Skip to main content

Advertisement

SpringerLink
Log in

The Role of Osmotic Therapy in Hemispheric Stroke

  • Original Article
  • Published:
Neurocritical Care Aims and scope Submit manuscript

Abstract

Background

Decompressive hemicraniectomy (DHC) can be lifesaving in hemispheric stroke complicated by cerebral edema. Conversely, osmotic agents have not been shown to improve survival, despite their widespread use. It is unknown whether medical measures can similarly confer survival in certain patient subgroups. We hypothesized that osmotic therapy (OT) without DHC may be associated with a greater likelihood of survival in particular populations depending on demographic, radiologic, or treatment characteristics.

Methods

We performed a retrospective cohort analysis of patients with large anterior circulation strokes with an NIH stroke scale (NIHSS) ≥10 who received OT. We compared clinical, radiologic, and treatment characteristics between two groups: (1) those who survived until discharge with only OT (medical management success) and (2) those who required either DHC or died (medical management failure).

Results

Thirty patients met eligibility criteria. Median NIHSS was 19 [interquartile range (IQR) 13–24], and median GCS was 10 [IQR 8–14]. Forty-seven percent of the medical management cohort survived to discharge. Demographic characteristics associated with medical management success included NIHSS (p = 0.009) and non-black race (p = 0.003). Of the various interventions, the administration of OT after 24 hours and a smaller hypertonic saline dose was also associated with survival to discharge (p = 0.038 and 0.031 respectively).

Conclusion

Our results suggest that patients with moderate size hemispheric infarcts on presentation and those who do not require OT within the first 24 h of stroke may survive until discharge with medical management alone. Black race was also associated with conservative management failure, a finding that may reflect a cultural preference toward aggressive management. Further prospective studies are needed to better establish the utility of medical management of hemispheric edema in the setting of moderate size hemispheric infarcts.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Hays AN, Lazaridis C, Neyens R, et al. Osmotherapy: use among neurointensivists. Neurocrit Care. 2011;14:222–8.

    Article  CAS  PubMed  Google Scholar 

  2. Jauch EC, Saver JL, Adams HP, et al. Management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870–947.

    Article  PubMed  Google Scholar 

  3. Vahedi K, Hofmeijer J, Juettler E, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol. 2007;6:215–22.

    Article  PubMed  Google Scholar 

  4. Juttler E, Unterberg A, Woitzik J, et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. NEJM. 2014;370:1091–100.

    Article  PubMed  Google Scholar 

  5. Akins PT, Guppy KH. Sinking skin flaps, paradoxical herniation and external brain tamponade: a review of decompressive craniectomy management. Neurocrit Care. 2008;9(2):259.

    Article  Google Scholar 

  6. Cruz-Flores S, Berge E, Whittle IR. Surgical decompression for cerebral oedema in acute ischaemic stroke. Cochrane Database Syst Rev. 2012;1:CD003435.

    PubMed  Google Scholar 

  7. Hofmeijer J, Kapelle LJ, Algra A, et al. 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.

    Article  PubMed  Google Scholar 

  8. Vahedi K, Vicaut E, Mateo J. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke. 2007;38:2506–17.

    Article  PubMed  Google Scholar 

  9. Juttler E, Schwab S, Schmiedek P, et al. Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY): a randomized, controlled trial. Stroke. 2007;38:2518–25.

    Article  PubMed  Google Scholar 

  10. Berecski D, Liu M, do Prado GF, et al. Cochrane report: a systematic review of mannitol therapy for acute ischemic stroke and cerebral parenchymal hemorrhage. Stroke. 2000;31:2719–22.

    Article  Google Scholar 

  11. Kamel H, Navi BB, Nakagawa K, et al. Hypertonic saline versus mannitol in the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Crit Care Med. 2011;39(3):554–9.

    Article  CAS  PubMed  Google Scholar 

  12. Bereczki D, Mihalka L, Szatmari S, et al. Mannitol use in acute stroke case fatality at 30 days and 1 year. Stroke. 2003;43:1730–5.

    Article  Google Scholar 

  13. Candelise L, Colombo A, Spinnnler H. Therapy against brain swelling in stroke patients: a retrospective clinical study on 227 patients. Stroke. 1975;6:352–6.

    Article  Google Scholar 

  14. Santambrogio S, Martinotti R, Sardella F, et al. Is there real treatment for stroke? Clinical and statistical comparison of different treatments in 300 patients. Stroke. 1978;9:130–2.

    Article  CAS  PubMed  Google Scholar 

  15. Adams HP, Davis PH, Leira EC, et al. Baseline NIH stroke scale score strongly predicts outcome after stroke: a report of the trial of org 10172 in acute stroke treatment (TOAST). Neurology. 1999;53(1):126.

    Article  CAS  PubMed  Google Scholar 

  16. Rordorf G, Koroshetz W, Efird J, et al. Predictors of mortality in stroke patients admitted to an intensive care unit. Crit Care Med. 2000;28(5):1301–5.

    Article  CAS  PubMed  Google Scholar 

  17. Kim H, Jin ST, Kim YW, et al. Predictors of malignant brain edema in middle cerebral artery infarction observed on CT angiography. J Clin Neurosci. 2015;22:554–60.

    Article  PubMed  Google Scholar 

  18. Woo D, Broderick JP, Kohtari RU, et al. Does the national institutes of health stroke scale favor left hemisphere strokes? Stroke. 1999;30:2355–9.

    Article  CAS  PubMed  Google Scholar 

  19. Battey TWK, Karki M, Singhal AB, et al. Brain edema predicts outcome after nonlacunar ischemic stroke. Stroke. 2014;45:3643–8.

    Article  PubMed  Google Scholar 

  20. Choi HA, Fernandez A, Jeon SB, et al. Ethnic disparities in end-of-life care after subarachnoid hemorrhage. Neurocrit Care. 2015;22(3):423–8.

    Article  PubMed  Google Scholar 

  21. Barnato AE, Anthony DL, Skinner J, et al. Racial and ethnic differences in preferences for end-of-life treatment. J Gen Intern Med. 2009;6:695–701.

    Article  Google Scholar 

  22. Rubin MA, Dhar R, Diringer MN. Racial differences in withdrawal of mechanical ventilation do not alter mortality in neurologically injured patients. J Crit Care. 2014;29:49–53.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Departments of Neurology, Washington University School of Medicine, 660 South Euclid Avenue, Box 8111, St. Louis, MO, 63110, USA

    C. J. Ong

  2. Department of Neurology and Neurosurgery, Washington University in St. Louis, 660 South Euclid Avenue, Box 8111, St. Louis, MO, 63110, USA

    S. G. Keyrouz & M. N. Diringer

Authors
  1. C. J. Ong
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. S. G. Keyrouz
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. M. N. Diringer
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to C. J. Ong.

Ethics declarations

Conflict of interest

The authors report no relevant disclosures.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ong, C.J., Keyrouz, S.G. & Diringer, M.N. The Role of Osmotic Therapy in Hemispheric Stroke. Neurocrit Care 23, 285–291 (2015). https://doi.org/10.1007/s12028-015-0173-2

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12028-015-0173-2

Keywords

Search

Navigation