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Author Spotlight: Assessing Ischemic Stroke Damage Through Middle Cerebral Artery Occlusion Model
Published on: August 11, 2023
Outcomes After Decompressive Craniectomy for Ischemic Stroke: A Volumetric Analysis
Jonathan M Parish1, Anthony M Asher2, Deborah Pfortmiller3
1Department of Neurological Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA.
Insights
Decompressive hemicraniectomy outcomes were not improved by current guidelines. Larger stroke volumes may negatively impact results, suggesting infarct volume is a key factor for patient selection in DHC surgery.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Decompressive hemicraniectomy (DHC) treats space-occupying hemispheric infarcts.
- Current guidelines recommend DHC for patients under 60 within 48 hours of stroke onset.
Purpose of the Study:
- Evaluate neurologic outcomes following DHC.
- Assess the relationship between stroke volume and patient outcomes.
Main Methods:
- Retrospective review of 52 patients undergoing DHC (2016-2019).
- Volumetric analysis of infarct size using MRI and RAPID software.
- Outcomes assessed using modified Rankin Scale (mRS) at 90 days.
Main Results:
- Only 21.2% of patients achieved favorable outcomes (mRS ≤3).
- Surgery after 48 hours, age >60, and multivessel infarcts did not significantly impact outcomes.
- No patients with infarct volume >280 mL had favorable outcomes; a trend suggested smaller volumes correlate with better outcomes.
Conclusions:
- Current DHC guidelines may not optimize patient selection for malignant hemispheric infarct.
- Infarct volume appears to be a significant factor influencing DHC outcomes.
- Further research is needed to identify optimal candidates for DHC.
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.
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