Distribution of the scores of modified Ranking scale MRS after 12 months for patients treated with or without decompressive surgery. Reprinted from Vahedi K, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol. It must be noted that this study design is an unconventional approach in which a pooled analysis from 3 independent trials was planned in advance while these trials were still ongoing. The obvious advantage of such an approach is to keep the number of patients included to a minimum and to report the results much earlier than would have been possible based on individual trials alone.
However, this study design certainly has limitations that are strongly related to the nature of pooled analysis of independent trials. Eligibility criteria such as age, time to randomization, and neuroimaging criteria were not identical, resulting in differences in baseline characteristics, infarct morphology, and in timing of surgery between individual trials.
Nevertheless, there was no significant heterogeneity between the three trials with regard to all outcome measures and adjusted analysis did not make any differences to the results. The results will be published soon in Stroke. However, some aspects must be considered when offering this treatment. Thus, the decision to perform decompressive surgery in patients with space-occupying infarction should always be based on the wishes of the patient and their families in light of the potential to survive with long-term moderate disability.
Second, several nonrandomized trials suggest that decompressive surgery is less effective in elderly patients. Thus, to date, it remains unclear whether decompressive surgery is also beneficial in patients older than 60 years. A randomized controlled trial addressing this subject is underway. Third, whether decompressive hemicraniectomy is still beneficial if performed after the first 48 hours remains also unclear and is currently being tested in HAMLET.
Fourth, several complications of surgical decompression have been reported, including wound infection, subdural hygroma and hematoma, tissue shearing from inadequately large craniotomy, brain sagging, and hydrocephalus that should not be shunted when skull remains open.
Neurology expert witness discusses ischemic stroke and emergency room treatment
Several medical treatment strategies have been proposed to be effective in controlling cerebral edema and reducing elevated ICP after severe hemispheric stroke. However, conservative antiedema therapy, as exists today, is disappointing. None of these treatments is supported by adequate evidence of efficacy from experimental studies or clinical trials, and some interventions may even be detrimental. Earlier and more aggressive therapeutic approaches are strongly needed for these patients.
Immediate access to reperfusion therapy remains the cornerstone of stroke therapy and also the first step of antiedema treatment, because limiting final infarct size by restoration of blood flow may likely reduce the chance of developing massive postischemic edema. Whether this aggressive treatment is beneficial for elderly patients or when performed after 48 hours is currently being tested. Continuing medical education CME credit is available for this article.
Home Stroke Vol. View PDF. Tools Add to favorites Download citations Track citations Permissions. Jump to. You are viewing the most recent version of this article. Previous versions: September 27, Previous Version 1. Continued Study Type of Study No. Treated Interventions Treatment Results Prospec indicates prospective; ran-con, randomized controlled; retrospect, retrospective. Download figure Download PowerPoint. Disclosures None. Arch Neurol.
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Management of large hemispheric strokes in the neurological intensive care unit. Timing of neurologic deterioration in massive middle cerebral artery infarction: A multicenter review. Crit Care Med. Intensive Care Med. Treatment of space-occupying cerebral infarction. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest.
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Mannitol use in acute stroke: Case fatality at 30 days and 1 year. Effects of hypertonic saline hydroxyethyl starch solution and mannitol in patients with increased intracranial pressure after stroke. Multimodal online monitoring in middle cerebral artery territory stroke. The effects of mannitol on cerebral edema after large hemispheric cerebral infarct. Mannitol bolus preferentially shrinks non-infarcted brain in patients with ischemic stroke.
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Stroke:Case Study Section 2
Osmotherapy with hypertonic saline attenuates water content in brain and extracerebral organs. Global brain water increases after experimental focal cerebral ischemia: Effect of hypertonic saline. Hyperosmolar agents in neurosurgical practice: The evolving role of hypertonic saline. Circulatory and metabolic effects of glycerol infusion in patients with recent cerebral infarction.
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