Abstract
Background
Pooled European trial results of early decompressive craniectomy (DC) for severe hemispheric stroke did not require radiographic mass effect as an inclusion criterion. Early surgery for supratentorial cerebral hemorrhage does not improve functional status or survival compared to initial conservative medical management. Early versus delayed DC for hemispheric stroke has not been investigated.
Methods and Results
A prospective inpatient neurosurgical database from October 2007 to March 2015 was queried for neurocritical care admissions for hemispheric ischemic stroke in patients aged 18–60 under IRB approval. A retrospective chart review was conducted using a structured questionnaire and the electronic medical record. We identified 30 patients who met the inclusion criteria for the pooled European early DC stroke trial. The mean age was 46, and the median NIH stroke score was 19. All hemispheric stroke patients were monitored in the neurocritical care unit with hourly neurochecks and daily CT scans for a minimum of 3 days. Eighteen patients (60 %) were managed with medical treatment only (MTO) with an average maximal septal shift of 5.2 mm and a pineal shift of 3.1 mm. Twelve patients (40 %) underwent DC with an average maximal septal shift of 6.8 mm and a pineal shift of 4.1 mm. Modified Rankin (MR) outcomes at 3 months for the overall group, MTO, and DC were as follows: MR 0–3 60 % versus 67 % versus 50 %; MR 4–5 27 % versus 17 % versus 42 %; and death 13 % versus 17 % versus 8 %, respectively. Four patients in the MTO group declined DC; 3 died and one survived with an MR of 4. No patients developed brainstem herniation prior to referral for DC. Surgical complications occurred in 4/12 (33 %) patients.
Conclusions
Delayed DC for hemispheric stroke patients managed under protocol in the neurocritical care unit is a safe alternative to early, prophylactic DC for adults with severe hemispheric stroke. This strategy reduced DC rates by 60 % without an excess of death or survival with severe disabilities.
Similar content being viewed by others
References
Macdonald RL. Editorial: I am become misery, the spoiler of lives? I think not. J Neurosurg. 2012;117:745–8.
Rahme R, Zuccarello M, Kleindorfer D, Adeoye OM, Ringer AJ. Decompressive hemicraniectomy for malignant middle cerebral artery territory infarction: is life worth living? J Neurosurg. 2012;117:749–54.
Wijdicks EF, Sheth KN, Carter BS, Greer DM, Kasner SE, Kimberly WT, Schwab S, Smith EE, Tamargo RJ, Wintermark M, American Heart Association Stroke Council. Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:1222–38.
Howard BM, Barrow DL. Decompressive hemicraniectomy for malignant middle cerebral artery infarction: are we shepherds or wolves? World Neurosurg. 2015;83:473–6.
Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomized controlled trials. Lancet Neurol. 2007;6:215–22.
Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp HB, HAMLET investigators. 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. Lancet Neurol. 2009;8:326–33.
Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R. ‘Malignant’ middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol. 1996;53:309–15.
Schwab S, Steiner T, Aschoff A, Schwarz S, Steiner HH, Jansen O, Hacke W. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke. 1998;29:1888–93.
Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, Karimi A, Shaw MD, Barer DH, STICH investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet. 2005;365:387–97.
Mendelow AD, Gregson BA, Rowan EN, Murray GD, Gholkar A, Mitchell PM, STICH II Investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet. 2013;382:397–408.
Akins PT, Guppy KH. Sinking skin flaps, paradoxical herniation, and external brain tamponade: a review of decompressive craniectomy management. Neurocrit Care. 2008;9:269–76.
Akins PT, Belko J, Banerjee A, Guppy K, Herbert D, Slipchenko T, DeLemos C, Hawk M. Perioperative management of neurosurgical patients with methicillin-resistant Staphylococcus aureus. J Neurosurg. 2010;112:354–61.
Akins PT, Guppy KH, Sahrakar K, Hawk MW. Slippery platelet syndrome in subdural hematoma. Neurocrit Care. 2010;12:375–80.
DeLemos C, Abi-Nader J, Akins PT. Use of peripherally inserted central catheters as an alternative to central catheters in neurocritical care units. Crit Care Nurse. 2011;31:70–5.
Akins PT, Guppy KH, Axelrod YV, Chakrabarti I, Silverthorn JW, Williams AR. The genesis of low pressure hydrocephalus. Neurocri Care. 2011;15:641–8.
Akins PT, Axelrod YV, Arshad S, Hartman J, Ji C, Ciporen J, Hawk MW. Comprehensive stroke center treatment and outcomes for elderly patients with cerebral aneurysms and subarachnoid hemorrhage. J Am Geriatr Soc. 2012;60(10):1984–6.
Akins PT, Axelrod YA, Ji C, Ciporen J, Arshad S, Hawk M, Guppy KH. Cerebral venous sinus thrombosis complicated by subdural hematomas: case series and literature review. Surg Neurol Int. 2013;4:85.
Catherine Le, Guppy KH, Axelrod Y, Hawk MW, Silverthorn J, Inacio MC, Akins PT. Lower complication rates for cranioplasty with peri-operative bundle. Clin Neurol Neurosurg. 2014;120:41–4.
Frank JI, Schumm LP, Wroblewski K, Chyatte D, Rosengart AJ, Kordeck C, Thisted RA, HeADDFIRST Trialists. Hemicraniectomy and durotomy upon deterioration from infarction-related swelling trial: randomized pilot clinical trial. Stroke. 2014;45:781–7.
Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D’Urso P, Kossmann T, Ponsford J, Seppelt I, Reilly P, Wolfe R, DECRA Trial Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med. 2011;364:1493–502.
Sarov M, Guichard JP, Chibarro S, Guettard E, Godin O, Yelnik A, George B, Bousser MG, Vahedi K, DECIMAL investigators. Sinking skin flap syndrome and paradoxical herniation after hemicraniectomy for malignant hemispheric infarction. Stroke. 2010;41:560–2.
Creutzfeldt CJ, Tirschwell DL, Kim LJ, Schubert GB, Longstreth WT Jr, Becker KJ. Seizures after decompressive hemicraniectomy for ischaemic stroke. J Neurol Neurosurg Psychiatry. 2014;85:721–5.
Lee MH, Yang JT, Weng HH, Cheng YK, Lin MH, Su CH, Chang CM, Wang TC. Hydrocephalus following decompressive craniectomy for malignant middle cerebral artery infarction. Clin Neurol Neurosurg. 2012;114:555–9.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosures
This study did not receive any formal grant or industry support.
Rights and permissions
About this article
Cite this article
Akins, P.T., Axelrod, Y.V., Arshad, S.T. et al. Initial Conservative Management of Severe Hemispheric Stroke Reduces Decompressive Craniectomy Rates. Neurocrit Care 25, 3–9 (2016). https://doi.org/10.1007/s12028-016-0270-x
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12028-016-0270-x