Space-occupying Cerebral Infarction Research Articles

No Harmful Effect of Endovascular Treatment before Decompressive Surgery—Implications for Handling Patients with Space-Occupying Brain Infarction

This study explored short- and mid-term functional outcomes in patients undergoing decompressive hemicraniectomy (DHC) due to space-occupying cerebral infarction and asked whether there is a potentially harmful effect of a priorly performed endovascular treatment (EVT). Medical records were screened for patients requiring DHC due to space-occupying cerebral infarction between January 2016 and July 2021. Functional outcomes at hospital discharge and at 3 months were assessed by the modified Rankin Scale (mRS). Out of 65 patients with DHC, 39 underwent EVT before DHC. Both groups, i.e., EVT + DHC and DHC alone, had similar volumes (280 ± 90 mL vs. 269 ± 73 mL, t-test, p = 0.633) and proportions of edema and infarction (22.1 ± 6.5% vs. 22.1 ± 6.1%, t-test, p = 0.989) before the surgical intervention. Patients undergoing EVT + DHC tended to have a better functional outcome at hospital discharge compared to DHC alone (mRS 4.8 ± 0.8 vs. 5.2 ± 0.7, Mann–Whitney-U, p = 0.061), while the functional outcome after 3 months was similar (mRS 4.6 ± 1.1 vs. 4.8 ± 0.9, Mann–Whitney-U, p = 0.352). In patients initially presenting with a relevant infarct demarcation (Alberta Stroke Program Early CT Score ≤ 5), the outcome was similar at hospital discharge and after 3 months between patients with EVT + DHC and DHC alone. This study provided no evidence for a harmful effect of EVT before DHC in patients with space-occupying brain infarction.

The Relationship Between Colloid Transfusion During Surgical Decompression Hemicraniectomy Period and Postoperative Pneumonia or Long-Term Outcome After Space-Occupying Cerebral Infarction: A Retrospective Study

Colloid transfusion during surgical decompressive hemicraniectomy (DHC) to treat space-occupying cerebral infarction induced by middle cerebral artery (MCA) is controversial. A multicenter retrospective study was conducted to determine whether an increased colloid transfusion during surgery is associated with a lower incidence of postoperative pneumonia and better long-term outcomes after space-occupying cerebral infarction. Data from surgical DHC within 48 hours to treat space-occupying cerebral infarction that took place between November 30, 2013, and March 30, 2016, were collected in a multicenter chart. Univariate analysis, Spearman correlation, χ2 test, and bivariate and multivariate logistic regression were performed to account for the associations between colloid transfusion and postoperative pneumonia or long-term outcomes (indicated by modified Rankin Scale [mRS] scores). Univariate analysis showed that surgical duration and mRS were significantly different between the subjects older and younger than 60 years who underwent surgical DHC (P < 0.05). In the entire population studied, increased National Institutes of Health Stroke Scale was associated with a greater incidence of postoperative pneumonia (odds ratio [OR] 1.255, P= 0.003) and increased mRS (OR 1.229, P= 0.014). In the population older than 60 years, it was revealed that increased colloid transfusion was associated with a lower incidence of postoperative pneumonia (OR 0.761, P= 0.030) or better outcomes, as indicated with lower mRS (OR 0.837, P= 0.045). Our retrospective study demonstrated that there is a robust association between increased perioperative colloid transfusion and lower incidence of postoperative pneumonia and better outcomes among the patients older than 60 years after space-occupying cerebral infarction.

Preoperative lumbar drainage placement for surgical cranioplasty

ObjectiveIntraoperative reduction of cerebrospinal fluid may be required in patients undergoing cranioplasty (CP) surgery, especially in the presence of bulging cranial defects. Direct cannulation of the frontal horn of the lateral ventricle is associated with risks such as intracerebral haemorrhage or postoperative leakage of cerebrospinal fluid. Here we report our initial experiences with preoperative lumbar drain (LD) placement for cranioplasty surgery in patients with bulging cranial defects. MethodThe medical records of patients who were treated with LD prior to CP surgery at our institution were retrospectively analysed. Pre-, intra- and postoperative modalities, complications and outcome parameters are described. ResultsA total of 14 patients (mean age 46 years) were included in this analysis. The majority of patients had received decompressive craniectomy due to space-occupying cerebral infarction (64.3%) and traumatic brain injury (14.3%). CP was performed unilaterally with autologous bone graft in 93% of cases. No complications occurred during lumbar drainage placement and the grafts were implanted without the need of dural opening and ventricle puncture. LDs were maintained for an average of 17 ± 15 h (range, 1–48 h). There were no LD related complications in the further course. ConclusionOur initial experiences demonstrate that preoperative LD placement facilitates CP in patients with bulging cranial defects requiring surgical cranioplasty. Intraoperative puncture of ventricles for reducing cerebrospinal fluid is avoided and therefore, the risk of intracerebral haemorrhage and brain damage is reduced. Further studies are needed to evaluate the advantages of this technique as an alternative to conventional methods of intraoperative CSF reduction.

No benefits of hypothermia in patients treated with hemicraniectomy for large ischemic stroke.

Background Space-occupying middle cerebral artery brain infarcts are associated with the development of brain edema, which may lead to cerebral herniation and death despite early hemicraniectomy. Aims To evaluate the benefit of therapeutic hypothermia in patients with space-occupying cerebral infarction treated with hemicraniectomy within 48 h of stroke onset. Methods Patients aged 18-60 years with space-occupying cerebral infarction treated with hemicraniectomy within 48 h and hypothermia (33-34°C) were selected from a single university hospital between 2001 and 2010 (n = 53). Patients treated with hemicraniectomy alone served as comparison group (n = 58), originating from three randomized controlled trials evaluating the effects of early decompressive surgery (DECIMAL, DESTINY, HAMLET). Primary outcome was the score on the modified Rankin scale at 12 months dichotomized between modified Rankin scale 0-3 and modified Rankin scale 4-6. Secondary outcome measures were modified Rankin scale score 0-4 and survival. Risk ratios were adjusted with Poisson regression. Results Mean patient age was 48 years. Median time from stroke onset to hemicraniectomy was 23.5 h in both treatment groups. Treatment with hypothermia had no effect on the primary outcome (modified Rankin scale 0-3 versus 4-6 (13/53 (25%) versus 24/58 (41%)); adjusted risk ratio 0.66, 95% confidence interval 0.38-1.13). Fewer patients treated with hypothermia had a modified Rankin scale score of 0-4 (21/53 (40%) versus 42/58 (72%); adjusted risk ratio 0.53, 95% confidence interval 0.37-0.76) and fewer patients survived (26/53 (49%) versus 46/58 (79%); adjusted risk ratio 0.60, 95% confidence interval 0.44-0.82). Conclusions In patients with space-occupying cerebral infarction, treatment with hypothermia had no additional benefit on functional outcome compared with treatment with hemicraniectomy alone.

Decompressive Hemicraniectomy for Stroke in Older Adults: A Review.

Malignant cerebral edema is a potential consequence of large territory cerebral infarction, as the resultant elevation in intracranial pressure may progress to transtentorial herniation, brainstem compression, and death. In appropriate patients, decompressive hemicraniectomy (DHC) reduces mortality without increasing the risk of severe disability. However, as the foundational DHC randomized, controlled trials excluded patients greater than 60 years of age, the appropriateness of DHC in older adults remains controversial. Recent clinical trials among elderly participants, including DESTINY II, reported that DHC reduces mortality, but may leave patients with substantial morbidity. Nationwide analyses have demonstrated generalizability of such data. However, what constitutes an acceptable outcome – the perspective on quality of life after survival with substantial disability – varies between clinicians, patients, and caregivers. Consequently, quality of life measures are being increasingly incorporated into stroke research. This review summarizes the impact of DHC in space-occupying cerebral infarction, and the influence of patient age on postoperative survival, functional capacity, and quality of life—all key factors in the clinical decision process. Ultimately, these data underscore the inherent complexity in balancing scientific evidence, clinical expertise, and patient and family preference when pursuing hemicraniectomy among the elderly.

Patient Age and the Outcomes after Decompressive Hemicraniectomy for Stroke: A Nationwide Inpatient Sample Analysis.

Decompressive hemicraniectomy (DHC) for space-occupying cerebral infarction in older adults remains controversial, and there are limited nationwide data evaluating the outcomes after craniectomy for stroke by patient age. Patients who underwent DHC for ischemic stroke were extracted from the Nationwide Inpatient Sample (2002-2011). Multivariable logistic regression examined in-hospital mortality and a poor outcome (death, tracheostomy and gastrostomy, or discharge to institutional care). Covariates included year of admission, comorbidities, severity indices, and treatment variables (including the timing of decompression). Craniectomy was performed in 1673 patients: 62.4% were aged 18-60years, 20.6% aged 61-70years, and 17.0% aged greater than 70years. DHC was associated with reduced adjusted odds of in-hospital death compared with medical treatment alone among patients with cerebral edema in all age categories, including those older than 70years (p≤0.008). However, among surgical patients, the adjusted odds of mortality were significantly greater for patients aged 61-70 (30.7%, p=0.02) and greater than 70years (34.5%, p=0.02), but not different for patients aged 51-60 (22.8%), compared to those aged 18-50years (19.7%). The adjusted odds of a poor outcome also increased significantly with age, particularly for patients greater than 60years. In this nationwide analysis, DHC was associated with reduced mortality regardless of patient age, including among those aged greater than 70years. However, patients aged greater than 60years treated surgically experienced higher odds of mortality (32.4%), discharge to institutional care (47.1%), and a poor outcome (77.0%) compared with younger patients.

Surgical Decompression for Space-Occupying Cerebral Infarction

We assessed whether the effects of surgical decompression for space-occupying hemispheric infarction, observed at 1 year, are sustained at 3 years. Patients with space-occupying hemispheric infarction, who were enrolled in the Hemicraniectomy After Middle cerebral artery infarction with Life-threatening Edema Trial within 4 days after stroke onset, were followed up at 3 years. Outcome measures included functional outcome (modified Rankin Scale), death, quality of life, and place of residence. Poor functional outcome was defined as modified Rankin Scale >3. Of 64 included patients, 32 were randomized to decompressive surgery and 32 to best medical treatment. Just as at 1 year, surgery had no effect on the risk of poor functional outcome at 3 years (absolute risk reduction, 1%; 95% confidence interval, -21 to 22), but it reduced case fatality (absolute risk reduction, 37%; 95% confidence interval, 14-60). Sixteen surgically treated patients and 8 controls lived at home (absolute risk reduction, 27%; 95% confidence interval, 4-50). Quality of life improved between 1 and 3 years in patients treated with surgery. In patients with space-occupying hemispheric infarction, the effects of decompressive surgery on case fatality and functional outcome observed at 1 year are sustained at 3 years. http://www.controlled-trials.com. Unique identifier: ISRCTN94237756.

Surviving space-occupying cerebral infarction

Patients with space-occupying hemispheric infarction have a poor prognosis, with case fatality rates of up to 78% if treated conservatively.1 The only treatment option of proven benefit is surgical decompression through removal of a large part of the skull ipsilateral to the infarct, followed by a duraplasty—a hemicraniectomy. A pooled analysis of 3 small randomized controlled trials2–4 showed a large reduction in case fatality (71% vs 21%; absolute risk reduction, 50%; 95% confidence interval 34%–66%) after surgical decompression within 48 hours of stroke onset, compared to medical treatment. The chance of a favorable functional outcome at 12 months, defined as a score on the modified Rankin scale (mRS) ≤3, increased from 24% to 40%. Unfortunately, this large reduction in case fatality came at the expense of an increase in severe disability (mRS 4–5) at 12 months,4 from 6% to 40%. Because of the increase in severely disabled survivors, many have expressed concern about decompressive surgery on long-term quality of life. In randomized trials, this issue has received far less attention than that of death or dependency. Quality of life was assessed among survivors in 2 …

Decompressive Hemicraniectomy for Space-occupying Cerebral Infarction

The development of a space-occupying hemispheric infarction occurs in a subset of patients with ischaemic cerebrovascular stroke. It is a life-threatening condition with a high mortality rate of up to 80% with medical therapy alone. Previous retrospective and uncontrolled case series have suggested that decompressive hemicraniectomy can significantly reduce mortality to 20-30% compared to conservative treatment. This evidence has now been confirmed by the data of prospective randomised studies. The data also indicate that the reduction of mortality is not accompanied by an increase in the number of completely disabled patients. However, the number of disabled patients depending on the assistance of others increases significantly, and the patients and their caregivers need to be comprehensively informed about the long-term consequences prior to surgery. Furthermore, questions concerning the optimal time point for decompression and the upper age limit at which patients still benefit from surgery remain unanswered. Thus the indication for surgery is to a great extent still dependent on the individual situation of the patient and the experience of the treating physicians. This review covers the indications, the surgical technique, the prognostic factors and the clinical outcome with this procedure based on the data of retrospective series and the results of the recently published prospective randomised trials.

Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial

Patients with space-occupying hemispheric infarctions have a poor prognosis, with case fatality rates of up to 80%. In a pooled analysis of randomised trials, surgical decompression within 48 h of stroke onset reduced case fatality and improved functional outcome; however, the effect of surgery after longer intervals is unknown. The aim of HAMLET was to assess the effect of decompressive surgery within 4 days of the onset of symptoms in patients with space-occupying hemispheric infarction. Patients with space-occupying hemispheric infarction were randomly assigned within 4 days of stroke onset to surgical decompression or best medical treatment. The primary outcome measure was the modified Rankin scale (mRS) score at 1 year, which was dichotomised between good (0-3) and poor (4-6) outcome. Other outcome measures were the dichotomy of mRS score between 4 and 5, case fatality, quality of life, and symptoms of depression. Analysis was by intention to treat. This trial is registered, ISRCTN94237756. Between November, 2002, and October, 2007, 64 patients were included; 32 were randomly assigned to surgical decompression and 32 to best medical treatment. Surgical decompression had no effect on the primary outcome measure (absolute risk reduction [ARR] 0%, 95% CI -21 to 21) but did reduce case fatality (ARR 38%, 15 to 60). In a meta-analysis of patients in DECIMAL (DEcompressive Craniectomy In MALignant middle cerebral artery infarction), DESTINY (DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY), and HAMLET who were randomised within 48 h of stroke onset, surgical decompression reduced poor outcome (ARR 16%, -0.1 to 33) and case fatality (ARR 50%, 34 to 66). Surgical decompression reduces case fatality and poor outcome in patients with space-occupying infarctions who are treated within 48 h of stroke onset. There is no evidence that this operation improves functional outcome when it is delayed for up to 96 h after stroke onset. The decision to perform the operation should depend on the emphasis patients and relatives attribute to survival and dependency.

Delayed Decompressive Craniectomy Improves the Long-term Outcomes in Hypertensive Rats with Space-occupying Cerebral Infarction

No experimental data has been published on the long-term effects of decompressive craniotomy in hypertensive rats with space-occupying cerebral infarction. The aim of the present study was to investigate the efficacy of decompressive craniectomy in a middle cerebral artery occlusion (MCAO) model of hypertensive rats in a prolonged period. Totally 92 stroke-prone renovascular hypertensive rats (RHRSP) were subjected to left MCAO by an endovascular occlusion technique. The decompressive craniectomy was performed on 26 RHRSP at 1 and 24 h after MCAO, respectively. Infarct volume, neurological performance, and mortality were evaluated at 1, 2, 4, and 8 weeks after MCAO. The mortality was reduced from 52.5% in controls to 7.7% and 23.1% in the rats underwent craniectomy at 1 and 24 h after MCAO, respectively (P < 0.05, respectively). All of the treated rats presented smaller infarct volume from 1 week to 8 weeks and better neurological performance at 4-8 weeks after MCAO compared to the controls (P < 0.05, respectively). The craniectomy at early stage was more effective than that at late stage in reducing infarct volume and improving neurological performances at 1 and 2 weeks (P < 0.05, respectively). However, there was no significant difference in infarct volume and neurological scores between the treated groups of rats at 4 and 8 weeks after MCAO (P > 0.05). Although the early craniectomy is more effective than delayed craniectomy in improving short-term outcome, the latter has the similar beneficial effects as early craniectomy on long-term outcome in hypertensive rats with space-occupying cerebral infarction.

Recovery From Aphasia After Hemicraniectomy for Infarction of the Speech-Dominant Hemisphere

The space-occupying effect of cerebral edema limits survival chances of patients with severe ischemic stroke. Besides conventional therapies to reduce intracranial pressure, hemicraniectomy can be considered as a therapeutic option after space-occupying cerebral infarction. There is controversy regarding the use of this method in patients with infarction of the speech-dominant hemisphere. In 14 patients with infarction of the dominant hemisphere and subsequent treatment with hemicraniectomy, recovery from aphasic symptoms was evaluated retrospectively. A group of patients who were treated between 1994 and 2003 in our aphasia ward was selected for the study. In all patients, a psychometric quantification was accomplished applying the Aachen Aphasia Test at least twice within a mean observation period of 470 days. A significant improvement of the statistical parameters representing different aspects of aphasia was observed in 13 of 14 patients. Also, an increase of the ability to communicate was evident in 13 patients. Young age at the time of stroke and early poststroke decompressive surgery were identified as main predictors for recovery from aphasia. A significant improvement of aphasic symptoms can be observed in a preselected group of patients after a massive stroke of the speech-dominant hemisphere treated by consecutive hemicraniectomy. Therefore, decompressive surgery can be considered for the treatment of this kind of stroke.

The time course of ischemic damage and cerebral perfusion in a rat model of space-occupying cerebral infarction

We aimed to establish a rat model of space-occupying hemispheric infarction to evaluate potential treatment strategies. For adequate timing of therapy in future experiments, we studied the development of tissue damage, edema formation, and perfusion over time with different MRI techniques. Permanent middle cerebral artery (MCA) occlusion was performed in 32 Fisher-344 rats. Forty-six MRI experiments including diffusion weighted (DW), T 2-weighted (T 2W), flow-sensitive alternating inversion recovery (FAIR) perfusion-weighted, and T 1-weighted (T 1W) imaging before and after gadolinium were performed at 1, 3, 8, 16, 24, and 48 h of ischemia. MCA occlusion consistently led to infarction of the complete MCA territory. Mortality was 75%. Lesion volumes as derived from apparent diffusion coefficient (ADC) and T 2 maps increased to maximum values of 400±48 mm 3 at 24 h and 420±54 mm 3 at 48 h of ischemia, respectively. Midline shift peaked at 24 h. The area with diffusion–perfusion deficit decreased to a minimum at 24 h after onset of ischemia and perfusion of the contralateral hemisphere dropped at the same time point. Leakage of gadolinium through the blood–brain barrier in the entire infarct occurred within 3 h of ischemia. Permanent intraluminal MCA occlusion in Fisher-344 rats is an adequate model for space-occupying cerebral infarction. Rats may benefit from intervention aimed at reducing tissue shift and intracranial pressure (ICP), and at improving cerebral blood flow, if initiated before 24 h after MCA occlusion. The value of treatment modalities depending on an intact blood–brain barrier should be questioned.

Treatment of space-occupying cerebral infarction.

Patients with a hemispheric infarct accompanied by massive edema have a poor prognosis; the case fatality rate may be as high as 80%, and most survivors are left severely disabled. Various treatment strategies have been proposed to limit brain tissue shifts and to reduce intracranial pressure, but their use is controversial. We performed a systematic search of the literature to review the evidence of efficacy of these therapeutic modalities. Literature searches were carried out on MEDLINE and PubMed. Studies were included if they were published in English between 1966 and February 2002 and addressed the effect of osmotherapy, hyperventilation, barbiturates, steroids, hypothermia, or decompressive surgery in supratentorial infarction with edema in animals or humans. Animal studies of medical treatment strategies in focal cerebral ischemia produced conflicting results. If any, experimental support for these strategies is derived from studies with animal models of moderately severe focal ischemia instead of severe space-occupying infarction. None of the treatment options have improved outcome in randomized clinical trials. Two large nonrandomized studies of decompressive surgery yielded promising results in terms of reduction of mortality and improvement of functional outcome. There is no treatment modality of proven efficacy for patients with space-occupying hemispheric infarction. Decompressive surgery might be the most promising therapeutic option. For decisive answers, randomized, controlled clinical trials are needed.

Hemicraniectomy with dural augmentation in medically uncontrollable hemispheric infarction.

Surgical decompression to alleviate raised intracranial pressure has been reported repeatedly in the past decades in small series of patients. Only recently have there been indications from larger trials that surgical decompression may be beneficial in treating space-occupying hemispheric infarction. However, surgical requirements for the procedure to be effective have not yet been defined. Based on theoretical criteria, the authors operated on 43 patients with medically uncontrollable hemispheric infarctions. The craniectomies were planned to be as large as possible and performed in combination with a subtemporal decompression. Postoperative computerized tomography scans were evaluated for these criteria. The mean survival rate for the group of 43 patients was 72.1% and no surviving patient ended up in a vegetative state. The mean area of craniectomy was found to be 84.3 +/- 16.5 cm2 and the mean distance of the inferior craniectomy margin to the middle fossa was 1.8 +/- 1.3 cm. Comparison of survivors and nonsurvivors failed to show a significant difference in the size of craniectomy or the distance to the floor of the middle fossa. Compared with the reported 80% fatality rate for medically treated stroke patients, in this subgroup the outcome (72.1% survival rate) is remarkably good. The authors conclude that decompressive craniectomy is an effective treatment, able to reduce mortality, and to improve neurological outcome in patients with space-occupying cerebral infarction if the size of craniectomy is large enough. Nevertheless, there is a need for further investigation to identify patients who will benefit from surgery and predictors to optimize the timing of surgical intervention.