Skip to main content

Advertisement

SpringerLink
Log in

Factors that Can Help Select the Timing for Decompressive Hemicraniectomy for Malignant MCA Stroke

  • Original Article
  • Published:
Translational Stroke Research Aims and scope Submit manuscript

Abstract

In patients with malignant middle cerebral artery (MMCA) stroke, a vital clinically relevant question is determination of the speed with which infarction evolves to select the time for decompressive hemicraniectomy [DHC]. A retrospective, multicenter cross-sectional study of patients referred for DHC, based on the criteria of randomized controlled trials, was undertaken to identify factors for selecting the timing of DHC in MMCA stroke, stratified by time [< 48, 48–72, > 72 h]. Infarction volume and infarct growth rate [IGR] were measured on all CT scans. One hundred eighty-two patients [135 underwent DHC and 47 survived without DHC] were included in the analysis. After multivariate adjustment, factors showing the strongest independent association with DHC were patients < 55 years of age, septum pellucidum deviation, temporal lobe involvement, MCA with additional infarcts, and IGR on second CT. Of the five factors identified, different combinations of determining factors were observed in each subgroup. Both first and second IGRs were highest in the < 48, 48–< 72, and > 72 h [p < 0.001]. Patients who survived without surgery had the slowest IGRs. There was no association between time to DHC and infarct volume, although infarct volume was lower in patients who survived without DHC compared to the DHC subgroups. We identify the major risk factors associated with DHC in time-stratified subgroups of patients with MMCA. Evaluation of IGRs between the first and second scan and when possible second and third scan can help in selecting the timing of hemicraniectomy.

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

Similar content being viewed by others

References

  1. Wheeler HM, Mlynash M, Inoue M, Tipirnini A, Liggins J, Bammer R, et al. The growth rate of early DWI lesions is highly variable and associated with penumbral salvage and clinical outcomes following endovascular reperfusion. Int J Stroke Off J Int Stroke Soc. 2015;10(5):723–9.

    Article  Google Scholar 

  2. Schwab S, Steiner T, Aschoff A, Schwarz S, Steiner HH, Jansen O, et al. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke J Cereb Circ. 1998;29(9):1888–93.

    Article  CAS  Google Scholar 

  3. Fandino J, Keller E, Barth A, Landolt H, Yonekawa Y, Seiler RW. Decompressive craniotomy after middle cerebral artery infarction. Retrospective analysis of patients treated in three centres in Switzerland. Swiss Med Wkly. 2004;134(29–30):423–9.

    PubMed  Google Scholar 

  4. Cho D-Y, Chen T-C, Lee H-C. Ultra-early decompressive craniectomy for malignant middle cerebral artery infarction. Surg Neurol. 2003;60(3):227–32; discussion 232–3.

    Article  Google Scholar 

  5. Uhl E, Kreth FW, Elias B, Goldammer A, Hempelmann RG, Liefner M, et al. Outcome and prognostic factors of hemicraniectomy for space occupying cerebral infarction. J Neurol Neurosurg Psychiatry. 2004;75(2):270–4.

    CAS  PubMed  PubMed Central  Google Scholar 

  6. Gupta R, Connolly ES, Mayer S, Elkind MSV. Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review. Stroke J Cereb Circ. 2004;35(2):539–43.

    Article  Google Scholar 

  7. Kamran S, Akhtar N, Salam A, Alboudi A, Kamran K, Ahmed A, et al. Revisiting hemicraniectomy: late decompressive hemicraniectomy for malignant middle cerebral artery stroke and the role of infarct growth rate. Stroke Res Treat. 2017;2017:2507834.

    PubMed  PubMed Central  Google Scholar 

  8. McKenna A, Wilson CF, Caldwell SB, Curran D. Functional outcomes of decompressive hemicraniectomy following malignant middle cerebral artery infarctions: a systematic review. Br J Neurosurg. 2012;26(3):310–5.

    Article  Google Scholar 

  9. Dasenbrock HH, Robertson FC, Vaitkevicius H, Aziz-Sultan MA, Guttieres D, Dunn IF, et al. Timing of decompressive hemicraniectomy for stroke: a nationwide inpatient sample analysis. Stroke. 2017;48(3):704–11.

    Article  Google Scholar 

  10. Basu P, Jenkins H, Tsang K, Vakharia VN. National survey of neurosurgeons and stroke physicians on decompressive hemicraniectomy for malignant middle cerebral artery infarction. World Neurosurg. 2017;102:320–8.

    Article  Google Scholar 

  11. Daou B, Kent AP, Montano M, Chalouhi N, Starke RM, Tjoumakaris S, et al. Decompressive hemicraniectomy: predictors of functional outcome in patients with ischemic stroke. J Neurosurg. 2016;124(6):1773–9.

    Article  Google Scholar 

  12. Rosset A, Spadola L, Ratib O. OsiriX: an open-source software for navigating in multidimensional DICOM images. J Digit Imaging. 2004;17(3):205–16.

    Article  Google Scholar 

  13. Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R, et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA. 1995;274(13):1017–25.

    Article  CAS  Google Scholar 

  14. Schwamm LH, Koroshetz WJ, Sorensen AG, Wang B, Copen WA, Budzik R, et al. Time course of lesion development in patients with acute stroke: serial diffusion- and hemodynamic-weighted magnetic resonance imaging. Stroke J Cereb Circ. 1998;29(11):2268–76.

    Article  CAS  Google Scholar 

  15. Kamran S, Akhtar N, Alboudi A, Kamran K, Ahmad A, Inshasi J, et al. Prediction of infarction volume and infarction growth rate in acute ischemic stroke. Sci Rep. 2017;7(1):7565.

    Article  Google Scholar 

  16. Simard JM, Kent TA, Chen M, Tarasov KV, Gerzanich V. Brain oedema in focal ischaemia: molecular pathophysiology and theoretical implications. Lancet Neurol. 2007;6(3):258–68.

    Article  CAS  Google Scholar 

  17. Kamran S, Salam A, Akhtar N, Alboudi A, Ahmad A, Khan R, et al. Predictors of in-hospital mortality after decompressive hemicraniectomy for malignant ischemic stroke. J Stroke Cerebrovasc Dis Off J Natl Stroke Assoc. 2017;26(9):1941–7.

    Article  Google Scholar 

  18. Kasner SE, Demchuk AM, Berrouschot J, Schmutzhard E, Harms L, Verro P, et al. Predictors of fatal brain edema in massive hemispheric ischemic stroke. Stroke J Cereb Circ. 2001;32(9):2117–23.

    Article  CAS  Google Scholar 

  19. Krieger DW, Demchuk AM, Kasner SE, Jauss M, Hantson L. Early clinical and radiological predictors of fatal brain swelling in ischemic stroke. Stroke. 1999;30(2):287–92.

    Article  CAS  Google Scholar 

  20. Hofmeijer J, Algra A, Kappelle LJ, van der Worp HB. Predictors of life-threatening brain edema in middle cerebral artery infarction. Cerebrovasc Dis Basel Switz. 2008;25(1–2):176–84.

    Article  Google Scholar 

  21. Thomalla G, Hartmann F, Juettler E, Singer OC, Lehnhardt F-G, Köhrmann M, et al. Prediction of malignant middle cerebral artery infarction by magnetic resonance imaging within 6 hours of symptom onset: a prospective multicenter observational study. Ann Neurol. 2010;68(4):435–45.

    Article  Google Scholar 

  22. Ong CJ, Gluckstein J, Laurido-Soto O, Yan Y, Dhar R, Lee J-M. Enhanced detection of edema in malignant anterior circulation stroke (EDEMA) score: a risk prediction tool. Stroke. 2017 Jul;48(7):1969–72.

    Article  Google Scholar 

  23. Maramattom BV, Bahn MM, Wijdicks EFM. Which patient fares worse after early deterioration due to swelling from hemispheric stroke? Neurology. 2004;63(11):2142–5.

    Article  Google Scholar 

  24. Qureshi AI, Suarez JI, Yahia AM, Mohammad Y, Uzun G, Suri MFK, et al. Timing of neurologic deterioration in massive middle cerebral artery infarction: a multicenter review. Crit Care Med. 2003;31(1):272–7.

    Article  Google Scholar 

  25. Mori K, Nakao Y, Yamamoto T, Maeda M. 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. Surg Neurol. 2004;62(5):420–9; discussion 429–30.

    PubMed  Google Scholar 

  26. Schwab S, Steiner T, Aschoff A, Schwarz S, Steiner HH, Jansen O, et al. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke J Cereb Circ. 1998;29(9):1888–93.

    Article  CAS  Google Scholar 

  27. Basu P, Jenkins H, Tsang K, Vakharia VN. National survey of neurosurgeons and stroke physicians on decompressive hemicraniectomy for malignant middle cerebral artery infarction. World Neurosurg. 2017;102:320–8.

    Article  Google Scholar 

  28. von Olnhausen O, Thorén M, von Vogelsang A-C, Svensson M, Schechtmann G. Predictive factors for decompressive hemicraniectomy in malignant middle cerebral artery infarction. Acta Neurochir 2016 Feb 29;

  29. Wijdicks EFM, Sheth KN, Carter BS, Greer DM, Kasner SE, Kimberly WT, et al. 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(4):1222–38.

    Article  Google Scholar 

  30. Gupta A, Sattur MG, Aoun RJN, Krishna C, Bolton PB, Chong BW, et al. Hemicraniectomy for ischemic and hemorrhagic stroke. Facts and Controversies Neurosurg Clin N Am. 2017;28(3):349–60.

    Article  Google Scholar 

  31. Jung S, Gilgen M, Slotboom J, El-Koussy M, Zubler C, Kiefer C, et al. Factors that determine penumbral tissue loss in acute ischaemic stroke. Brain J Neurol. 2013;136(Pt 12):3554–60.

    Article  Google Scholar 

  32. Lansberg MG, Straka M, Kemp S, Mlynash M, Wechsler LR, Jovin TG, et al. MRI profile and response to endovascular reperfusion after stroke (DEFUSE 2): a prospective cohort study. Lancet Neurol. 2012;11(10):860–7.

    Article  Google Scholar 

  33. Lansberg MG, Thijs VN, O’Brien MW, Ali JO, de Crespigny AJ, Tong DC, et al. Evolution of apparent diffusion coefficient, diffusion-weighted, and T2-weighted signal intensity of acute stroke. AJNR Am J Neuroradiol. 2001;22(4):637–44.

    CAS  PubMed  Google Scholar 

  34. Cohen-Gadol AA, Bradley CC, Williamson A, Kim JH, Westerveld M, Duckrow RB, et al. Normal magnetic resonance imaging and medial temporal lobe epilepsy: the clinical syndrome of paradoxical temporal lobe epilepsy. J Neurosurg. 2005;102(5):902–9.

    Article  Google Scholar 

  35. Nakano S, Iseda T, Kawano H, Yoneyama T, Ikeda T, Wakisaka S. Correlation of early CT signs in the deep middle cerebral artery territories with angiographically confirmed site of arterial occlusion. AJNR Am J Neuroradiol. 2001;22(4):654–9.

    CAS  PubMed  Google Scholar 

  36. Kamran S, Bhutta Z, Akhtar N, Bates V, Salam A, Shuaib A. Abstract TP59: to estimate the time of stroke onset by using Ct scan and stroke severity scale. Stroke. 2017;48(Suppl 1):ATP59.

    Google Scholar 

  37. Wade DT. Evaluating outcome in stroke rehabilitation (quality control and clinical audit). Scand J Rehabil Med Suppl. 1992;26:97–104.

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar

    Saadat Kamran, Abdul Salam, Naveed Akhtar, Rajvir Singh, Numan Amir & Ashfaq Shuaib

  2. Weill Cornell-School of Medicine, Ar-Rayyan, Qatar

    Saadat Kamran, Naveed Akhtar & Rayaz A. Malik

  3. Rashid Hospital, Dubai, UAE

    Ayman Alboudi & Jihad Inshasi

  4. College of Liberal Arts, University of Illinois, Chicago, IL, USA

    Kainat Kamran

  5. Kindi Institute, Qatar University, Doha, Qatar

    Uwais Qidwai

Authors
  1. Saadat Kamran
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Abdul Salam
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Naveed Akhtar
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ayman Alboudi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kainat Kamran
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Rajvir Singh
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Numan Amir
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Jihad Inshasi
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Uwais Qidwai
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Rayaz A. Malik
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Ashfaq Shuaib
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Saadat Kamran.

Ethics declarations

The study adhered to the tenets of the declaration of Helsinki and was approved by the Institutional Review Board of Hamad Medical Corporation, Qatar [15246/15], Shifa International Hospital, Pakistan 421-270-2014, and Rashid Hospital, UAE DSREC 12/2015_09.

Conflict of Interest

The authors declare that they have no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kamran, S., Salam, A., Akhtar, N. et al. Factors that Can Help Select the Timing for Decompressive Hemicraniectomy for Malignant MCA Stroke. Transl. Stroke Res. 9, 600–607 (2018). https://doi.org/10.1007/s12975-018-0616-0

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12975-018-0616-0

Keywords

Search

Navigation