Massive Hemispheric Infarction Research Articles

Limits and Prognostic Factors for Surgical Decompression in The Management of Massive Hemispheric Infarction

Limits and Prognostic Factors for Surgical Decompression in The Management of Massive Hemispheric Infarction

Abstract W P228: Delayed Decompression Hemicraniectomy in Massive Hemispheric Infarction Reduces Mortality but Does Not Improve Functional Outcome

Background: Massive hemispheric infarctions associated with extensive cerebral edema are associated with grave prognosis. Decompressive hemicraniectomy improves outcomes if performed within 48-hours of stroke-onset. In Asia, surgical decompression is often performed late, often after significant clinic-radiological deterioration occurs. We report our experience with decompressive hemicraniectomy when performed after clinical deterioration, radiologolic herniation or pupil dilatation. Methods: In this retrospective review, we identified acute anterior circulation ischemic stroke patients who underwent ‘delayed’ decompressive hemicraniectomy at our tertiary institution during 2006-2012. We defined ‘delayed’ surgical intervention as the decompressive hemicraniectomy performed after rapid neurological deterioration (drop of 2 or more points on the Glasgow Coma Scale), evidence of cerebral herniation on clinical and/or neuroimaging criteria. Poor functional outcomes were assessed by modified Rankin score 4-6 points at 90 days. Results: A total of 54 patients (11males, mean age 56 years; range 26-77 years) were included in this study, 36 (67%) male. Mean NIHSS at the time of hospital admission was 21 points (range 12-29). All patient developed clinical deterioration, pupil dilatation and/or radiological signs of cerebral herniation before decompressive surgery. Median time elapsed between stroke onset and surgery was 50.5 hours (range 11-144). Poor functional outcomes were noted in 40 (74%) with mortality in 16 (30%). Univariate analysis revealed higher age, late time to surgery, pupil dilatation and rapid neurological deterioration before surgery associated with poor outcomes. However logistic regression revealed only delayed hemicraniectomy (OR 1.153 per hour increase; 95% confidence interval 1.036-1.283, p=0.009) as the independent predictor of poor functional outcome. Conclusions: Although delayed decompressive hemicraniectomy in massive hemispheric ischemic stroke reduces mortality, it results in poor functional outcomes. Our results support early surgical intervention, independent of clinical deterioration or radiological herniation for reducing disabilities and the burden on the families.

Early prediction of poor outcome in severe hemispheric stroke by EEG patterns and gradings

Objectives: To find out the EEG abnormal patterns in massive cerebral hemispheric infarction (MCHI) and their correlation with poor outcome, and to construct an EEG grading for predicting the outcome of MCHI patients.Methods: Between 2000 and 2010, 162 patients with MCHI who met the selection criterions were selected for this study. All the patients underwent EEG examinations within 3 days after stroke onset and repeated on day 2 and 3. We classified the EEG recordings into 9 patterns and anglicized the correlation between EEG patterns and outcome. Then according to the results of the correlation between EEG patterns and outcome we constructed an EEG grading for predicting the outcome of MCHI patients.Results: We revealed that patterns of dominant alpha without reactivity, RAWOD, burst-suppression, α/θ-coma, epileptiform activity (without burst-suppression), and generalized suppression were correlated to poor outcome. We further modified the Young grading according to the correlation between EEG patterns and outcome. We found that the modified grading was superior to existing EEG gradings in predicting the outcome of MCHI patients, and it could predict the outcome of MCHI more accurately.Conclusions: MCHI is common in N-ICU (Neurology Intensive Care Unit). The EEG analysis would detect the degree of brain lesion during the ischemia within the acute stage after stroke onset. The EEG evaluation might assist the neurophysicians to predict outcome of patients and make decisions on the treatments.

Measurement of Brain Edema by Noninvasive Cerebral Electrical Impedance in Patients with Massive Hemispheric Cerebral Infarction

Background: Malignant cerebral infarction often occurs in patients with massive cerebral infarction. Monitoring brain edema is therefore helpful to make correct clinical decisions. Our previous studies have confirmed that cerebral electrical impedance (CEI) can sensitively reflect the brain edema after stroke. Methods: The CEI was measured consecutively by a noninvasive brain edema monitor in 69 patients with massive hemispheric cerebral infarction (MHCI). The results of the CEI were converted into the perturbation index (PI). The characteristics of dynamic changes of the CEI after MHCI were analyzed. Receiver-operating characteristics analysis was used to calculate predictive values for PI and other known parameters including NIHSS score and infarct volume. Results: (1) The overall rate of positive CEI was 88.4% (61/69) in all patients with MHCI. (2) The PI on the infarct side increased significantly within 24 h after stroke onset and reached a peak level 3–5 days after stroke onset (p < 0.01). (3) Age, NIHSS score at admission, infarct volume, and the PI at 24 h after stroke onset were significantly different between the malignant and nonmalignant groups. The best predictor of a malignant MHCI was the PI at 24 h after stroke onset with a cut-off value of 10.02 (90.9% sensitivity, 87.2% specificity, 76.9% positive predictive value, 95.3% negative predictive value). Conclusions: The noninvasive CEI can sensitively reflect the brain edema in patients with MHCI. Monitoring the CEI may help to predict malignant MHCI and guide treatment decisions.

Surgical decompression for cerebral oedema in acute ischaemic stroke

Large cerebral infarction has a high case fatality. Despite the use of conventional medical treatments such as hyperventilation, mannitol, diuretics, corticosteroids and barbiturates, the outcome of this condition remains poor. Decompressive surgery to relieve intracranial pressure is performed in some cases, although evidence of any clinical benefits has not been available until recently. This is an update of a Cochrane review first published in 2002. To examine the effects of decompressive surgery in patients with massive acute ischaemic stroke complicated with cerebral oedema, and to judge whether decompressive surgery is effective in improving survival or survival free of severe disability. We searched the Cochrane Stroke Group's Trials Register (last searched October 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 7), MEDLINE (1966 to October 2010), EMBASE (1980 to October 2010) and Science Citation Index (October 2010). We also searched the reference lists of all relevant articles. Randomised controlled studies of decompressive surgery plus medical treatment versus medical treatment alone in patients with clinically and radiologically confirmed cerebral infarcts complicated with cerebral oedema. One author assessed the titles and retrieved the relevant studies. The same author extracted data, with discussion among all authors for clarification. Outcomes were death at the end of follow-up, death or disability defined as the modified Rankin Scale (mRS) > 3 at the end of follow-up, death or severe disability defined as mRS > 4 at 12 months and disability defined as mRS 4 or 5 at 12 months. The results are given using the Peto odds ratio (Peto OR) with 95% confidence intervals (CIs). We included three trials in this review, involving 134 patients who were 60 years of age or younger. The time window for the intervention was 30 hours from stroke onset in two studies and 96 hours in one study. All trials were stopped early. Surgical decompression reduced the risk of death at the end of follow-up (OR 0.19, 95% CI 0.09 to 0.37) and the risk of death or disability defined as mRS > 4 at 12 months (OR 0.26, 95% CI 0.13 to 0.51). Death or disability defined as mRS > 3 at the end of follow-up was no different between the treatment arms (OR 0.56, 95% CI 0.27 to 1.15). Surgical decompression lowers the risk of death and death or severe disability defined as mRS > 4 in selected patients 60 years of age or younger with a massive hemispheric infarction and oedema. Optimum criteria for patient selection and for timing of decompressive surgery are yet to be defined. Since survival may be at the expense of substantial disability, surgery should be the treatment of choice only when it can be assumed, based on their preferences, that it is in the best interest of patients. Since all the trials were stopped early, an overestimation of the effect size cannot be excluded.

Application of Electrophysiologic Techniques in Poor Outcome Prediction Among Patients With Severe Focal and Diffuse Ischemic Brain Injury

To explore various electrophysiologic examinations as predictors for poor outcome in patients with severe ischemic brain injury, by comparing the prognostic ability of EEG, short-latency somatosensory evoked potentials (SLSEP), and brain stem auditory evoked potentials (BAEP). EEG, SLSEP, and BAEP were recorded in 161 patients with severe ischemic brain injuries (Glasgow Coma Scale ≤ 8), 77 with anoxic-ischemic encephalopathy after cardiopulmonary resuscitation, while 84 experienced massive hemispheric infarction at between 1 and 7 days after the onset. Outcomes were reviewed after 6 months using the Glasgow Outcome Scale. Six months after the onset, poor outcomes (Glasgow Outcome Scale, 1-2) were identified in 66 and 54 patients among the anoxic-ischemic encephalopathy and the massive hemispheric infarction group, respectively. By using the prognostic authenticity analysis of predictors, unfavorable EEG patterns, lack of EEG reactivity, pathologic N20 of SLSEP, and pathologic wave V of BAEP showed the high sensitivity (92.4%-97.0%, 95% confidence interval [CI]: 82.5%-99.5%), while bilateral absence of SLSEP N20 showed the highest specificity (100%, 95% CI: 67.9%-100%) and positive predictive value (100%, 95% CI: 90.4%-100%) in the anoxic-ischemic encephalopathy group. In the massive hemispheric infarction group, unfavorable EEG patterns showed the highest sensitivity (96.3%, 95% CI: 86.2%-99.4%) while bilateral absence of SLSEP N20 and BAEP wave V showed the highest specificity (100%, 95% CI: 85.9%-100%) and positive predictive value (100%, 95% CI: 80.8%-100%). The predictive power of electrophysiologic examinations is different according to the etiology of ischemic brain injury. Short-latency somatosensory evoked potentials (N20) can be considered the most powerful method to predict poor outcome in anoxic-ischemic encephalopathy. Combination of EEG (unfavorable EEG patterns) and SLSEP (N20)/BAEP (wave V) is best suited in massive hemispheric infarction to predict poor outcome.

High Mortality Among Children with Sickle Cell Anemia and Stroke Who Discontinue Chronic Blood Transfusion After Transition to An Adult Program

AbstractAbstract 1629 Introduction:The Comprehensive Sickle Cell Disease study (CSCD) of 4082 patients showed that the likelihood of developing stroke was 11% by the age of 20 years for patients with sickle cell anemia (SS).The stroke prevention trials (STOP I and STOP II) in SS showed that blood transfusion prevents the occurrence of primary stroke in children with abnormal TransCranial Doppler (TCD) velocities (STOP1) and discontinuation of transfusions after 30 months resulted in a high rate of reversion to abnormal TCD velocities and stroke (STOP II). To that end all children with abnormal TCD velocities are managed with chronic blood transfusion without interruption as long as they are in pediatrics. The problem arises when they are due to be transferred to adult care after the age of 18 years. The transition process from pediatrics to adult programs is marred with several issues that often result in interruption or discontinuation of the quality care the patients had as children. There is little or no information in the literature about the outcome of children with stroke after transition to adult programs. In this study we report the outcome of 22 patients, 10 males and 12 females, with SS and stroke who were referred to our adult program from several Children's hospitals between 1993 and 2009. Patients & Methods:Records were kept prospectively. The mean age of patients at transition was 22.4 ± 3.10 years. Blood bank data were performed and computerized according to FDA and AABB regulations. Blood counts and % Hb S were done before and after each transfusion. Hb S was kept below 30% or 50% after transfusion. Metabolic profiles were done every 6 months or more often if needed. Molecular diagnostics including alpha genotypes and beta globin haplotypes were done by described methods. Statistical analysis was by the 2-tailed t test. Results:All patients had ischemic strokes during childhood and one had hemorrhagic stroke superimposed on cerebral infarction. Two patients developed moyamoya after transition. No alpha gene deletion was detected in 18 patients, 4 had one alpha gene deletion and none had 2 alpha gene deletion. The Ben/CAR haplotype was found in 7 patients, Ben/Ben in 5, Ben/Sen in 4 and other combinations in 6 patients; 21 patients were heterozygous for the Ben haplotype. Hb F was 1.0–7.0% except for one patient on hydroxyurea (HU) with 20% Hb F. All patients were kept on the same regimen of transfusion they had as children; 15 were kept on exchange transfusion two of whom were non-compliant, two were kept on simple transfusion plus HU and the remaining 5 patients refused to have chronic blood transfusion and were kept on normal care. Some of the causes for refusal were due to alloimmunization and difficult venous access. One of these 5 patients agreed to be on HU. Patients on blood exchange required an average of 55 ± 13.5 (40-98) units of RBC annually. Those on simple transfusion required up to 24 units annually. Alloimmunization was present in 10 patients with the number of alloantibodies between 1 and 6 per patient. The most common alloantibodies were ant-E and anti-K. Patients who were compliant with blood transfusion were rarely hospitalized for painful crises. Patients who were noncompliant with blood transfusion or who refused to be maintained on chronic transfusion were hospitalized for painful crises 5.7 ± 5.00 times annually (p<.025). All 5 patients who refused to be maintained on chronic blood transfusion died within 3 years after transition. Cause of death was massive intraventricular hemorrhage in one patient proven by autopsy, massive hemispheric infarct proven by imaging in the second patient leading to coma and death in the hospital and sudden death during hospitalization for painful crises in the remaining 3 patients. Two patients who were not compliant with chronic blood transfusion died within 2 years after transition due to ARDS. Thus the overall rate of death after transition was 32% and the major cause was discontinuation of chronic blood transfusion. The mean age at death was 27.0 ± 3.16 years whereas the mean age of patients who are alive is 35.4 ± 5.92 years (p<.001). Conclusion:Our data indicate that about one third of patients with SS and stroke die within 3 years after transition especially if chronic blood transfusion is discontinued or if compliance was poor. It is imperative that all efforts should be made to maintain adequate chronic blood transfusion for children with SCD and stroke after transition to adult care. Disclosures:No relevant conflicts of interest to declare.

The comparison of medical treatment and surgical therapy on massive hemispheric infarction

Objective To analyze the therapeutic effect of the decompressive craniectomy and medical treatment for patients with the massive hemispheric infarction. Method The mortality , overall prognosis and disability of 66 patients who were operated on deeompressive craniectomy and 52 patients with medical treatment were analyzed. Results The mortality of the operative patients(35.6%) was lower(P =0. 031)than the conservative patients(69. 2%)in the group whose age were below 60,the mortality of the operative patients(52.4%) was lower (P = 0. 015) than the conservative patients (82. 1%) in the group whose age were above 60 ; the prognosis of the operative patients (55.6%) was better(P = 0. 048) than the conservative patients(23. I%)in the group whose age were below 60, the prognosis of the operative patients (23.8%) was better(P =0. 007) than the conservative patients(0%)in the group whose age were above 60;the disability of the operative survivors (13.8%) was lower than the conservative survivors(25%)in the group whose age were below 60, but had no statistical significance, the disability of the operative survivors (50%) was lower(P =0. 044) than the conservative survivors(100%)in the group whose age were above 60. Conclusions The surgical therapy decreases mortality, improves the quality of life, decreases the disability of survivors,especially in the younger patients. Key words: Brain infaretion; Decompressive eraniectomy; Medical treatment

塞栓性大脳半球梗塞に対する早期外減圧術の有効性

「目的」塞栓性大脳半球梗塞に対する早期外減圧術の有効性について検討を行った．「方法」当院に入院した塞栓性大脳半球梗塞患者のうちCT上梗塞体積が200 ml以上かつ80才以内の患者94名を3グループ（保存群29名，脳ヘルニア徴候が出現してから手術を施行した後期群33名，脳ヘルニア徴候の出現前に手術を施行した早期群32名）に分類しretrospectiveに比較，検討した．「結果及び結論」1，6カ月後の死亡率は保存群（62.1%，69.0%）と比べ後期群（15.2%，24.2%）で有意に改善した（p<0.01）．さらに早期群では良好であった．また梗塞体積240 ml以上，正中偏位8 mm以上は悪性脳梗塞と強く関連していた．6カ月後のGOS，BIは早期群で後期群より有意に改善されたが（p<0.05），後期群は保存群と比べ有意な差はなかった．特に70才以下の早期群は有意にBIの改善が得られた．

Clinical review: Therapy for refractory intracranial hypertension in ischaemic stroke

The treatment of patients with large hemispheric ischaemic stroke accompanied by massive space-occupying oedema represents one of the major unsolved problems in neurocritical care medicine. Despite maximum intensive care, the prognosis of these patients is poor, with case fatality rates as high as 80%. Therefore, the term 'malignant brain infarction' was coined. Because conservative treatment strategies to limit brain tissue shift almost consistently fail, these massive infarctions often are regarded as an untreatable disease. The introduction of decompressive surgery (hemicraniectomy) has completely changed this point of view, suggesting that mortality rates may be reduced to approximately 20%. However, critics have always argued that the reduction in mortality may be outweighed by an accompanying increase in severe disability. Due to the lack of conclusive evidence of efficacy from randomised trials, controversy over the benefit of these treatment strategies remained, leading to large regional differences in the application of this procedure. Meanwhile, data from randomised trials confirm the results of former observational studies, demonstrating that hemicraniectomy not only significantly reduces mortality but also significantly improves clinical outcome without increasing the number of completely dependent patients. Hypothermia is another promising treatment option but still needs evidence of efficacy from randomised controlled trials before it may be recommended for clinical routine use. This review gives the reader an integrated view of the current status of treatment options in massive hemispheric brain infarction, based on the available data of clinical trials, including the most recent data from randomised trials published in 2007.

Neurological Recovery After Decompressive Craniectomy for Massive Ischemic Stroke

Decompressive craniectomy has demonstrated efficacy in reducing morbidity and mortality in critically ill patients with massive hemispheric cerebral infarction. However, little is known about the patterns of functional recovery that exist in patients after decompressive craniectomy, and controversy still exists as to whether craniotomy and infarct resection ("strokectomy") are appropriate alternatives to decompression alone. We therefore used functional magnetic resonance imaging (f-MRI) to assess the extent and location of functional recovery in patients after decompressive craniectomy for massive ischemic stroke. f-MRI was obtained in three patients with massive nondominant cerebral infarction who had undergone decompressive craniectomy for severe cerebral edema 13 to 26 months previously. Brain activation was triggered by hand-gripping or foot- movement tasks. Imaging results were combined with periodic clinical follow-up to determine the extent of neurological recovery. Activation of the contralateral hemisphere was seen in the sensorimotor cortex, premotor, and supplementary motor areas. Lesser activation patterns were seen in equivalent regions of the infarcted hemisphere. Peri-infarct activation foci were seen in two of the three patients, but no activation occurred within the area of infarction as defined by the initial stroke seen on diffusion-weighted MRI. All three patients demonstrated some corresponding neurological improvement. After massive hemispheric cerebral infarction requiring decompressive craniectomy, patients may experience functional recovery as a result of activation in both the infarcted and contralateral hemispheres. The evidence of functional recovery in peri-infarct regions suggests that decompression alone may be preferable to strokectomy where the risk of damage to adjacent nonischemic brain may be greater.

Early external decompressive craniectomy with duroplasty improves functional recovery in patients with massive hemispheric embolic infarction: Timing and indication of decompressive surgery for malignant cerebral infarction

Background Extensive cerebral hemispheric infarction associated with massive brain swelling is known as malignant infarction because of the rapid clinical deterioration and mortality as high as 80% unless appropriate treatment is performed. Decompressive craniectomy is an effective treatment, but patient selection, timing, functional recovery, and complications remain unclear. Methods Seventy-one patients with massive embolic hemispheric infarctions (infarct volume >200 cm 3) associated with brain swelling were retrospectively divided into 3 groups according to the therapeutic modalities: 21 patients were treated conservatively (conservative group); 50 patients were treated by external decompressive craniectomy with duroplasty in 2 groups; 29 patients treated after the appearance of clinical and radiologic findings of brain herniation (late surgery group); and 21 patients treated before the onset of brain herniation (early surgery group). Results The mortality at 1 and 6 months in the conservative group were 61.9% and 71.4%, respectively. The mortality at 1 and 6 months in the late surgery group were significantly improved to 17.2% and 27.6%, respectively, ( p < 0.01) and in the early surgery group were further improved to 4.8% and 19.1%, respectively. The functional recovery of the patients was estimated by the Glasgow Outcome Scale (GOS) and Barthel Index (BI) at 6 months after the ictus. The GOS scores of the early surgery group were significantly better than that of the late surgery group ( p < 0.05). The mean BI score of the survivors in the late surgery group (26.9 ± 30.4) was not significantly different from that of the conservative group (28.3 ± 42.2), but was significantly improved in the early surgery group (52.9 ± 34.2) compared with the late surgery group ( p < 0.05). Conclusions Early decompressive craniectomy with duroplasty before the onset of brain herniation should be performed to achieve satisfactory functional recovery if the infarct volume of the hemispheric cerebral infarction is more than 200 cm 3 and computed tomography on the second day after the ictus shows mass effect.

Delayed Complete Bilateral Ptosis Associated With Massive Infarction of the Right Hemisphere

To characterize the phenomenon of complete bilateral ptosis associated with massive infarction of the right cerebral hemisphere, particularly with respect to its time course and relationship to herniation syndromes. In May through July 2002, consecutive patients admitted to the neurology/neurosurgery intensive care unit at the Mayo Clinic in Rochester, Minn, with massive infarction of the right cerebral hemisphere, and later, complete bilateral ptosis, underwent serial neurologic examinations and neuroimaging. Six patients with massive infarction of the right cerebral hemisphere developed complete bilateral ptosis. All had normal eyelid opening at initial examination and later developed ptosis, which clearly preceded signs of herniation. Three patients died after herniation syndromes developed. In the 3 survivors, improvement in ptosis closely followed resolution of midbrain distortion seen on computed tomographic scans. The precise anatomical explanation for complete bilateral ptosis is unclear, but upper brainstem involvement seems most likely. Complete bilateral ptosis is a valuable clinical sign in patients with a massive hemispheric infarction that precedes herniation and could provide an opportunity for early intervention.

Drenaje ventricular externo en el infarto completo de la arteria cerebral media

Increased intracranial pressure (ICP) due to complete middle cerebral artery territory infarction does not respond to medical treatment and is often followed by transtentorial herniation and death. Some authors have reported good outcome after performing decompressive hemicraniectomy in this condition. The potential clinical benefit of intracranial pressure reduction by means of an external ventriculostomy in such cases is unknown.The present paper discusses the case of a 33 year old female who suffered a massive infarction of the territory of the right middle cerebral artery with transtentorial herniation and left lateral ventricular dilation who rapidly improved after performing external ventriculostomy without hemicraniectomy. The brain tissue partial oxygen pressure (PtiO2) was monitored in the left frontal lobe and a fair correlation with clinical events was found.External ventricular drainage without hemicraniectomy could be lifesaving in some case of massive ( malignant ) hemispheric infarction and more studies on this therapeutic approach would be needed. Monitoring PtiO2 in these patients would be useful in adopting therapeutic decisions.

Spontaneous carotid artery aneurysms

Spontaneous carotid artery aneurysms are infrequently reported, and are almost always non-atherosclerotic. The records of 29 patients with a spontaneous carotid aneurysm treated in an academic vascular unit between 1990 and 1998 were reviewed. All 29 patients were black South Africans; three had bilateral aneurysms. There were 24 men and five women, of mean age 35 (range 13-62) years. Some 25 aneurysms involved the common carotid artery, 12 of which affected the bifurcation, and seven were located in the internal carotid artery. Twenty-five aneurysms were managed surgically, four of which were ligated owing to sepsis. Histo- logical evaluation showed human immunodeficiency virus-related arteritis in four, tuberculous aneurysms in ten, Takayasu's arteritis in two, atherosclerosis in three and non-specific chronic inflammation in four patients. Microbiological examination was negative in all but one patient who had Salmonella sp. cultured. Outcome was generally favourable, but one patient died from massive hemispheric infarction. There were no other new neurological deficits. Carotid aneurysms pose a considerable surgical challenge but are amenable to operative intervention with good result. Ligation appears to be well tolerated in this group of predominantly non-atherosclerotic aneurysms.

Re: Feasibility and Safety of Moderate Hypothermia After Massive Hemispheric Infarction

Re: Feasibility and Safety of Moderate Hypothermia After Massive Hemispheric Infarction

Critical care of acute ischemic stroke.

Advances in neurologic therapeutics and intensive care medicine have expanded the arsenal of treatments available for the critical care of ischemic stroke. Several agents are available for acute reperfusion of the ischemic brain. These include intravenous recombinant tissue-plasminogen activator (rtPA), which is effective in a 3-hour time window, and intra-arterial thrombolytics, which may be effective within 6 hours. In addition, newer agents such as Ancrod and abciximab may be effective within the acute time period. Efforts to prevent secondary brain injury in critically ill patients with stroke often include prevention and reduction of fever, induced hypertension, and mechanical ventilation. Finally, death due to severe brain edema after massive hemispheric infarction can often be prevented with surgical or medical intervention. Unfortunately, there is a critical lack of well-designed clinical studies to guide the clinician in the use of these interventions. In addition, there is concern that some of these interventions may preserve life at the cost of quality of life. This article reviews the evidence behind these approaches to the critical care of ischemic stroke.

Aggressive decompressive surgery in patients with massive hemispheric embolic cerebral infarction associated with severe brain swelling.

Massive hemispheric cerebral infarction, also known as malignant infarction, is characterized by rapid clinical deterioration due to brain swelling and downward transtentorial herniation, and is associated with a mortality of 80%. Early patient selection and establishment of the optimum therapeutic modality are important to improve the outcome. Early clinical, computed tomography (CT), and angiographic characteristics were analysed to identify patients with malignant infarction and external and internal decompression was performed, with unco-parahippocampectomy if needed, and the outcomes were compared with those of conservative treatment. Thirty-four of 55 patients admitted with large cerebral infarctions due to embolism showed rapid clinical deterioration due to brain swelling and herniation. These 34 patients were treated under a diagnosis of malignant infarction by decompressive surgical treatment (19 cases) or conservative treatment (15 cases). CT showed significantly higher infarction volume in patients with malignant infarction (288 +/- 62 cm3) compared to patients with non-malignant infarction (200 + 57 cm3, P < 0.001) and angiography showed a higher incidence of recanalization of the occluded vessels in patients with malignant infarction (58%) compared to patients with non-malignant infarction (15%, P < 0.05). Discriminant analysis revealed that an infarction volume of more than 240 cm3 was predictive of malignant infarction with 76.4% accuracy. Basic clinical characteristics on admission and deterioration were not statistically different between the surgically treated and conservatively treated groups of patients with malignant infarction. The shift of midline structures was significantly improved (14 +/- 3.5 to 10 +/- 4.7 mm) after surgical treatment (P < 0.05). compared to deterioration (12 +/- 5.8 to 15 +/- 4.5 mm) after conservative treatment. The mortality was 67% in the conservative group and 16% in the surgical group. Surgical treatment significantly improved the mortality and Glasgow Outcome Scale score (P < 0.01). However, the mean Barthel Index scores of the survivors were not significantly different. An infarct volume of more than 240 cm3 on CT and angiographic recanalization of the occluded artery are predictors of fatal brain swelling after massive cerebral infarction. Decompressive surgical treatment dramatically improves the mortality of massive hemispheric infarction.

Management of Massive Hemispheric Cerebral Infarct: Is There a Ray of Hope?

Catastrophic infarcts of the cerebral hemisphere often involve occlusion of the middle cerebral artery. In approximately 50% of these patients, consciousness declines because of brain swelling. Management includes prevention of further systemic complications, and recent studies have suggested that decompressive hemicraniectomy or moderate hypothermia may improve outcome. Mortality may be decreased, but morbidity should be carefully evaluated in clinical trials before these interventions are accepted as standard.

Hemicraniectomy for massive cerebral infarction: Evoked potentials as presurgical prognostic factors

In patients with massive hemispheric infarctions, mortality exceeds 80% with medical therapy alone. In certain conditions hemicraniectomy may result in meaningful survival. We studied presurgical clinical and electrophysiological parameters that may serve as prognostic factors to assess efficacy of decompressive surgery. We evaluated 26 consecutive patients with severe focal neurological deficit, deterioration of consciousness, and massive hemispheric infarction by cranial computerized tomography who underwent hemicraniectomy. Clinical examination included pupillary size and reaction, and determination of level of consciousness on an hourly basis. Median nerve somatosensory evoked potentials and brainstem auditory evoked potentials were obtained before and after hemicraniectomy. Outcome was assessed by using the Barthel Index. Clinical and evoked potential data were correlated with the outcome. Fisher's Exact Test was applied to establish statistical significance. With surgery 18 of 26 patients survived on an average intensive care treatment of 29.6 (+/-27.5) days. Barthel Index at discharge was 61.7 (+/-24.4) in survivors. Presurgical pupillary reaction, level of consciousness, and somatosensory evoked potentials were not found to correlate with outcome. In contrast, presurgical brainstem auditory evoked potentials showed a significant correlation with survival (P<.05). All patients with good outcomes (Barthel Index >/=60: n=12, 46.1%) had normal brainstem auditory evoked potentials before surgery. Clinical parameters did not reliably forecast prognosis in patients with massive cerebral infarction treated with hemicraniectomy.