of hydrocephalus after DC.

Predictors of clinical failure of decompressive hemicraniectomy for malignant hemispheric infarction

ObjectThe aim of this study is to identify pre-operative clinical and/or radiological predictors of clinical failure of decompressive hemicraniectomy (DH) in the setting of malignant hemispheric infarction. These predictors could guide the decision for adjunctive internal brain decompression (e.g. strokectomy) at the time of the initial DH. MethodsRetrospective chart review of all patients with malignant hemispheric infarction who underwent DH at our institution, from November 2008 to January 2013. Demographics, pre- and post-operative clinical characteristics and neuroimaging data were reviewed. The surgical outcome after DH was evaluated and clinical failure was defined as follows: lack of post-operative resolution of basal cistern effacement, and/or failure to achieve a post-operative decrease in midline shift by at least 50%, and/or post-operative neurological deterioration felt to be due to persistent mass effect, with or without a second, salvage operation (strokectomy). ResultsOut of 26 patients included in the study, 7 were considered to have clinical failure of their DH. Preoperative clinical and imaging variables were similar in the two groups, except that the presence of a nonreactive pupil immediately before surgery was associated clinical failure of the DH (p=0.0015). Patients in the clinical failure group had a lower postoperative GCS motor score and a strong but not statistically significant trend towards less favorable functional outcome (GOS 1–3). ConclusionsThe presence of a nonreactive pupil before surgery is associated with clinical failure of DH, and should be taken into account when deciding whether to perform strokectomy at the time of DH.

The intensive care management of acute ischemic stroke: an overview

Acute ischemic stroke (AIS) is a leading cause of morbidity and mortality worldwide. In part due to the availability of more aggressive treatments, increasing numbers of patients with AIS are being admitted to the intensive care unit (ICU). Despite the availability of consensus guidance for the general management of AIS, there is little evidence to support its ICU management. The purpose of this article is to provide a contemporary perspective, and our recommendations, on the ICU management of AIS. We reviewed the current general AIS guidelines provided by the European Stroke Organisation, the American Stroke Association, and the U.K. National Institute for Health and Care Excellence, as well as the wider literature, for the data most relevant to the ICU management of AIS. There are four interventions in AIS supported by class I evidence: care on a stroke unit, intravenous tissue plasminogen activator within 4.5 h of stroke onset, aspirin within 48 h of stroke onset, and decompressive craniectomy for supratentorial malignant hemispheric cerebral infarction. However, robust evidence for specific AIS management principles in the ICU setting is weak. Management principles currently focus on airway and ventilation management, hemodynamic and fluid optimization, fever and glycemic control, management of anticoagulation, antiplatelet and thromboprophylaxis therapy, control of seizures and surgical interventions for malignant middle cerebral artery and cerebellar infarctions. We have provided our recommendations for the principles of ICU management of AIS, based on the best available current evidence. Encouragement of large-scale recruitment of patients with AIS into clinical trials should aid the development of robust evidence for the benefit of different interventions in the ICU on outcome.

Decompressive Hemicraniectomy for Malignant Hemispheric Stroke in the Elderly: Comparison of Outcomes between Individuals 61-70 and >70 Years of Age

Malignant hemispheric infarction is a life-threatening condition with a high mortality rate. Decompressive hemicraniectomy (DHC) is frequently a life-saving procedure that has shown the highest grade of evidence for patients 18 to 60 years of age. However, the efficacy of DHC in patients>60 years of age has rarely been investigated. A retrospective study was conducted in a single academic institution. Surrogates of patients with clinical signs of impending brain herniation despite standard medical therapy were offered the option of DHC regardless of age or the side of the lesion. The clinical data from 18 patients>60 years of age who underwent DHC for malignant hemispheric infarction in our institution were analyzed. Patients were classified into the following 2 groups: 61-70 and >70 years of age, and their demographics and surgical outcomes were compared. The variables compared included the male:female ratio, side of the lesion, type of stroke, site of vascular occlusion, use of thrombolytic therapy, National Institutes of Health Stroke Scale score, stroke onset-to-DHC interval, duration of hospital stay, infectious complications, and 90-day mortality rate. There were no significant intergroup differences in any of the demographic variables evaluated. However, the 30-day mortality rate was significantly higher in the group that was >70 years of age (0% v 60%; P=.01) than in the group that was 61 to 70 years of age. We suggest that the efficacy of DHC in malignant hemispheric stroke patients between 61 and 70 years of age be further investigated in future randomized trials. By contrast, it appears unlikely that patients>70 years of age would benefit from DHC.

Abstract TMP15: Contralateral Hemispheric Atrophy After Major Hemispheric Infarction

Objective: Atrophy of the ipsilateral hemisphere, cerebral peduncle, and contralateral cerebellum predict outcome after stroke; little is known of the effect of stroke on the contralateral hemisphere although it plays an important role in functional reorganization. Methods: All patients who underwent decompressive hemicraniectomy for malignant hemispheric infarction at UH-CMC between 1/2003-12/2009 were analyzed with IRB approval. Patients with adequate CT scans both prior to surgery and after reconstructive cranioplasty were included; those with communicating hydrocephalus, confounding lesions or ≥ 10 mm of midline shift were excluded. Brainlab iPlan® software (Germany) was used to manually trace the infarct, non-infarct ipsilateral and contralateral hemisphere on axial, sagittal and coronal slices. Results: Of 30 patients, 9 met inclusion criteria. The inter-rater reliability of volumetric analyses was excellent (r=0.99). The mean contralateral hemisphere volume at follow-up was significantly reduced compared to the baseline study (465.987 ± 78.32 cc vs 493.429 ±76.92 cc, p&lt; 0.0001, Fisher’s two-tailed t-test ). Contralateral hemispheric atrophy was identified in all patients (mean 27.441 cc, range 4.985 - 42.807 cc) and represented a loss of 5.7% (1.2 - 11.16%) of the original volume. Contralateral hemispheric atrophy was significantly related to the volume of the infarct and the time from stroke onset to decompressive hemicraniectomy but not to the extent of midline shift on the post-operative scan nor &lt;10 mm on the pre-operative scan. Contralateral hemispheral atrophy was identified early and not related to the length of follow-up (median 4.5, range 2-43 months). Conclusions: Contralateral hemispheric atrophy occurs within months of major hemispheral infarction and is related to infarct size and the time to decompressive hemicraniectomy.

Where are We Now with Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction?

In spite of the best medical treatment, large hemispheric infarction, resulting from acute occlusion of either the internal carotid or the proximal middle cerebral artery with insufficient collateral blood flow is associated with a high case fatality rate of approximately 60%. Thus, a decompressive hemicraniectomy is considered a life-saving procedure for this devastating disease. Findings of three recent randomized, controlled clinical trials and their meta-analysis showed that early surgical decompression not only reduced the number of case fatalities but also increased the incidence of favorable outcomes. The authors review the pathophysiology, historical background in previous studies, operative timing, surgical technique and clinical outcomes of surgical decompression for malignant hemispheric infarction.