Vacuum Drains versus Passive Drains versus No Drains in Decompressive Craniectomies-A Randomized Controlled Trial on Subgaleal Drain Complication Rates (VADER Trial).

OBJECTIVE: Subgaleal drains are generally deemed necessary for cranial surgeries including decompressive craniectomies (DCs) to avoid excessive postoperative subgaleal hematoma (SGH) formation. Many surgeries have moved away from routine prophylactic drainage but the role of subgaleal drainage in cranial surgeries has not been addressed. METHODS: This was a randomized controlled trial at 2 centers. A total of 78 patients requiring DC were randomized in a 1:1:1 ratio into 3 groups: vacuum drains (VD), passive drains (PD), and no drains (ND). Complications studied were need for surgical revision, SGH amount, new remote hematomas, postcraniectomy hydrocephalus (PCH), functional outcomes, and mortality. RESULTS: Only 1 VD patient required surgical revision to evacuate SGH. There was no difference in SGH thickness and volume among the 3 drain types (P = 0.171 and P = 0.320, respectively). Rate of new remote hematoma and PCH was not significantly different (P = 0.647 and P = 0.083, respectively), but the ND group did not have any patient with PCH. In the subgroup analysis of 49 patients with traumatic brain injury, the SGH amount of the PD and ND group was significantly higher than that of the VD group. However, these higher amounts did not translate as a significant risk factor for poor functional outcome or mortality. VD may have better functional outcome and mortality. CONCLUSIONS: In terms of complication rates, VD, PD, and ND may be used safely in DC. A higher amount of SGH was not associated with poorer outcomes. Further studies are needed to clarify the advantage of VD regarding functional outcome and mortality, and if ND reduces PCH rates.

Decompressive craniectomy: indications and results of 24 cases at the neurosurgery clinic of Fann university hospital of Dakar.

Decompressive craniectomy is a surgical technique considered to be the last step in the management of intracranial hypertension. The objective of our study was to evaluate our results in the management of intracranial hypertension by decompressive craniectomy. This was a retrospective study of 24 cases of decompressive craniectomy performed over a 9-year period (from January 2010 to December 2019) at the Fann Neurosurgery Clinic. The mean age of the patients was 33.82 years, there was a male predominance with a sex ratio of 2.42. The most frequent indication was severe cranioencephalic trauma with 50%. The cerebral computed tomography (CT) scan was the key examination and was performed in all our patients. Complications were entirely infectious and were the cause of 73.33% of deaths. Thirty-five percent of the patients had received prior treatment before the decompressive craniectomy. The functional prognosis was good in 44.44% of cases, moderate in 33.33% of cases, 1 (11.11%) patient had a severe disability and 1 (11.11%) patient was in a vegetative state. Mortality rate was 62.5% of patients in our study series. Despite the lack of sophisticated techniques for diagnosis and monitoring of intracranial hypertension, our results remain acceptable with 37.5% survival. The early completion of this surgery allows us to be more efficient with a significant reduction in morbidity and mortality.

Mortality After Trauma Craniotomy Is Decreasing in Older Adults-A Nationwide Population-Based Study.

OBJECTIVE: No evidence-based guidelines are available for operative neurosurgical treatment of older patients with traumatic brain injuries (TBIs), and no population-based results of current practice have been reported. The objective of the present study was to investigate the rates of trauma craniotomy operations and later mortality in older adults with TBI in Finland. METHODS: Nationwide databases were searched for all admissions with a TBI diagnosis and after trauma craniotomy, and later deaths for persons aged ≥60 years from 2004 to 2018. RESULTS: The study period included 2166 patients (64% men; mean age, 70.3 years) who had undergone TBI-related craniotomy. The incidence rate of operations decreased with a concomitant decrease in adjusted mortality (30-day mortality, P < 0.001; 1-year mortality, P < 0.001) and increase in mean patient age (R2 = 0.005; P < 0.001) during the study period. The cumulative mortality was 25% at 30 days and 38% at 1 year. The comorbidities increasing the hazard for 30-day mortality were diabetes, a history of malignancy, peripheral vascular disease, and a history of myocardial infarction. For 1-year mortality, the comorbidities were heart failure and a history of myocardial infarction. Evacuation of an epidural hematoma decreased the hazard for mortality. In contrast, evacuation of an intracerebral hematoma and decompressive craniectomy increased the risk at both 30 days and 1 year. CONCLUSIONS: Among older adults in Finland, the rate of trauma craniotomy and later mortality has been decreasing although the mean age of operated patients has been increasing. This can be expected to be related to an improved understanding of geriatric TBIs and, consequently, improved selection of patients for targeted therapy.

Decompressive Hemicraniectomy for Acute Ischemic Stroke in the US: Characteristics and Outcomes.

OBJECTIVES: Decompressive hemicraniectomy can be life-saving for malignant middle cerebral artery acute ischemic stroke (AIS). However, utilization and outcomes for hemicraniectomy in the US are not known. We sought to analyze baseline characteristics and outcomes of patients receiving hemicraniectomy for AIS in the US. MATERIALS AND METHODS: We identified adults who received hemicraniectomy for AIS, identified with validated International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9) code in the Nationwide Readmissions Database 2014. We calculated 30-day readmission rates, reasons for readmission, and procedures performed. RESULTS: 2850 of 531,896 AIS patients (0.54%) received hemicraniectomy. Although patients receiving hemicraniectomy were more likely to be younger (57.0, 95% CI 56.0-58.0; vs 70.9, 95% CI 70.6-71.2; p < 0.0001) and male (40% vs 51.2% female; p<0.0001), 46.3% of patients who received hemicraniectomy were age 60 years and older. Patients 60 years or older receiving hemicraniectomy were more likely to die (29.9% vs 21.9%, p = 0.0081). Hemicraniectomy was more frequently performed at large hospitals (75.3% vs 57.7%; p < 0.0001) in urban areas (99.1% vs 90.3%; p < 0.0001) designated as metropolitan teaching hospitals (88.3% vs 63.4%; p < 0.0001). 30-day readmissions were most commonly due to infection (31.5%), non-infectious medical complications (17.7%), and surgical complications (13.8%). These readmissions were critical. CONCLUSIONS: Although hemicraniectomy is used more frequently in the treatment of younger, male, ischemic stroke patients, only half of the patients receiving hemicraniectomy in 2014 were <60 years old. Regardless of age, hemicraniectomy is a geographically segregated procedure, only being performed in large metropolitan teaching hospitals.

Random Forest-Based Prediction of Outcome and Mortality in Patients with Traumatic Brain Injury Undergoing Primary Decompressive Craniectomy.

BACKGROUND: Various prognostic models are used to predict mortality and functional outcome in patients after traumatic brain injury with a trend to incorporate machine learning protocols. None of these models is focused exactly on the subgroup of patients indicated for decompressive craniectomy. Evidence regarding efficiency of this surgery is still incomplete, especially in patients undergoing primary decompressive craniectomy with evacuation of traumatic mass lesions. METHODS: In a prospective study with a 6-month follow-up period, we assessed postoperative outcome and mortality of 40 patients who underwent primary decompressive craniectomy for traumatic brain injuries during 2018-2019. The results were analyzed in relation to a wide spectrum of preoperatively available demographic, clinical, radiographic, and laboratory data. Random forest algorithms were trained for prediction of both mortality and unfavorable outcome, with their accuracy quantified by area under the receiver operating curves (AUCs) for out-of-bag samples. RESULTS: At the end of the follow-up period, we observed mortality of 57.5%. Favorable outcome (Glasgow Outcome Scale [GOS] score 4-5) was achieved by 30% of our patients. Random forest-based prediction models constructed for 6-month mortality and outcome reached a moderate predictive ability, with AUC = 0.811 and AUC = 0.873, respectively. Random forest models trained on handpicked variables showed slightly decreased AUC = 0.787 for 6-month mortality and AUC = 0.846 for 6-month outcome and increased out-of-bag error rates. CONCLUSIONS: Random forest algorithms show promising results in prediction of postoperative outcome and mortality in patients undergoing primary decompressive craniectomy. The best performance was achieved by Classification Random forest for 6-month outcome.

Outcomes After Decompressive Craniectomy for Ischemic Stroke: A Volumetric Analysis.

BACKGROUND: Decompressive hemicraniectomy (DHC) is a treatment of space-occupying hemispheric infarct. Current surgical guidelines use criteria of age <60 years and surgery within 48 hours of stroke onset. OBJECTIVE: The purpose of this study was to evaluate the neurologic outcome after DHC and evaluate the relationship of stroke volume and outcomes. METHODS: A retrospective review was performed of patients undergoing DHC for cerebral infarct from 2016 to 2019. Unfavorable outcome was defined as modified Rankin Scale (mRS) score >3. Patients with precraniectomy magnetic resonance imaging were selected as a subset for volumetric stroke volume analysis using RAPID software (iSchemaView, Redwood City, California), with stroke volume defined as apparent diffusion coefficient <620 on diffusion-weighted imaging. RESULTS: Fifty-two patients met the inclusion criteria. At 90 days, favorable outcome was achieved in 11 patients (21.2%), and 41 patients (78.8%) had unfavorable outcomes (15 [29%] died). Surgery after 48 hours, age >60 years, and multivessel distribution did not significantly affect 90-day mRS score (P = 0.091, 0.111, and 0.664, respectively). In volumetric subset analysis, 10 patients of 41 (31.3%) achieved favorable outcomes, and no patients with volume of infarct >280 mL had a favorable outcome. There was a trend of lower volumes associated with favorable outcomes, but this did not meet significance (favorable 207 ± 68.7 vs. unfavorable 262 ± 117.1; P = 0.163). CONCLUSIONS: Outcomes after DHC for malignant hemispheric infarct were not affected by current accepted guidelines. Volume of infarct may have an effect on outcome after DHC. Further research to aid in predicting which patients benefit from decompressive craniectomy is warranted.

Fixed Positioning for Decompressive Hemicraniectomy Provides a Larger Diameter Flap than Nonfixed Positioning: A Single-Institution Experience.

BACKGROUND: Decompressive hemicraniectomy (DHC) is well established as an effective life-saving intervention. Although literature documents a correlation between mortality and hemicraniectomy flap size, no literature exists demonstrating whether a larger flap may be achieved with 3-pin fixation devices versus nonfixed positioning (e.g., occipital headrest, gel donut). Therefore, positioning for DHC remains the preference of the institution and attending physician. METHODS: Patients undergoing DHC during 2005-2016 were identified using Current Procedural Terminology codes. Inclusion criteria were: operative note available in the electronic medical record and postoperative head computed tomography (hCT). Exclusion criteria were: age <18 years, missing data in electronic medical record, no postoperative hCT performed, and craniectomy not done with intention of performing a hemicraniectomy (i.e., craniotomy converted to craniectomy). Anteroposterior diameter of the hemicraniectomy flap was measured in millimeters on the postoperative hCT. The average diameter was compared between the fixed positioning and nonfixed positioning groups. RESULTS: Analysis included 522 patients who met inclusion criteria; 363 were in the fixed positioning group, and 159 were in the nonfixed positioning group. The average hemicraniectomy diameter was 132.17 mm in the fixed positioning group, and 129.74 mm in the nonfixed positioning group, which was statistically significant (P = 0.027). CONCLUSIONS: This is the first large-scale single-institution study evaluating whether operative positioning for DHC affects the size of a hemicraniectomy flap. Positioning in 3-point fixation led to a statistically significant larger average diameter compared with nonfixed positioning. This indicates that the risks associated with pin fixation as well as additional time spent in positioning in this fashion are offset by the ability to obtain a larger hemicraniectomy flap, which is associated with decreased mortality.

Predictors of outcome in 1-month survivors of large middle cerebral artery infarcts treated by decompressive hemicraniectomy.

BACKGROUND: Decompressive hemicraniectomy (DH) increases survival without severe dependency in patients with large middle cerebral artery (LMCA) infarcts. The objective was to identify predictors of 1-year outcome after DH for LMCA infarct. METHODS: We conducted this study in consecutive patients who underwent DH for LMCA infarcts, in a tertiary stroke centre. Using multivariable logistic regression analyses, we evaluated predictors of (1) 30-day mortality and (2) poor outcome after 1 year (defined as a modified Rankin Scale score of 4-6) in 30-day survivors. RESULTS: Of 212 patients (133 men, 63%; median age 51 years), 35 (16.5%) died within 30 days. Independent predictors of mortality were infarct volume before DH (OR 1.10 per 10 mL increase, 95% CI 1.04 to 1.16), delay between symptom onset and DH (OR 0.41, 95% CI 0.23 to 0.73 per 12 hours increase) and midline shift after DH (OR 2.59, 95% CI 1.09 to 6.14). The optimal infarct volume cut-off to predict death was 210 mL or more. Among the 177 survivors, 77 (43.5%) had a poor outcome at 1 year. Independent predictors of poor outcome were age (OR 1.08 per 1 year increase, 95% CI 1.03 to 1.12) and weekly alcohol consumption of 300 g or more (OR 5.30, 95% CI 2.20 to 12.76), but not infarct volume. CONCLUSION: In patients with LMCA infarcts treated by DH, stroke characteristics (infarct volume before DH, midline shift after DH and early DH) predict 30-day mortality, while patients' characteristics (age and excessive alcohol intake) predict 1-year outcome survivors.

Predictors of 30-Day Mortality in Traumatic Brain-Injured Patients after Primary Decompressive Craniectomy.

OBJECTIVE: Primary decompressive craniectomy (DC) is an important therapeutic technique for severe head-injured patients with space-occupying lesions in emergency situations, but these patients are still at high risk for unfavorable outcomes. This study aimed to investigate the predictors of 30-day mortality in adult patients undergoing primary DC after traumatic brain injury (TBI). METHODS: All adult patients (≥18 years of age) who underwent primary DC from January 2012 to March 2019 were included. Demographic, clinical, surgical, and laboratory variables were collected for analysis. Early mortality was defined as 30-day mortality after DC. First, a univariate analysis (P < 0.05) was used to compare survivors and nonsurvivors. Multivariate logistic regression analysis was used to identify the predictors of 30-day mortality for patients who underwent primary DC. RESULTS: A total of 387 patients were enrolled in the study. The 30-day mortality was 31.52% (122/387). The median age at presentation was 49 years (interquartile range, 38-60), and 316 (81.65%) patients were male. In the multivariate logistic regression analysis, the factors associated with 30-day mortality included age (odds ratio [OR], 1.068; 95% confidence interval [CI], 1.040-1.096; P < 0.001), bilateral unreactive pupils (OR, 12.734; 95% CI, 4.129-39.270; P < 0.001), subdural hemorrhage (OR, 3.468; 95% CI, 1.305-9.218; P < 0.013), completely effaced basal cistern (OR, 3.52; 95% CI, 1.568-7.901; P = 0.002), intraoperative hypotension (OR, 11.532; 95% CI, 4.222-31.499; P < 0.001), preoperative activated partial thromboplastin time (OR, 6.905; 95% CI, 2.055-23.202; P = 0.002), and Injury Severity Score (OR, 1.081; 95% CI, 1.031-1.133; P = 0.002). CONCLUSIONS: In patients undergoing primary DC after traumatic brain injury, the predictors of 30-day mortality include age, bilateral unreactive pupils, subdural hemorrhage, completely effaced basal cistern, intraoperative hypotension, preoperative activated partial thromboplastin time, and Injury Severity Score.

Hemicraniectomy for Supratentorial Primary Intracerebral Hemorrhage: A Retrospective, Propensity Score Matched Study.

BACKGROUND AND PURPOSE: Spontaneous supratentorial intracerebral hemorrhage (ICH) contributes disproportionately to stroke mortality, and randomized trials of surgical treatments for ICH have not shown benefit. Decompressive hemicraniectomy (DHC) improves functional outcome in patients with malignant middle cerebral artery ischemic stroke, but data in ICH patients is limited. We hypothesized that DHC would reduce in-hospital mortality and poor functional status (defined as modified Rankin scale ≥5) among survivors at 3 months, without increased complications. METHODS: We performed a retrospective, case-control, propensity score matched study to determine whether hemicraniectomy affected outcome in patients with spontaneous supratentorial ICH. The propensity score consisted of variables associated with outcome or predictors of hemicraniectomy. Forty-three surgical patients were matched to 43 medically managed patients on ICH location, sex, and nearest neighbor matching. Three-month functional outcomes, in-hospital mortality, and in-hospital complications were measured. RESULTS: In the medical management group, 72.1% of patients had poor outcome at 3 months compared with 37.2% who underwent hemicraniectomy (odds ratio 4.8, confidence interval 1.6-14). In-hospital mortality was 51.2% for medically managed patients and 16.3% for hemicraniectomy patients (odds ratio 8.5, confidence interval 2.0-36.8). There were no statistically significant differences in the occurrence of in-hospital complications. CONCLUSIONS: In our retrospective study of selected patients with spontaneous supratentorial ICH, DHC resulted in lower rate of in-hospital mortality and better 3-month functional status compared with medically managed patients. A randomized trial is necessary to evaluate DHC as a treatment for certain patients with spontaneous supratentorial ICH.

Older Age Is Not Associated with Worse Outcomes Following Decompressive Hemicraniectomy for Spontaneous Intracerebral Hemorrhage.

BACKGROUND: Decompressive hemicraniectomy (DHC) is commonly offered after large spontaneous intracerebral hemorrhage (ICH) as a life-saving measure. Based on limited available evidence, surgery is sometimes avoided in the elderly. The association between age and outcomes following DHC in spontaneous ICH remains largely understudied. OBJECTIVE: The goal of this study is to investigate the influence of older age on outcomes of patients who undergo DHC for spontaneous ICH. METHODS: In this retrospective cohort study, inpatient data were obtained from the United States Nationwide Inpatient Sample from 2000 to 2011. Using International Classification of Diseases, ninth revision designations, patients with a primary diagnosis of nontraumatic ICH who underwent DHC were identified. The primary outcome of interest was the association of age to inpatient mortality and poor outcome. Subjects were grouped by age: 18-50, 51-60, 61-70, and more than 70 years. Sample characteristics were compared across age groups using χ2 testing, and univariate and multivariate Poisson Regression was performed using a generalized equation to estimate rate ratios for primary and secondary outcomes. RESULTS: One thousand one hundred and forty four patient cases were isolated. Death occurred in an estimated 28.9% and poor outcome in 86.4%. In multivariate Poisson regression models, there was no difference in hospital mortality or poor outcome by age group. Although younger patients were more likely to be diagnosed with herniation, total complication rate was similar between age groups. CONCLUSIONS: Our study results do not provide evidence that age independently predicts in-hospital mortality or poor outcomes. The true influence of age on outcomes is unclear, and further study is needed to determine which factors may be best in selecting candidates for DHC following spontaneous ICH.

Recent Nationwide Impact of Mechanical Thrombectomy on Decompressive Hemicraniectomy for Acute Ischemic Stroke.

Background and Purpose- The treatment of patients with acute ischemic stroke has been revolutionized by endovascular mechanical thrombectomy (MT), leading to dramatically improved outcomes. Here, we analyzed the impact of recent changes in stroke management on nationwide trends in patient characteristics, treatment modalities, and outcomes. Methods- The National Inpatient Sample was analyzed using International Classification of Diseases, Ninth and Tenth Editions, Clinical Modification codes to identify adult stroke patients with anterior-circulation, large-vessel occlusion in the pre- (2012-2014) and the post-MT trial period (2015-2016). Univariate and multivariable predictors of decompressive hemicraniectomy (DHC) were ascertained in patients developing malignant cerebral edema. Results- The nationwide query identified 519 320 adult stroke patients with annually increasing volume (92 320 to 129 340), stroke severity, and treatment at urban teaching centers. DHC was performed in 9.5% of patients developing malignant cerebral edema (n=33 530) and was associated with a high rate of discharge to long-term nursing care (65%) and mortality (23%). Over time, the rate of MT (3.4% to 9.8%) increased whereas the rate of DHC for malignant cerebral edema declined from 11.4% to 4.8% (P<0.001). In a binary logistic regression model controlling for potential confounders (eg, age, severity of illness), MT patients were 43% less likely to require DHC (odds ratio, 0.7; 95% CI, 0.6-0.9). Conclusions- Nationwide trends indicated that successful reperfusion of penumbra with MT in stroke patients leads to a declining indication for DHC whereas stroke volume increases over time.

Factors associated with mortality in acute subdural hematoma: Is decompressive craniectomy effective?

BACKGROUND: Despite rapid diagnosis and aggressive neurosurgical intervention, acute subdural hematoma (ASDH) is a severe type of head injury that can result in high morbidity and mortality. Although surgical procedures, such as craniotomy and decompressive craniectomy (DC), can be effective, the preferred approach for treating an ASDH remains controversial. The aim of this report was to evaluate factors associated with mortality in patients with ASDH and determinants of outcome in those with ASDH who underwent DC. METHODS: The demographic details and clinical and radiological characteristics of a total of 93 patients with ASDH who underwent DC during a 60-month period from 2012 to 2017 were evaluated to determine the effect on mortality and any association with the Glasgow Coma Scale (GCS) score recorded on arrival. RESULTS: Sixty-five male and 28 female subjects with a mean age of 59.82+-19.49 years (range: 16-88 years) were included in the study. Sixteen patients (17.2%) died following the surgery. Older age (p=0.007) and lower GCS scores (p=0.022) were statistically significantly associated with the mortality rate. The mean hematoma thickness was 15.46+-5.73 mm, and the mean midline shift was 9.90+-4.84 mm. The mortality rate was positively correlated with an excessive midline shift (p=0.011; r=0.262) and age (p=0.022; r=0.237) in patients with ADSH. A midline shift of ≥10 mm and a hematoma thickness of ≥15 mm was significantly associated with mortality (p=0.014; p=0.039). The etiology of the trauma; comorbidities of subarachnoid, epidural, or intracranial hemorrhage; compression fractures; or contusions were not significantly correlated. CONCLUSION: The results indicated that there was a higher mortality rate among older patients and those with a GCS score of <6 on arrival. A midline shift of ≥10 mm and a hematoma thickness of ≥15 mm were significantly related to mortality. Our study supports the conclusion that DC may help prevent further midline shift and be associated with a lower mortality rate compared with a craniotomy.

Decompressive hemicraniectomy after malignant middle cerebral artery infarction: does hospital of origin matter?

Decompressive hemicraniectomy (DHC) has been shown to reduce mortality in malignant middle cerebral artery (MCA) infarction. Our primary objective was to compare 1-year mortality between patients receiving DHC for malignant MCA infarction at our institution based on hospital of origin. We retrospectively reviewed the medical records of all patients treated for malignant MCA infarction with DHC at our institution over a 3-year period. One-year mortality rates and time to surgery were comparable regardless of whether the patient first attended the tertiary referral centre or a peripheral centre.

Comparison of craniotomy and decompressive craniectomy in large supratentorial intracerebral hemorrhage.

Intracerebral hemorrhage (ICH) is devastating disease with high mortality and morbidity rates. Most ICH is evacuated by either craniotomy (CR) or decompressive craniectomy (DC) although optimal treatment has not been established yet. The objective of this study was to compare clinical outcomes of spontaneous ICH patients between CR and DC groups and determine clinical factors affecting clinical prognosis. We retrospectively analyzed our single-center experience with large supratentorial ICH. From January 2011 to December 2016, 286 consecutive supratentorial large ICH patients underwent surgery in our institute. We compared CR group and DC group with regard to age, sex, GCS score, hematoma volume, midline shift, ICH score, and time from ictus to surgery. Statistical analysis was done using the t-test or x2 test, and odds ratio was calculated. During study period, CR was performed in 139 patients while DC was performed in 125 patients. There were no significant difference in 30-day mortality between the CR group and the DC group (13.7% vs 15.2%, p = 0.729). However, 12-month functional survival was 46.0% in the CR group, which was significantly (p = 0.014) higher than that (32.0%) of the DC group. In conclusion, the 30-day mortality of CR group was not inferior to that of the DC group while its 12-month functional survival was superior to that of the DC group. This suggests better functional outcome might be obtained for selected large ICH patients with CR than with DC.

Long-term outcome following decompressive craniectomy: an inconvenient truth?

PURPOSE OF REVIEW: There is little doubt that decompressive craniectomy can reduce mortality following malignant middle cerebral infarction or severe traumatic brain injury. However, the concern has always been that the reduction in mortality comes at the cost of an increase in the number of survivors with severe neurological disability. RECENT FINDINGS: There has been a number of large multicentre randomized trials investigating surgical efficacy of the procedure. These trials have clearly demonstrated a survival benefit in those patients randomized to surgical decompression. However, it is only possible to demonstrate an improvement in outcome if the definition of favourable is changed such that it includes patients with either a modified Rankin score of 4 or upper severe disability. Without this recategorization, the results of these trials have confirmed the 'Inconvenient truth' that surgery reduces mortality at the expense of survival with severe disability. SUMMARY: Given these results, the time may have come for a nuanced examination of the value society places on an individual life, and the acceptability or otherwise of performing a procedure that converts death into survival with severe disability.

Intracranial Pressure Soon After Hemicraniectomy in Malignant Middle Cerebral Artery Infarction.

BACKGROUND: Decompressive hemicraniectomy reduces secondary brain injury related to brain edema and increased intracranial pressure (ICP) in patients with malignant middle cerebral artery infarction (MMI). However, a substantial proportion of patients still die despite hemicraniectomy due to refractory brain swelling. OBJECTIVE: We aim to investigate whether ICP measured immediately after hemicraniectomy may indicate decompression effects and predict survival in patients with MMI. METHODS: We included 25 patients with MMI who underwent ICP monitoring and brain computed tomography within the first hour of hemicraniectomy. Midline shifts were measured as radiological surrogates of decompression. The Glasgow Coma Scale and pupillary enlargements during the first day after hemicraniectomy were assessed as clinical surrogates of decompression. Long-term survival status at 6 months was used as the final outcome. We analyzed the relationships between early ICP and findings of midline shift, Glasgow Coma Scale, pupillary enlargement, and survival. RESULTS: Initial ICP was correlated with mean ICP ( P < .001) and maximal ICP ( P < .001) during the first postoperative day. Intracranial pressure was associated with midline shifts ( P = .009), lower Glasgow Coma Scale scores ( P = .025), and the pupillary enlargement ( P = .015). Sixteen (64.0%) patients survived at 6 months. In a Cox proportional hazard model, elevated ICP was associated with mortality at 6 months (hazard ratio: 1.13; 95% confidence interval: 1.03-1.24; P = .008). CONCLUSION: Increase in ICP soon after hemicraniectomy was associated with midline shift, poor neurological status, and mortality in patients with MMI. Measurements of ICP soon after hemicraniectomy may permit earlier interventions as well as more refined clinical assessments.

Herniation despite Decompressive Hemicraniectomy in Large Hemispherical Ischemic Strokes.

BACKGROUND: Despite decompressive hemicraniectomy (DHC), progressive herniation resulting in death has been reported following middle cerebral artery (MCA) strokes. We aimed to determine the surgical parameters measured on brain computed tomography (CT) scan that are associated with progressive herniation despite DHC in large MCA strokes. METHODS: Retrospective chart review of medical records of patients with malignant hemispheric infarction who underwent DHC for cerebral edema was performed. Infarct volume was calculated on CT scans obtained within 24 hours of ictus. Radiological parameters of craniectomy bone flap size, brain volume protruding out of the skull, adequate centering of the craniectomy over the stroke bed, and the infarct volume outside the craniectomy bed (volume not centered [VNC]) were measured on the postoperative brain CT. RESULTS: Of 41 patients who underwent DHC, 7 had progressive herniation leading to death. Radiographic parameters significantly associated with progressive herniation included insufficient centering of craniectomy bed on the stroke bed (P = .03), VNC (P = .011), additional anterior cerebral artery infarction (P = .047), and smaller craniectomy length (P = .05). Multivariate logistic regression analysis for progressive herniation using craniectomy length and VNC as independent variables demonstrated that a higher VNC was significantly associated with progressive herniation despite surgery (P = .029). CONCLUSIONS: In large MCA strokes, identification of large infarct volume outside the craniectomy bed was associated with progressive herniation despite surgery. These results will need to be verified in larger prospective studies.

Predictors of In-Hospital Mortality after Decompressive Hemicraniectomy for Malignant Ischemic Stroke.

OBJECTIVE: The purpose of this retrospective multicenter, pooled-data analysis was to determine the factors associated with in-hospital mortality in decompressive hemicraniectomy (DHC) for malignant middle cerebral artery (MMCA) stroke. PATIENTS AND METHODS: The authors reviewed pooled DHC database from 3 countries for patients with MMCA with hospital mortality in spite of DHC to identify factors that predicted in-hospital mortality after DHC. The identified factors were applied to the group of patients who were selected for DHC but either refused surgery and died or stabilized and did not undergo DHC. FINDINGS: There were 137 patients who underwent DHC. Multiple logistic regression analysis showed middle cerebral artery (MCA) with additional infarcts (odds ratio [OR], 7.9: 95% confidence interval [CI], 2.4-26; P = .001), preoperative midline shift of septum pellucidum of 1 cm or more (OR, 3.83: 95% CI, 1.13-12.96; P = .031), and patients who remained unconscious on day 7 postoperatively (8.82: 95% CI; OR, 1.08-71.9; P = .042) were significant independent predictors for in-hospital mortality. The identified factors were applied to the group of MMCA patients not operated (n = 19 refused, n = 47 stabilized) single (P < .001), and two predictive factors (P < .001) were significantly more common in patients who died. Whereas two predicative factors were identified in only 9%-18.2% of survivors, the presence of all three predictive factors was seen only in patients who expired (P < .001). The Hosmer-Lemeshow goodness-of-fit statistics (chi-square = 4.65; P value = .589) indicate that the model adequately describes the data. CONCLUSION: Direct physical factors, such as MCA with additional territory infarct, extent of midline shift, and postoperative consciousness level, bore a significant relationship to in-hospital mortality in MMCA patients undergoing DHC.