WM1-4 Decompressive craniectomy versus strokectomy for malignant middle cerebral artery (MCA) infarction

2019 ◽  
Vol 90 (3) ◽  
pp. e1.2-e1
Author(s):  
S Moughal ◽  
D Boeris ◽  
A Hainsworth ◽  
E Pereira ◽  
A Shtaya ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Decompressive Craniectomy ◽  
Modified Rankin Scale ◽  
Poor Outcome ◽  
Post Surgery ◽  
Significant Difference ◽  
Malignant Mca Infarction ◽  
Group Post

ObjectivesTo compare the outcomes of decompressive craniectomy (DC) with craniotomy and debulikng of stroke tissue (Strokectomy (SC)) for malignant MCA infarction at our centre.DesignRetrospective records review.SubjectsAll Patients with malignant MCA infraction that underwent DC and SC between Jan 2012 and Sep 2017.Methods20 patients had DC (11F/9M, mean age 44.7±1.8 y) and four patients had SC (1F/3M) 51.5±5.9 7 y). Outcomes were assessed by Modified Rankin Scale (mRS) scores before surgery and at latest follow up (3–6 months). mRS was dichotomised as good (0–3) and poor (4–6). Craniotomy size was measured by antero-posterior (AP) diameter and compared between the groups.Results18 patients (90%) of the DC group had mRS 4–6 before surgery versus 100% in the SC group. Post-surgery 15 patients (75%) of the DC group had poor outcome with 7 mortalities (35%) in comparison to one patient (25%) with poor outcome in the SC group and no mortalities. The average craniotomy size in DC was 120.1±4.1 mm versus 85.5±13.1 mm in the SC, p=0.003 students t test). Six patients of the DC group underwent cranioplasty where two developed post-operative seizures. There was no significant difference in age, sex and side of craniotomy (7 Left/13 Right in DC vs 2 Left/2 Right in SC).ConclusionsStrokectomy is comparable to decompressive craniectomy in outcomes without taking the extra risks and costs of cranioplasty. Further studies are required to promote this approach.

Abstract 134: Endovascular Revascularization Is Associated With Better Outcomes Than Systemic Throbmolysis Alone For Tandem Internal Carotid And Middle Cerebral Artery Occlusion

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Joshua Pepper ◽  
Rashmi Pashankar ◽  
Joseph Schindler ◽  
Ketan Bulsara
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Endovascular Therapy ◽  
Internal Carotid ◽  
Complication Rates ◽  
Modified Rankin Scale ◽  
Systemic Thrombolysis ◽  
Iatrogenic Complications ◽  
Significant Difference

Background and Purpose: Tandem Internal Carotid Artery and Middle Cerebral Artery or “TIM” occlusions are highly resistant to conventional therapy (systemic thrombolysis) and independently predicts poor patient outcome. Recent evidence suggests that patients treated more aggressively with either endovascular stenting of occluded carotid arteries and/or intra-arterial tissue plasminogen activator (tPA) may have superior outcomes. Here we evaluate all the available data to help assess the best intervention for this patient population that currently has limited treatment options. Methods: Data from Medline and the Cochrane database of systemic reviews was searched. The search terms used includes (tandem OR combined) AND (middle cerebral OR internal carotid) AND (OCCLU* or lesion or stenos* or blocka*). All studies had to be in English. All duplicates were identified and removed. To be included the studies needed to report on three key aspects: 1) baseline characteristics (age; NIHSS at presentation); 2) treatment (time to treatment; modality); and 3) outcome (report of patient state at discharge or follow up on the Modified Rankin Scale). Patients were grouped according to whether they received endovascular intervention or stand alone IV tPA. Patients were considered independent if they had a Modified Rankin Scale score of ≤ 2 at follow up or discharge. Results: Over 2,500 studies were evaluated. Seventeen studies met the inclusion criteria, with a total of 219 patients. Patients treated with endovascular therapy (n=60) (stenting and/or intra-arterial tPA) were 32% more likely to be independent (p<0.0001) and 28% less likely to have a significant disability (p= 0.0004) compared to patients given systemic thrombolysis (n=139). There was no significant difference in mortality or complication rates between the groups. Conclusion: Endovascular therapy appears to be superior compared with systemic thrombolysis in treating patients with TIM occlusions. The risk of iatrogenic complications with more aggressive intervention does not appear to outweigh the outcome benefit. Further and larger studies are needed to assess the benefits and risks of endovascular therapy in patients with TIM lesions.

scholarly journals Effects of early decompressive craniectomy on functional outcome of patients with malignant middle cerebral artery infarctions

2021 ◽  
Author(s):  
Ahmad Soltani ◽  
Mohammad Ali Mashari ◽  
Seyed Ehsan Mohammadianinejad ◽  
Seyed Amirhossein Pishva ◽  
Seyedeh Maryam Pishva ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Functional Outcome ◽  
Medical Therapy ◽  
Cerebral Artery ◽  
Decompressive Craniectomy ◽  
Therapy Group ◽  
Lower Mortality ◽  
Significant Difference ◽  
Neurosurgical Intensive Care Unit ◽  
Malignant Mca Infarction

Background: This study aimed to compare the functional outcome of patients with malignant middle cerebral artery (MCA) infarction who had undergone either early decompressive craniectomy (DC) or optimal medical therapy (OMT). Methods: This study was conducted during a 2- year period in Golestan Hospital of Ahvaz, Iran. The selected patients with malignant MCA infarction who were admitted within 48 hours of presenting signs were included. The patients were randomly assigned to undergo either early DC (n = 12) or OMT (n = 12) in the neurosurgical intensive care unit (ICU). The functional outcomes in the subjects were evaluated with the Glasgow Outcome Scale (GOS) and the National Institutes of Health Stroke Scale (NIHSS) at discharge, 6, and 12-month intervals. Results: The patients who underwent DC had significantly higher GOS at discharge (P = 0.013), 6 (P = 0.022), and 12 (P = 0.042) months as compared to the medical therapy group. However, the NIHSS score did not show any significant difference between the two groups during the study. Likewise, DC was associated with lower mortality at 6 (P = 0.027) and 12 (P = 0.014) months; moreover, the lower mortality rate (P = 0.014), severe disability (P = 0.040), higher good recovery (P < 0.001), and moderate disability (P < 0.001) were observed after 12 months of follow-up. Conclusion: These findings suggest that early DC in patients with malignant MCA can decrease mortality and improve the functional outcome according to GOS criteria compared to medical therapy.

TREATMENT OF GIANT MIDDLE CEREBRAL ARTERY ANEURYSMS WITH A FLOW REPLACEMENT BYPASS USING THE EXCIMER LASER-ASSISTED NONOCCLUSIVE ANASTOMOSIS TECHNIQUE

Neurosurgery ◽  
2008 ◽  
Vol 63 (1) ◽  
pp. 12-22 ◽  
Author(s):  
Tristan P.C. van Doormaal ◽  
Albert van der Zwan ◽  
Bon H. Verweij ◽  
Kuo S. Han ◽  
David J. Langer ◽  
...  
Keyword(s):  
Intracranial Aneurysm ◽  
Middle Cerebral Artery ◽  
Excimer Laser ◽  
Scale Score ◽  
Cerebral Artery ◽  
Functional Health ◽  
Hemorrhagic Complication ◽  
Modified Rankin Scale ◽  
Giant Intracranial Aneurysm

ABSTRACT OBJECTIVE To define the clinical value of the flow replacement bypass using the excimer laser-assisted nonocclusive anastomosis (ELANA) technique in the treatment of patients with a noncoilable, nonclippable giant intracranial aneurysm of the middle cerebral artery (MCA). METHODS Between 1999 and 2006, 22 patients with a giant intracranial aneurysm of the MCA were treated in our hospital with an ELANA flow replacement bypass and MCA occlusion. We collected data on patient characteristics, operative aspects, complications, and functional health scores using the modified Rankin Scale. Mean follow-up was 3.6 years (range, 0.2–7.7 yr). RESULTS We were able to construct a patent bypass in 20 (91%) of 22 patients. All 34 ELANA attempts resulted in a patent anastomosis with a strong backflow directly after ELANA catheter retraction. The patients did not need to undergo temporary occlusion in any of the ELANA constructions. Mean ± standard deviation intracranial-to-intracranial bypass flow was 53 ± 13 ml/min. MCA aneurysm treatment was attempted in all 20 patients who had a patent bypass and was successful in 19 of them. There was a fatal hemorrhagic complication in one patient (5%), a nonfatal hemorrhagic complication in three patients (14%), and a nonfatal ischemic complication in six patients (27%). At follow-up, 17 patients (77%) had a functionally favorable outcome (modified Rankin Scale score at follow-up was the same as or less than the preoperative modified Rankin Scale score). All of these patients were independent at follow-up (modified Rankin Scale score ≤2). CONCLUSION This study demonstrates satisfactory results in the treatment of giant MCA aneurysms with an ELANA flow replacement bypass, considering the very grave natural history and treatment complexity of these lesions. The ELANA technique is a useful tool in the treatment armamentarium of the vascular neurosurgeon.

Persistence of Hyperdense Middle Cerebral Artery Sign on Follow-Up CT Scan after Intravenous Thrombolysis Is Associated with Poor Outcome

2012 ◽  
Vol 33 (5) ◽  
pp. 446-452 ◽  
Author(s):  
Prakash R. Paliwal ◽  
Aftab Ahmad ◽  
Liang Shen ◽  
Leonard L.L. Yeo ◽  
Pei Kee Loh ◽  
...  
Keyword(s):  
Ct Scan ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Intravenous Thrombolysis ◽  
Poor Outcome ◽  
Hyperdense Middle Cerebral Artery

Decompressive Craniectomy in Pregnant Women

2021 ◽  
Author(s):  
Adrián Fernández García ◽  
Herbert Daniel Jiménez Zapata ◽  
Mercedes C. de Lera Alfonso ◽  
Carlos Sánchez Fernández ◽  
Paloma Jiménez Arribas ◽  
...  
Keyword(s):  
Pregnant Women ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Decompressive Craniectomy ◽  
Review Of The Literature ◽  
Healthy Baby ◽  
Second Surgery ◽  
Malignant Mca Infarction

AbstractMalignant middle cerebral artery (MCA) infarction warranting decompressive craniectomy (DC) is unusual in the population younger than 40 years. Specifically, only a few cases affecting pregnant women have been described in the literature. We present the case of a 39-year-old woman in the 24th week of pregnancy who suffered a right malignant MCA infarction that eventually required DC. The patient delivered a healthy baby and underwent a second surgery for cranioplasty 7 months later. We present both this case and a review of the literature, including all cases of DC in pregnant women published to date.

scholarly journals Preliminary Results of Randomized Controlled Study on Decompressive Craniectomy in Treatment of Malignant Middle Cerebral Artery Stroke

Medicina ◽  
2012 ◽  
Vol 48 (10) ◽  
pp. 76 ◽  
Author(s):  
Janis Slezins ◽  
Valdis Keris ◽  
Raimonds Bricis ◽  
Andrejs Millers ◽  
Egils Valeinis ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Decompressive Craniectomy ◽  
Infarct Volume ◽  
Cerebral Infarct ◽  
National Institutes Of Health ◽  
Controlled Study ◽  
Probability Of Survival ◽  
Best Medical Treatment ◽  
Significant Difference

Background and Objective. Studies on decompressive craniectomy (DCE) after a malignant middle cerebral artery (MCA) stroke in selected population show an increased probability of survival without increasing the number of very severely disabled. Cerebral infarct volume (CIV) as a triage criterion for performing surgery has not been discussed in literature. The aim of this study was to investigate the value of CIV and initial National Institutes of Health Stroke Scale (NIHHS) and Glasgow Coma Scale (GCS) scores as possible triage criteria in the surgical treatment of patients with “malignant” MCA stroke. Material and Methods. According to the study protocol, 28 patients with a malignant MCA stroke were included and analyzed prospectively. The patients were randomly divided either into the DCE plus best medical treatment (BMT) group or BMT alone group. CIV and NIHHS and GCS scores were measured at time of enrollment in every case. Clinical outcome was evaluated 1 year after the treatment. Results. Six patients survived: 5 in the DCE group (none of them was older than 60 years) and 1 in the BMT group (P=0.03/0.06). Among survivors, none had a cerebral infarct volume of more than 390 cm3 (P=0.05). All survivors in the DCE group had favorable outcomes. There was no significant difference in the NIHSS and GCS scores between the groups and survivors/nonsurvivors (P>0.05). Conclusions. Decompressive surgery in the selected patients is likely to increase the probability of survival with a favorable outcome without increasing the number of severely disabled survivors. Patients with CIV of more than 390 cm3 may be bad candidates for DCE, and the prognosis is likely to be bad regardless the treatment strategy. The initial NIHHS and GCS scores did not prove any prognostic value in outcome.

scholarly journals Analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial

2018 ◽  
Vol 128 (1) ◽  
pp. 120-125 ◽  
Author(s):  
Robert F. Spetzler ◽  
Joseph M. Zabramski ◽  
Cameron G. McDougall ◽  
Felipe C. Albuquerque ◽  
Nancy K. Hills ◽  
...  
Keyword(s):  
Ruptured Aneurysm ◽  
Modified Rankin Scale ◽  
Clinical Trial Registration ◽  
Treatment Groups ◽  
Significant Difference ◽  
Initial Hospitalization ◽  
Intent To Treat ◽  
Post Hoc ◽  
Saccular Aneurysms

OBJECTIVEThe Barrow Ruptured Aneurysm Trial (BRAT) is a prospective, randomized trial in which treatment with clipping was compared to treatment with coil embolization. Patients were randomized to treatment on presentation with any nontraumatic subarachnoid hemorrhage (SAH). Because all other randomized trials comparing these 2 types of treatments have been limited to saccular aneurysms, the authors analyzed the current BRAT data for this subgroup of lesions.METHODSThe primary BRAT analysis included all sources of SAH: nonaneurysmal lesions; saccular, blister, fusiform, and dissecting aneurysms; and SAHs from an aneurysm associated with either an arteriovenous malformation or a fistula. In this post hoc review, the outcomes for the subgroup of patients with saccular aneurysms were further analyzed by type of treatment. The extent of aneurysm obliteration was adjudicated by an independent neuroradiologist not involved in treatment.RESULTSOf the 471 patients enrolled in the BRAT, 362 (77%) had an SAH from a saccular aneurysm. Patients with saccular aneurysms were assigned equally to the clipping and the coiling cohorts (181 each). In each cohort, 3 patients died before treatment and 178 were treated. Of the 178 clip-assigned patients with saccular aneurysms, 1 (1%) was crossed over to coiling, and 64 (36%) of the 178 coil-assigned patients were crossed over to clipping. There was no statistically significant difference in poor outcome (modified Rankin Scale score > 2) between these 2 treatment arms at any recorded time point during 6 years of follow-up. After the initial hospitalization, 1 of 241 (0.4%) clipped saccular aneurysms and 21 of 115 (18%) coiled saccular aneurysms required retreatment (p < 0.001). At the 6-year follow-up, 95% (95/100) of the clipped aneurysms were completely obliterated, compared with 40% (16/40) of the coiled aneurysms (p < 0.001). There was no difference in morbidity between the 2 treatment groups (p = 0.10).CONCLUSIONSIn the subgroup of patients with saccular aneurysms enrolled in the BRAT, there was no significant difference between modified Rankin Scale outcomes at any follow-up time in patients with saccular aneurysms assigned to clipping compared with those assigned to coiling (intent-to-treat analysis). At the 6-year follow-up evaluation, rates of retreatment and complete aneurysm obliteration significantly favored patients who underwent clipping compared with those who underwent coiling.Clinical trial registration no.: NCT01593267 (clinicaltrials.gov)

Abstract TP195: Pre-Stroke Cognitive Impairment is Associated With Poor Outcome in Acute Ischemic Stroke Patients Treated With Mechanical Thrombectomy

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Takuya Kanamaru ◽  
Satoshi Suda ◽  
Junya Aoki ◽  
Kentaro Suzuki ◽  
Yuki Sakamoto ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Cognitive Impairment ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Modified Rankin Scale ◽  
Good Outcome ◽  
Poor Outcome ◽  
Poor Outcome Group ◽  
Outcome Group ◽  
Significant Difference

Background: It is reported that pre-stroke cognitive impairment is associated with poor functional outcome after stroke associated with small vessel disease. However, it is not clear that pre-stroke cognitive impairment is associated with poor outcome in patients treated with mechanical thrombectomy. Method: We enrolled 127 consecutive patients treated with mechanical thrombectomy for acute ischemic stroke from December 2016 to November 2018. Pre-stroke cognitive function was evaluated using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). We retrospectively compared poor outcome (a score of 3 to 6 on the modified Rankin Scale at 90 days) group (n=75) with good outcome (a score of 0, 1, or 2 on the modified Rankin Scale at 90 days) group (n=52) and examined that IQCODE could be the predictor of PO. Result: IQCODE was significantly higher in poor outcome group than in good outcome group (89 vs. 82, P=0.0012). Moreover, age (77.2 years old vs. 71.6 years old, P= 0.0009), the percentage of female (42.7% vs. 17.3%, P= 0.0021), complication of hypertension (HT, 68.0% vs. 44.2%, P=0.0076), National Institutes of Health Stroke Scale (NIHSS) at admission (20 vs. 11, P<0.0001), the percentage of postoperative intracerebral hemorrhage (ICH, 33.3% vs. 15.4%, P=0.0233) were higher in poor outcome group than in good outcome group, too. However, there was no significant difference between poor outcome and good outcome groups in occlusion site (P= 0.1229), DWI-ASPECTS (P= 0.2839), the duration from onset to recanalization (P=0.4871) and other risk factors. Multivariable logistic regression analysis demonstrated that IQCODE, HT and NIHSS at admission were associated with poor outcome (P= 0.0128, P=0.0061 and P<0.0001, respectively). Conclusion: Cognitive impairment could be associated with poor outcome in patients treated with mechanical thrombectomy.

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