Outcome following decompressive craniectomy for malignant middle cerebral artery infarction in children

Aim Mortality from malignant middle cerebral artery infarction (MMCAI) approaches 80% in adult series. Although decompressive craniectomy decreases mortality and leads to an acceptable outcome in selected adult patients, there are few data on MMCAI in children with stroke. This study evaluated the frequency of MMCAI and the use of decompressive craniectomy in children. Method We retrospectively reviewed cases of MMCAI from five pediatric tertiary care centers. Results Ten children (two females, eight males; median age 9y 10mo, range 22mo–14y) had MMCAI, with a median Glasgow Coma Scale score of 6 (range 3–9). MMCAI represented fewer than 2% of cases of pediatric arterial ischemic stroke. Three patients who did not undergo decompression, all of whom had monitoring of intracranial pressure, developed intractable intracranial hypertension, and fulfilled criteria for brain death. In contrast, seven patients underwent decompressive craniectomy and survived, with rapid improvement in their level of consciousness postoperatively. All seven survivors now walk independently with mild to moderate residual hemiparesis and speak fluently, even though four had left‐sided infarcts. Interpretation Decompressive craniectomy can lead to a moderately good outcome for children with MMCAI and should be considered, even with symptomatic stroke and deep coma. Monitoring of intracranial pressure may delay life‐saving treatment.     

Outcome and prognostic factors of hemicraniectomy for space occupying cerebral infarction

Objective: To determine long term functional outcome and length of survival of patients undergoing decompressive craniectomy for space occupying infarction of the middle cerebral artery (MCA), and to identify risk factors associated with death and unfavourable outcomes

Methods: Databases of patients undergoing decompressive craniectomy for space occupying MCA infarction compiled at eight neurosurgical departments (1996–2001) were merged, and 188 patients were evaluated. Mortality was calculated by the Kaplan–Meier method. Clinical outcome was rated using the Glasgow outcome scale (GOS). The prognostic impact of patient related covariates on length of survival and the GOS was analysed multivariately.

Results: The unadjusted 3, 6, and 12 month mortality rates were 7.9%, 37.6%, and 43.8%, respectively (median follow up, 26 weeks). In the "best" multivariate model, age >50 years (p<0.02) and the involvement of two or more additional vascular territories (p<0.01) had an unfavourable impact on length of survival. The adjusted six month mortality was as low as 20.0% (no risk factor) and as high as 59.7% (two risk factors). A GOS score of 3 was significantly associated with age >50 years (p<0.0003): 34.9% of the patients 50 years of age achieved a GOS score of >3, as compared with 12.0% of the elderly subpopulation. The side of the infarct did not have prognostic relevance.

Conclusions: Results of surgical treatment in patients <50 years of age undergoing decompressive craniectomy are encouraging. The effectiveness of decompressive craniectomy for patients >50 years remains questionable and should be analysed in the framework of a prospective randomised study.

     

Physician awareness of decompressive hemicraniectomy for malignant middle cerebral artery infarction in Saudi Arabia and the Gulf countries

Objectives:To explore the perspective on Decompressive craniectomy (DH) of each of these specialties to establish common grounds for improved clinical practice.Method:An electronic survey was distributed via email and social media groups to members of these specialties in Kingdom of Saudi Arabia and the Gulf countries. Local practices, common triggers for referral for DH, perceived outcomes of these procedures, individual impression of what constitutes good clinical outcomes were explored.Results:There are 89 physicians participated: 41 (46.1%) neurologists, 34 (38.2%) neurosurgeons, and 14 (15.7%) intensivests. Participants are mostly practicing in intermediate volume centers or high volume centers. Half of the neurosurgeons preferred to be consulted immediately on candidates with large middle cerebral artery (MCA) strokes. The most important referral trigger for DH was clinical changes. The modified Rankin Scale (mRS) cutoff for good clinical outcome was 3 for 73.6% of respondents. There was agreement that DH only improves survival (64.4%). A third of the neurologists considered it to improve functional outcome compared to 15.4% of intensivests and 14.8% of neurosurgeons. There was agreement (66.7%) that patients older than 60 years with involvement of more than one territory should be excluded from DH. Only 7.7% of neurosurgeons excluded patients with dominant hemispheric strokes.Conclusion:Our physicians’ views are variable in what’s called acceptable outcome, and further studies are needed to to test the characteristics that helps in decision making such as hemisphere dominancy, time onset of stroke and vital radiological signs. This is seen despite the literature being full of data that supports the DC over medical management in malignant MCA infarction. Better multidisciplinary education initiatives are needed to unify the understanding and help improve the practices in this challenging subset of patients.

The middle cerebral artery (MCA) supplies most of the cerebral hemisphere and most of its functional areas and its infarctions related to its occlusion are considered the most common vascular territory affected in ischemic strokes. Less than 20% of middle cerebral artery infarction patients’ recover to independent living with very few achieving complete recovery.1,2 A subset of patients with massive stroke in the MCA territory undergo cytotoxic edema which ends up with elevated intracranial pressure (ICP), decreases cerebral perfusion pressure (CPP) and either fatal herniation up to 80% of the cases or severe disability. Surgical management of malignant MCA stroke is standardized as a hemispheric Decompressive craniectomy (DC) with expansive duraplasty. This type of surgery results in significant reduction of the intracranial pressure from the brain edema and prevent herniation by allowing the brain to swell outward without causing midline shift and uncle herniation. This method may reduce mortality and morbidity if performed in the first 48 hours of the MCA insult.3The decision whether to perform DC remains a controversial issue despite supporting evidence form randomized trials with no definitive evidence-based guideline is available to date.4 Five randomized clinical trials studied the mortality and morbidity in hemicraniectomy as compared to non-surgical management. The DECIMAL1 trial was an open, prospective, randomized, multi-center trial that included 38 patients. While HAMLET4 trail was also an open, randomized multicenter trial but included 68 patients. Another trial called DISTENY5 was a controlled, prospective, randomized clinical trial enrolled 32 patients. However, these studies were subject to different interpretation given their small sample sizes and the relatively low number of patients with independent recovery as opposed to those with moderate disability. Thus, their findings did not widely translate into a describable change in medical practice. The aim of this study is to explore the perspective on DC of different specialties involved in the management decisions and the care of stroke patients, and to study the factors that influence the decision based on perceived or actual effectors.     

去骨瓣减压术治疗大脑中动脉供血区恶性梗死的临床观察

目的观察去骨瓣减压术(DHC)治疗恶性大脑中动脉脑梗死(m-MCAI)患者的临床指标,探讨DHC的手术时机,以提高手术疗效。方法收集80例行DHC的m-MCAI患者,根据预后分为预后良好组(GOS 4~5分)26例,预后不良组(GOS 1~3分)54例。记录各组患者脑梗死体积,是否予重组人组织型纤溶酶原激活剂(rt-PA)溶栓治疗,脑萎缩程度,中线移位情况,NIHSS评分及急性生理和慢性健康评分Ⅱ(APACHEⅡ),术前GCS评分、是否出现瞳孔不等大,病情恶化至手术时间,起病至病情恶化时间。结果两组患者中线移位、瞳孔不等大、术前GCS、术前APACHEⅡ的差异有统计学意义(P0.05~0.01)。术前GCS(OR=0.549,95%CI:0.328~0.919,P=0.023)、术前APACHEⅡ(OR=1.098,95%CI:1.007~1.197,P=0.034)是影响DHC治疗的m-MCAI患者预后的独立危险因素。合并肾功能不全的m-MCAI患者行DHC后预后不良(P=0.032)。结论患者出现严重昏迷,瞳孔散大,中线结构严重移位前行DHC,是提高疗效的关键,术前GCS及APACHEⅡ可用于评估预后,肾功能不全的患者,DHC手术风险更高。     

Hydrocephalus following decompressive craniectomy for malignant middle cerebral artery infarction

Objective

The aim of this study was to evaluate the incidence of hydrocephalus and understand the influence of hydrocephalus on the functional outcome of patients undergoing decompressive craniectomy for malignant middle cerebral artery (MCA) infarction.

Methods

We retrospectively analyzed data of consecutive patients who underwent decompressive craniectomy for malignant MCA infarction. Clinical and imaging data were reviewed to confirm the incidence of hydrocephalus and evaluate the impact of hydrocephalus on functional outcome. The functional outcomes of patients were estimated with the Glasgow outcome score at 1 year after stroke onset.

Results

Seventeen patients who received decompressive craniectomy for malignant MCA infarction from January 2003 to December 2006 were enrolled. Persistent hydrocephalus developed in 5 patients. The functional outcomes in these patients were uniformly poor regardless of cerebrospinal fluid diversion surgery. Our data revealed that functional outcome was related to patient age and the duration from infarction to craniectomy.

Conclusions

Persistent hydrocephalus is common in patients who receive decompressive craniectomy for malignant MCA infarction. However, the shunt procedure does not significantly improve the patient's clinical condition. The timing of operation in relation to the functional outcome may be critical.     

Prognosis of patients after hemicraniectomy in malignant middle cerebral artery infarction

Background and Purpose: There are unsatisfactory therapeutic options for treatment of large infarctions of the middle cerebral artery with secondary development of life threatening brain edema. In most cases, post-ischemic brain edema can not be adequately treated by conservative means. However, several studies have shown that operative procedures such as decompressive hemicraniectomy can decrease mortality. Apart from mortality, the morbidity and quality of life are major features with which to estimate therapeutic benefit. The aim of this study was to acquire follow-up data on quality of life and outcome in patients treated with hemicraniectomy after stroke. Methods: Eighteen patients were treated with decompressive hemicraniectomy after life threatening middle cerebral artery infarction between July 1997 and April 2000 in our clinic. Six patients (33 %) died within the first six months after the procedure. All twelve surviving patients were seen in a follow-up examination 7 to 26 months after the stroke and tested using the Rankin-Scale, Barthel Index (BI), Aachener Life Quality Inventory (ALQI) and Zung Self-Rating Depression Scale. Results: Survivors with a mean age of 40.7 ± 16.5 years were significantly younger than non-survivors with a mean age of 64.5 ± 9.2 years (p = 0.006). Mean Barthel-Index of surviving patients was 61.1 ± 26.1 points, mean Rankin-Scale 3.3 ± 1.2 points. Two patients were able to return to work. Patients younger than 45 years (n = 7) had a significantly better outcome (BI 75.7 ± 20.7) than patients over 45 years (n = 5) (BI 42.0 ± 22.7 points, p = 0.026). Among five patients with an infarction of the left hemisphere, four had a slight to moderate Broca aphasia and one patient a global aphasia. Quality of life assessment by ALQI showed moderate disability (58.0 ± 22.7 of 107 points) with no significant difference between left- and right-hemispheric infarctions. Using the Zung Self-Rating Depression Scale six patients were ranked as slightly depressive, one patient as moderately depressive and five patients as not depressive. Eleven out of twelve survivors, as well as their relatives, approved of the decision to have the operation. Conclusions: The study provides evidence that hemicraniectomy as treatment of severe space occupying ischemic brain edema saves lives and results in good quality of life in a high proportion of patients, especially in the young. This conclusion is restricted by the lack of a control group, which was deemed unethical in studying a potentially life saving therapy. Received: 27 November 2001, Received in revised form: 22 February 2002, Accepted: 28 February 2002     

Technical aspects of decompressive craniectomy for malignant middle cerebral artery infarction

Decompressive craniectomy is considered a life-saving procedure for malignant middle cerebral artery territory infarction in selected patients. However, the procedure is associated with a significant risk of morbidity and mortality, and there is no universal agreement as to how this operation should be combined with optimal medical management. In this review we consider the goals of this procedure and the technical aspects which may be employed to optimise results.     

大骨瓣减压术抢救恶性大脑中动脉梗塞疗效分析

目的　总结大骨瓣减压术抢救恶性大脑中动脉梗塞 (mMCAI)的临床经验。方法　总结我院经头颅CT证实并进行大骨瓣减压术的 16例mMCAI患者的临床资料、辅助检查、治疗等 ,以分析手术时机及其他因素与预后的相关性。结果　死亡 6例 (6 / 16 )。死亡和存活患者的中线结构移位的中位数分别为 10 .5mm和 7mm ,手术距脑疝的时间中位数分别为 15 .5h和 4h。手术前加强脱水后瞳孔一度回缩的患者有 7例 ,其中 6例存活。手术前 12h内TCD检查示MCA主干闭塞的 3例患者均死亡 ,部分再通的 5例患者全部存活。 3个月时存活患者BI评分 ,仅有 1例严重残疾。结论　大骨瓣减压术治疗mMCAI是重要的救命措施 ,但要把握手术时机 ,术前强力脱水后瞳孔能短时回缩及TCD监测MCA有部分再通的患者预后较好。     

Factors predictive of fatality in massive middle cerebral artery territory infarction and clinical experience of decompressive hemicraniectomy

To determine the factors predictive of fatality in massive middle cerebral artery (MCA) territory infarction and outcome of decompressive hemicraniectomy, 62 patients who were retrospectively verified with first event massive MCA infarctions were enrolled in this study. Amongst them, 21 received decompressive hemicraniectomy during hospitalization. Clinical data between early and late hemicraniectomy groups were also compared. Significant deterioration occurred in 40 cases, 21 of whom received decompressive hemicraniectomy. The other 19 received conservative treatment. The mortality rate of these 40 cases between decompressive hemicraniectomy and conservative treatment was 29% (six of 21) and 42% (eight of 19), respectively. Factors that predicted fatalities in our massive MCA infarction patients with or without decompressive hemicraniectomy were total scores of baseline GCS at the time of admission, associated with coronary artery diseases, and significant deterioration during hospitalization. This study confirms the lifesaving procedure of hemicraniectomy that prevents death in patients deteriorating because of cerebral edema after infarction, although it may produce severe disability with an unacceptably poor quality of life in survival. Despite high mortality and morbidity, decompressive hemicraniectomy to prevent cerebral herniation when significant deterioration is demonstrated are essential for maximizing the potential for survival.     

大骨瓣减压术抢恶性大脑中动脉梗塞疗效分析

目的总结大骨瓣减压术抢救恶性大脑中动脉梗塞(mMCAI)的临床经验.方法总结我院经头颅CT证实并进行大骨瓣减压术的16例mMCAI患者的临床资料、辅助检查、治疗等,以分析手术时机及其他因素与预后的相关性.结果死亡6例(6/16).死亡和存活患者的中线结构移位的中位数分别为10.5 mm和7 mm,手术距脑疝的时间中位数分别为15.5 h和4 h.手术前加强脱水后瞳孔一度回缩的患者有7例,其中6例存活.手术前12h内TCD检查示MCA主干闭塞的3例患者均死亡,部分再通的5例患者全部存活.3个月时存活患者BI评分,仅有1例严重残疾.结论大骨瓣减压术治疗mMCAI是重要的救命措施,但要把握手术时机,术前强力脱水后瞳孔能短时回缩及TCD监测MCA有部分再通的患者预后较好.     

Health status and life satisfaction after decompressive craniectomy for malignant middle cerebral artery infarction

Objectives –  To study the long-term outcome in patients with malignant middle cerebral artery (MCA) infarction treated with decompressive craniectomy. The outcome is described in terms of survival, impairment, disabilities and life satisfaction.
Materials and methods –  Patients were examined at a minimum of 1 year (mean 2.9, range 1–6) after the surgery and classified according to the Glasgow Outcome Scale (GOS), the National Institutes of Health Stroke scale (NIHSS), the Barthel Index (BI), the short-form health survey (SF-36) and the life satisfaction checklist (LiSat-11).
Results –  Eighteen patients were included. The long-term survival was 78%. The mean NIHSS score was 13.8 (range 6–20). No patient was left in a vegetative state. The mean BI was 63.9 (5-100). The SF-36 scores showed that the patients' view of their health was significantly lower in most items compared with that of a reference group. According to the LiSat checklist, 83% found their life satisfying/rather satisfying and 17% found their life rather dissatisfying/dissatisfying.
Conclusion –  We conclude that the patients remained in an impaired neurological condition, but had fairly good insight into their limitations. Although their life satisfaction was lower compared with that of the controls, the majority felt that life in general could still be satisfying.     

去骨瓣减压术治疗老年恶性大脑中动脉梗死的疗效观察

目的 探讨去骨板减压术治疗老年（>60岁）恶性大脑中动脉梗死（MMI）的临床疗效。方法 回顾分析2011年8月至2016年8月收治的47例老年MMI的临床资料;其中21行去骨板减压术治疗（观察组）,26例保守治疗（对照组）。发病12个月采用改良Rankin量表（mRS）评分和GOS评分评估预后,采用Log-rank χ2检验进行生存分析。结果 观察组发病3个月、半年和1年累积生存率（分别为71.75%、53.82%和35.88%）均明显高于对照组（分别为50.47%、33.65%和8.97%;P<0.05）。发病12个月,观察组mRS评分、GOS评分均明显优于对照组（P<0.05）。治疗后,观察组脑疝发生率（14.29%,3/21）明显低于对照组（57.69%,15/26;P<0.05）。结论 老年MMI行去骨瓣减压术较保守治疗可以提高生存率,并改善预后。     

Outcome after decompressive craniectomy in patients with dominant middle cerebral artery infarction: A preliminary report

Introduction:

Life-threatening, space occupying, infarction develops in 10-15% of patients after middle cerebral artery infarction (MCAI). Though decompressive craniectomy (DC) is now standard of care in patients with non-dominant stroke, its role in dominant MCAI (DMCAI) is largely undefined. This may reflect the ethical dilemma of saving life of a patient who may then remain hemiplegic and dysphasic. This study specifically addresses this issue.

Materials and Methods:

This retrospective analysis studied patients with DMCAI undergoing DC. Patient records, operation notes, radiology, and out-patient files were scrutinized to collate data. Glasgow outcome scale (GOS), Barthel index (BI) and improvement in language and motor function were evaluated to determine functional outcome.

Results:

Eighteen patients between 22 years and 72 years of age were included. 6 week, 3 month, 6 month and overall survival rates were 66.6% (12/18), 64% (11/17), 62.5% (10/16) and 62.5% (10/16) respectively. Amongst ten surviving patients with long-term follow-up, 60% showed improvement in GOS, 70% achieved BI score >60 while 30% achieved full functional independence. In this group, motor power and language function improved in 9 and 8 patients respectively. At last follow-up, 8 of 10 surviving patients were ambulatory with (3/8) or without (5/8) support. Age <50 years corresponded with better functional outcome amongst survivors (P value –0.0068).

Conclusion:

Language and motor outcomes after DC in patients with DMCAI are not as dismal as commonly perceived. Perhaps young patients (<50 years) with DMCAI should be treated with the same aggressiveness that non-DMCAI is currently dealt with.Key Words: Craniectomy, dominant, middle cerebral artery, outcome, stroke     

Hemicraniectomy and durotomy for malignant middle cerebral artery infarction

Decompressive surgery with hemicraniectomy and durotomy for malignant MCA infarction remains a salvage procedure but can be associated with reasonable clinical outcomes in highly selected patients. This selection of patients appropriate for intervention is of the utmost importance, but exact criteria remain to be defined; older age and increased numbers of associated medical comorbidities seem to define a group of patients who would not derive long term benefit, however. The determination as to whether or not surgery is equally beneficial for dominant or nondominant hemispheric infarction is hampered by lack of good comparative data, but selected case series suggest that some patients who have dominant hemispheric infarction achieve a reasonable degree of independence. Although a well-defined principle of stroke practice is that "time is brain," there are no clear data as to when intervention should be done, as there are some patients who have large MCA infarction and who may not progress to cerebral herniation. Clinicians managing the growing population of patient status post hemicraniectomy should also be aware of this process of the syndrome of the trephined and the potential for resolution that may prompt earlier cranial reconstruction. At present, the decision to proceed with this aggressive intervention of hemicraniectomy and durotomy for large ischemic infarction remains a case-by-case individualized approach, based on patient and family preferences and clinicians' subjective perspective as to patients' potential for clinical recovery.