Advertisement

Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: A real-world study

  • Fabio Pilato
    Correspondence
    Corresponding authors at: Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico, via Álvaro del Portillo 21, 00128 Rome, Italy.
    Affiliations
    Unit of Neurology, Neurophysiology, Department of Medicine, Università Campus Bio-Medico di Roma, Rome, Italy
    Search for articles by this author
  • Giovanni Pellegrino
    Affiliations
    IRCCS San Camillo Hospital, Via Alberoni 80, 30126 Venice, Italy
    Search for articles by this author
  • Rosalinda Calandrelli
    Affiliations
    Fondazione Policlinico Universitario A. Gemelli - IRCCS, UOC Radiologia e Neuroradiologia, Dipartimento di diagnostica per immagini, radioterapia oncologica ed ematologia, Rome, Italy
    Search for articles by this author
  • Aldobrando Broccolini
    Affiliations
    Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurologia – Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Rome, Italy

    Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168 Rome, Italy
    Search for articles by this author
  • Giacomo Della Marca
    Affiliations
    Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurologia – Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Rome, Italy

    Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168 Rome, Italy
    Search for articles by this author
  • Giovanni Frisullo
    Affiliations
    Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurologia – Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Rome, Italy
    Search for articles by this author
  • Roberta Morosetti
    Affiliations
    Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurologia – Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Rome, Italy
    Search for articles by this author
  • Paolo Profice
    Affiliations
    Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurologia – Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Rome, Italy
    Search for articles by this author
  • Valerio Brunetti
    Affiliations
    Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurologia – Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Rome, Italy
    Search for articles by this author
  • Fioravante Capone
    Affiliations
    Unit of Neurology, Neurophysiology, Department of Medicine, Università Campus Bio-Medico di Roma, Rome, Italy
    Search for articles by this author
  • Gabriella D'Apolito
    Affiliations
    Fondazione Policlinico Universitario A. Gemelli - IRCCS, UOC Radiologia e Neuroradiologia, Dipartimento di diagnostica per immagini, radioterapia oncologica ed ematologia, Rome, Italy
    Search for articles by this author
  • Vincenzo Quinci
    Affiliations
    Fondazione Policlinico Universitario A. Gemelli - IRCCS, UOC Radiologia e Neuroradiologia, Dipartimento di diagnostica per immagini, radioterapia oncologica ed ematologia, Rome, Italy
    Search for articles by this author
  • Alessio Albanese
    Affiliations
    Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168 Rome, Italy

    Fondazione Policlinico Universitario A. Gemelli IRCCS UOC Neurochirurgia, Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Rome, Italy.
    Search for articles by this author
  • Annunziato Mangiola
    Affiliations
    Dipartimento di Neuroscienze, Università G. D'Annunzio-Chieti, Ospedale Santo Spirito, Pescara, Italy
    Search for articles by this author
  • Enrico Marchese
    Affiliations
    Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168 Rome, Italy

    Fondazione Policlinico Universitario A. Gemelli IRCCS UOC Neurochirurgia, Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Rome, Italy.
    Search for articles by this author
  • Angelo Pompucci
    Affiliations
    UOC di Neurochirurgia, Ospedale S. Maria Goretti, Via G. Reni 1, 04100 Latina, Italy
    Search for articles by this author
  • Vincenzo Di Lazzaro
    Correspondence
    Corresponding authors at: Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico, via Álvaro del Portillo 21, 00128 Rome, Italy.
    Affiliations
    Unit of Neurology, Neurophysiology, Department of Medicine, Università Campus Bio-Medico di Roma, Rome, Italy
    Search for articles by this author
Published:August 03, 2022DOI:https://doi.org/10.1016/j.jns.2022.120376

      Highlights

      • Decompressive hemicraniectomy is a lifesaving therapy for mMCA in the real world
      • Selected patients with malignant MCA may benefit from decompressive hemicraniectomy.
      • Cost-utility and perioperative complications should be considered for DHC
      • Patients and families should be correctly counseled about DHC

      Abstract

      Background

      Malignant middle cerebral artery infarction (mMCA) is a devastating disease with rates of fatality as high as 80%. Decompressive hemicraniectomy (DHC) reduces mortality, but many survivors inevitably remain severely disabled.
      This study aimed to analyze patients with mMCA undergoing DHC or best medical treatment (BMT) baseline characteristics and factors linked to therapeutic choice and determinants of prognosis.

      Methods

      We recorded clinical and radiological features of patients undergoing BMT or DHC. The two groups were compared for epidemiology, clinical presentation, neuroimaging, and prognosis. Regression analysis was performed to identify predictors of surgical treatment and outcome.

      Results

      One hundred twenty-five patients were included (age 67.41 ± 1.39 yo; 65 M). Patients undergoing DHC (N = 57) were younger (DHC 55.71 ± 1.48 yo vs. BMT 77.22 ± 1.38) and had midline shift (DHC 96.5% (55/57) vs. BMT 35.3% (24/68), a larger volume of the affected hemisphere and reduced ventricles volume as compared to BMT.
      The chance of surgery depended on age (Exp(B) = 0.871, p < 0.001), clinical status at onset (NIHSS Exp(B) = 0.824, p = 0.030) and volume of the ventricle of the affected hemisphere (Exp(B) = 0.736, p = 0.006).
      Death rate during admission was significantly lower for DHC (DHC 15% (6/41) vs BMT 71.7% (38/53), Fisher's test = 30.234, p < 0.001).

      Conclusion

      Although DHC may cause prolonged hospitalization and long-term disabled patients, it is a lifesaving therapy that should be considered for selected patients with mMCA but perioperative complications and cost-utility should be considered. Patients and families should be correctly counseled about this therapeutic choice and its short- and long-term consequences.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of the Neurological Sciences
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Roth G.A.
        • Abate D.
        • Abate K.H.
        • et al.
        Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the global burden of disease study 2017.
        Lancet. 2018; 392: 1736-1788https://doi.org/10.1016/S0140-6736(18)32203-7
        • Meschia J.F.
        • Bushnell C.
        • Boden-Albala B.
        • et al.
        Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2014; 45: 3754-3832https://doi.org/10.1161/STR.0000000000000046
        • Berkhemer O.A.
        • Fransen P.S.S.
        • Beumer D.
        • et al.
        A randomized trial of intraarterial treatment for acute ischemic stroke.
        N. Engl. J. Med. 2015; 372: 11-20https://doi.org/10.1056/NEJMoa1411587
        • Peng G.
        • Huang C.
        • Chen W.
        • et al.
        Risk factors for decompressive craniectomy after endovascular treatment in acute ischemic stroke.
        Neurosurg. Rev. 2019; https://doi.org/10.1007/s10143-019-01167-4
        • Beez T.
        • Munoz-Bendix C.
        • Steiger H.-J.
        • Beseoglu K.
        Decompressive craniectomy for acute ischemic stroke.
        Crit. Care. 2019; 23https://doi.org/10.1186/s13054-019-2490-x
        • Hacke W.
        • Schwab S.
        • Horn M.
        • et al.
        “Malignant” middle cerebral artery territory infarction: clinical course and prognostic signs.
        Arch. Neurol. 1996; 53: 309-315https://doi.org/10.1001/archneur.1996.00550040037012
        • Moulin D.E.
        • Lo R.
        • Chiang J.
        • Barnett H.J.
        Prognosis in middle cerebral artery occlusion.
        Stroke. 1985; 16: 282-284https://doi.org/10.1161/01.str.16.2.282
        • Jeon S.-B.
        • Koh Y.
        • Choi H.A.
        • Lee K.
        Critical care for patients with massive ischemic stroke.
        J Stroke. 2014; 16: 146-160https://doi.org/10.5853/jos.2014.16.3.146
        • Hofmeijer J.
        • Kappelle L.J.
        • 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: 326-333https://doi.org/10.1016/S1474-4422(09)70047-X
        • Jüttler 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: 2518-2525https://doi.org/10.1161/STROKEAHA.107.485649
        • Vahedi K.
        • Vicaut E.
        • Mateo J.
        • et al.
        Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL trial).
        Stroke. 2007; 38: 2506-2517https://doi.org/10.1161/STROKEAHA.107.485235
        • 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: 215-222https://doi.org/10.1016/S1474-4422(07)70036-4
        • Heinsius T.
        • Bogousslavsky J.
        • Van Melle G.
        Large infarcts in the middle cerebral artery territory. Etiology and outcome patterns.
        Neurology. 1998; 50: 341-350https://doi.org/10.1212/wnl.50.2.341
        • Di Lazzaro V.
        • Profice P.
        • Dileone M.
        • et al.
        Delayed hypothermia in malignant ischaemic stroke.
        Neurol. Sci. 2012; 33: 661-664https://doi.org/10.1007/s10072-011-0824-9
        • Kimberly W.T.
        • Bevers M.B.
        • von Kummer R.
        • et al.
        Effect of IV glyburide on adjudicated edema endpoints in the GAMES-RP trial.
        Neurology. 2018; 91: e2163-e2169https://doi.org/10.1212/WNL.0000000000006618
        • Jüttler E.
        • Unterberg A.
        • Woitzik J.
        • et al.
        Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke.
        N. Engl. J. Med. 2014; 370: 1091-1100https://doi.org/10.1056/NEJMoa1311367
        • Thomalla G.
        • Hartmann F.
        • Juettler E.
        • 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: 435-445https://doi.org/10.1002/ana.22125
        • Inzitari D.
        • Carlucci G.
        Italian stroke guidelines (SPREAD): evidence and clinical practice.
        Neurol. Sci. 2006; 27: S225-S227https://doi.org/10.1007/s10072-006-0622-y
        • Jauch E.C.
        • Saver J.L.
        • Adams H.P.
        • et al.
        Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2013; 44: 870-947https://doi.org/10.1161/STR.0b013e318284056a
        • Jo K.
        • Bajgur S.S.
        • Kim H.
        • et al.
        A simple prediction score system for malignant brain edema progression in large hemispheric infarction.
        PLoS One. 2017; 12e0171425https://doi.org/10.1371/journal.pone.0171425
        • Torbey M.T.
        • Bösel J.
        • Rhoney D.H.
        • et al.
        Evidence-based guidelines for the management of large hemispheric infarction.
        Neurocrit. Care. 2015; 22: 146-164
        • Van Swieten J.C.
        • Koudstaal P.J.
        • Visser M.C.
        • et al.
        Interobserver agreement for the assessment of handicap in stroke patients.
        Stroke. 1988; 19: 604-607https://doi.org/10.1161/01.STR.19.5.604
        • Abecassis I.J.
        • Young C.C.
        • Caldwell D.J.
        • et al.
        The Kempe incision for decompressive craniectomy, craniotomy, and cranioplasty in traumatic brain injury and stroke.
        J. Neurosurg. 2021; 1–10https://doi.org/10.3171/2020.11.JNS203567
        • Yu Y.
        • Zhang F.-L.
        • Qu Y.-M.
        • et al.
        Intracranial calcification is predictive for hemorrhagic transformation and prognosis after intravenous thrombolysis in non-cardioembolic stroke patients.
        J. Atheroscler. Thromb. 2021; 28: 356-364https://doi.org/10.5551/jat.55889
        • Zhou Y.-Q.
        • Son G.-H.
        • Shi Y.-Q.
        • et al.
        Quantitative segmentation analysis of the radiological changes by using ITK-SNAP: risk assessment of the severity and recurrence of medication-related osteonecrosis of the jaw.
        Int. J. Med. Sci. 2021; 18: 2209-2216https://doi.org/10.7150/ijms.56408
        • Hofmeijer J.
        • Amelink G.J.
        • Algra A.
        • et al.
        Hemicraniectomy after middle cerebral artery infarction with life-threatening edema trial (HAMLET). Protocol for a randomised controlled trial of decompressive surgery in space-occupying hemispheric infarction.
        Trials. 2006; 7: 29https://doi.org/10.1186/1745-6215-7-29
        • Jüttler E.
        • Unterberg A.
        • Woitzik J.
        • et al.
        Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke.
        N. Engl. J. Med. 2014; 370: 1091-1100https://doi.org/10.1056/NEJMoa1311367
        • Renna R.
        • Pilato F.
        • Profice P.
        • et al.
        Risk factor and etiology analysis of ischemic stroke in young adult patients.
        J. Stroke Cerebrovasc. Dis. 2014; 23: e221-e227https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.10.008
        • Bhattacharyya A.
        • Tahir A.
        • Chandrashekar A.
        • et al.
        A cost-utility analysis of decompressive hemicraniectomy versus medical treatment in the management of space-occupying brain oedema post middle cerebral artery infarction.
        Eur. J. Neurol. 2019; 26: 313-e19https://doi.org/10.1111/ene.13814
        • Qureshi A.I.
        • Suarez J.I.
        • Yahia A.M.
        • et al.
        Timing of neurologic deterioration in massive middle cerebral artery infarction: a multicenter review.
        Crit. Care Med. 2003; 31: 272-277https://doi.org/10.1097/00003246-200301000-00043
        • Wijdicks E.F.M.
        • Sheth K.N.
        • Carter B.S.
        • 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: 1222-1238https://doi.org/10.1161/01.str.0000441965.15164.d6
        • Maier I.L.
        • Behme D.
        • Schnieder M.
        • et al.
        Early computed tomography-based scores to predict decompressive hemicraniectomy after endovascular therapy in acute ischemic stroke.
        PLoS One. 2017; 12e0173737https://doi.org/10.1371/journal.pone.0173737
        • Kastrau F.
        • Wolter M.
        • Huber W.
        • Block F.
        Recovery from aphasia after Hemicraniectomy for infarction of the speech-dominant hemisphere.
        Stroke. 2005; 36: 825-829https://doi.org/10.1161/01.STR.0000157595.93115.70
        • Lin T.-K.
        • Chen S.-M.
        • Huang Y.-C.
        • et al.
        The outcome predictors of malignant large infarction and the functional outcome of survivors following decompressive Craniectomy.
        World Neurosurg. 2016; 93: 133-138https://doi.org/10.1016/j.wneu.2016.06.005
        • Rahme R.
        • Curry R.
        • Kleindorfer D.
        • et al.
        How often are patients with ischemic stroke eligible for decompressive hemicraniectomy?.
        Stroke. 2012; 43: 550-552https://doi.org/10.1161/STROKEAHA.111.635185
        • Shi J.
        • Wu H.
        • Dong Z.
        • et al.
        Automated quantitative lesion water uptake in acute stroke is a predictor of malignant cerebral edema.
        Eur. Radiol. 2022; https://doi.org/10.1007/s00330-021-08443-2
        • Bruno A.
        • Paletta N.
        • Verma U.
        • et al.
        Limiting brain shift in malignant hemispheric infarction by decompressive Craniectomy.
        J. Stroke Cerebrovasc. Dis. 2021; 30105830https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.105830
        • Verdolotti T.
        • Pilato F.
        • Cottonaro S.
        • et al.
        ColorViz, a new and rapid tool for assessing collateral circulation during stroke.
        Brain Sci. 2020; 10: E882https://doi.org/10.3390/brainsci10110882
        • Pilato F.
        • Verdolotti T.
        • Calandrelli R.
        • et al.
        Color-coded multiphase computed tomography angiography may predict outcome in anterior circulation acute ischemic stroke.
        J. Neurol. Sci. 2021; 430119989https://doi.org/10.1016/j.jns.2021.119989
        • Pilato F.
        • Profice P.
        • Dileone M.
        • et al.
        Stroke in critically ill patients.
        Minerva Anestesiol. 2009; 75: 245-250
        • Pilato F.
        • Silva S.
        • Valente I.
        • et al.
        Predicting factors of functional outcome in patients with acute ischemic stroke admitted to neuro-intensive care unit-a prospective cohort study.
        Brain Sci. 2020; 10: E911https://doi.org/10.3390/brainsci10120911
        • Geurts M.
        • van der Worp H.B.
        • Kappelle L.J.
        • et al.
        Surgical decompression for space-occupying cerebral infarction: outcomes at 3 years in the randomized HAMLET trial.
        Stroke. 2013; 44: 2506-2508https://doi.org/10.1161/STROKEAHA.113.002014
        • Dasenbrock H.H.
        • Robertson F.C.
        • Vaitkevicius H.
        • et al.
        Timing of decompressive Hemicraniectomy for stroke: a Nationwide inpatient sample analysis.
        Stroke. 2017; 48: 704-711https://doi.org/10.1161/STROKEAHA.116.014727
        • Dowlati E.
        • Pasko K.B.D.
        • Molina E.A.
        • et al.
        Decompressive hemicraniectomy and cranioplasty using subcutaneously preserved autologous bone flaps versus synthetic implants: perioperative outcomes and cost analysis.
        J. Neurosurg. 2022; 1–8https://doi.org/10.3171/2022.3.JNS212637
        • Gupta R.
        • Connolly E.S.
        • Mayer S.
        • Elkind M.S.V.
        Hemicraniectomy for massive middle cerebral artery territory infarction.
        Stroke. 2004; 35: 539-543https://doi.org/10.1161/01.STR.0000109772.64650.18
        • Rumalla K.
        • Ottenhausen M.
        • Kan P.
        • Burkhardt J.-K.
        Recent Nationwide impact of mechanical thrombectomy on decompressive Hemicraniectomy for acute ischemic stroke.
        Stroke. 2019; 50: 2133-2139https://doi.org/10.1161/STROKEAHA.119.025063