Skip to main content

Advertisement

SpringerLink
Log in

Decompressive Hemicraniectomy in Elderly Patients With Space-Occupying Infarction (DECAP): A Prospective Observational Study

  • Original Article
  • Published:
Neurocritical Care Aims and scope Submit manuscript

Abstract

Background

Decompressive hemicraniectomy improves survival rates and functional outcome in patients with space-occupying middle cerebral artery (MCA) infarction. We sought to determine clinical outcomes in elderly patients with MCA infarction treated with hemicraniectomy and to identify factors associated with functional outcome.

Methods

We performed a prospective, single-center observational study aiming to include patients aged ≥ 61 years with large MCA infarction treated with hemicraniectomy. The primary endpoint was the functional outcome according to modified Rankin Scale (mRS) score at 6 months after hemicraniectomy. Secondary endpoints included outcome measures at 12 months. A pooled analysis of individual patient data from the single-center cohort and a DESTINY 2 trial subgroup was performed to identify factors associated with functional status at 12 months.

Results

We included 40 MCA infarction patients who underwent hemicraniectomy between 2012 and 2017 at our university hospital (median [IQR] patient age 64 [62–67] years, National Institutes of Health Stroke Scale score 17 [16–21]). The dominant hemisphere was affected in 22/40 patients. Hemicraniectomy was performed within 31 [23–53] h of symptom onset. At 6 months after hemicraniectomy, 6/40 patients (15%) were moderately or moderately severely disabled (mRS score 3 or 4), 19 (47.5%) severely disabled (mRS score 5), and 15 (37.5%) had died. Compared to surgically treated DESTINY 2 patients, the single-center patients less likely exhibited favorable functional outcome at 6 months (mRS scores 0–4; odds ratio 0.239 [95% CI 0.082–0.696]). Case-fatality rate at 12 months was 43%. In a pooled analysis including 79 patients from DECAP and DESTINY 2, no significant associations of baseline and treatment factors with the clinical status at 12 months were observed.

Conclusions

In this single-center cohort of elderly patients with space-occupying MCA infarction and decompressive hemicraniectomy, the probability for survival without severe disability was low. Lethality at 6 and 12 months was comparable to previously reported data from a randomized trial.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R. “Malignant” middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol. 1996;53:309–15.

    Article  CAS  Google Scholar 

  2. Heinsius T, Bogousslavsky J, Van Melle G. Large infarcts in the middle cerebral artery territory. Etiology and outcome patterns. Neurology. 1998;50:341–50.

    Article  CAS  PubMed  Google Scholar 

  3. Hofmeijer J, Algra A, Kappelle LJ, van der Worp HB. Predictors of life-threatening brain edema in middle cerebral artery infarction. Cerebrovasc Dis. 2008;25:176–84.

    Article  PubMed  Google Scholar 

  4. Thomalla G, Hartmann F, Juettler E, Singer OC, Lehnhardt F-G, Köhrmann M, 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;68:435–45.

    Article  PubMed  Google Scholar 

  5. Scahill RI, Frost C, Jenkins R, Whitwell JL, Rossor MN, Fox NC. A longitudinal study of brain volume changes in normal aging using serial registered magnetic resonance imaging. Arch Neurol. 2003;60:989–94.

    Article  PubMed  Google Scholar 

  6. Huttner HB, Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol. 2009;8:949–58.

    Article  PubMed  Google Scholar 

  7. Neugebauer H, Kollmar R, Niesen W-D, Bösel J, Schneider H, Hobohm C, et al. DEcompressive surgery Plus hypoTHermia for Space-Occupying Stroke (DEPTH-SOS): a protocol of a multicenter randomized controlled clinical trial and a literature review. Int J Stroke. 2013;8:383–7.

    Article  PubMed  Google Scholar 

  8. Schneider H, Krüger P, Algra A, Hofmeijer J, van der Worp HB, Jüttler E, et al. No benefits of hypothermia in patients treated with hemicraniectomy for large ischemic stroke. Int J Stroke. 2017;12:732–40.

    Article  PubMed  Google Scholar 

  9. Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol. 2007;6:215–22.

    Article  PubMed  Google Scholar 

  10. Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp HB, 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;8:326–33.

    Article  PubMed  Google Scholar 

  11. Jüttler E, Hacke W. Early decompressive hemicraniectomy in older patients with nondominant hemispheric infarction improves outcome. Stroke. 2011;42:843–4.

    Article  PubMed  Google Scholar 

  12. Jüttler E, Bösel J, Amiri H, Schiller P, Limprecht R, Hacke W, et al. DESTINY II: DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY II. Int J Stroke. 2011;6:79–86.

    Article  PubMed  Google Scholar 

  13. Jüttler E, Unterberg A, Woitzik J, Bösel J, Amiri H, Sakowitz OW, et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med. 2014;370:1091–100.

    Article  CAS  PubMed  Google Scholar 

  14. Puetz V, Campos CR, Eliasziw M, Hill MD, Demchuk AM. Calgary stroke program. Assessing the benefits of hemicraniectomy: what is a favourable outcome? Lancet Neurol. 2007;6:580.

    Article  PubMed  Google Scholar 

  15. Ropper AH. Hemicraniectomy-to halve or halve not. N Engl J Med. 2014;370:1159–60.

    Article  CAS  PubMed  Google Scholar 

  16. Alexander P, Heels-Ansdell D, Siemieniuk R, Bhatnagar N, Chang Y, Fei Y, et al. Hemicraniectomy versus medical treatment with large MCA infarct: a review and meta-analysis. BMJ Open. 2016;6:e014390.

    Article  PubMed  PubMed Central  Google Scholar 

  17. van Middelaar T, Richard E, van der Worp HB, van den Munckhof P, Nieuwkerk PT, Visser MC, et al. Quality of life after surgical decompression for a space-occupying middle cerebral artery infarct: a cohort study. BMC Neurol. 2015;15:156.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Dasenbrock HH, Robertson FC, Aziz-Sultan MA, Guittieres D, Du R, Dunn IF, et al. Patient age and the outcomes after decompressive hemicraniectomy for stroke: a nationwide inpatient sample analysis. Neurocrit Care. 2016;25:371–83.

    Article  PubMed  Google Scholar 

  19. Saver JL, Filip B, Hamilton S, Yanes A, Craig S, Cho M, et al. Improving the reliability of stroke disability grading in clinical trials and clinical practice: the Rankin Focused Assessment (RFA). Stroke. 2010;41:992–5.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Gupta R, Connolly ES, Mayer S, Elkind MSV. Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review. Stroke. 2004;35:539–43.

    Article  PubMed  Google Scholar 

  21. Arac A, Blanchard V, Lee M, Steinberg GK. Assessment of outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 60 years of age. Neurosurg Focus. 2009;26:E3.

    Article  PubMed  Google Scholar 

  22. Neugebauer H, Jüttler E. Hemicraniectomy for malignant middle cerebral artery infarction: current status and future directions. Int J Stroke. 2014;9:460–7.

    Article  PubMed  Google Scholar 

  23. Hofmeijer J, van der Worp HB, Kappelle LJ, Amelink GJ, Algra A, van Zandvoort MJE. Cognitive outcome of survivors of space-occupying hemispheric infarction. J Neurol. 2013;260:1396–403.

    Article  PubMed  Google Scholar 

  24. Zweckberger K, Juettler E, Bösel J, Unterberg WA. Surgical aspects of decompression craniectomy in malignant stroke: review. Cerebrovasc Dis. 2014;38:313–23.

    Article  PubMed  Google Scholar 

  25. Neugebauer H, Fiss I, Pinczolits A, Hecht N, Witsch J, Dengler NF, et al. Large size hemicraniectomy reduces early herniation in malignant middle cerebral artery infarction. Cerebrovasc Dis. 2016;41:283–90.

    Article  PubMed  Google Scholar 

  26. Torbey MT, Bösel J, Rhoney DH, Rincon F, Staykov D, Amar AP, et al. Evidence-based guidelines for the management of large hemispheric infarction: a statement for health care professionals from the Neurocritical Care Society and the German Society for Neuro-intensive Care and Emergency Medicine. Neurocrit Care. 2015;22:146–64.

    Article  PubMed  Google Scholar 

  27. Dasenbrock HH, Robertson FC, Vaitkevicius H, Aziz-Sultan MA, Guttieres D, Dunn IF, et al. Timing of decompressive hemicraniectomy for stroke: a nationwide inpatient sample analysis. Stroke. 2017;48:704–11.

    Article  PubMed  Google Scholar 

  28. Ropper AH. Management of raised intracranial pressure and hyperosmolar therapy. Pract Neurol. 2014;14:152–8.

    Article  PubMed  Google Scholar 

  29. Schneider H, Hertel F, Kuhn M, Ragaller M, Gottschlich B, Trabitzsch A, et al. Decannulation and functional outcome after tracheostomy in patients with severe stroke (DECAST): a prospective observational study. Neurocrit Care. 2017;27:26–34.

    Article  PubMed  Google Scholar 

  30. Neugebauer H, Schneider H, Bösel J, Hobohm C, Poli S, Kollmar R, et al. Hypothermia in addition to decompressive surgery after malignant infarction. European Stroke J. 2017;2(Suppl 1):61.

    Google Scholar 

  31. Neugebauer H, Heuschmann PU, Jüttler E. DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY-Registry (DESTINY-R): design and protocols. BMC Neurol. 2012;12:115.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

We thank the study patients and their relatives for their contribution to the study. The clinical study was conducted at the University Hospital, Technische Universität Dresden, Dresden, Germany. Statistical analyses were mainly performed at the Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany.

Funding

None.

Author information

Authors and Affiliations

  1. Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany

    Jan Rahmig, Sigrid Wöpking, Jessica Barlinn & Heinz Reichmann

  2. Department of Neurology, Ostalb-Klinikum Aalen, Aalen, Germany

    Eric Jüttler

  3. Department Medical Biometry, Institute of Medical Biometry and Informatics (IMBI), University of Heidelberg, Heidelberg, Germany

    Lorenz Uhlmann & Ronald Limprecht

  4. Department of Neurosurgery, University Hospital, Technische Universität Dresden, Dresden, Germany

    Gabriele Schackert

  5. Medical Faculty, Technische Universität Dresden, Dresden, Germany

    Hauke Schneider

  6. Department of Neurology, University Hospital, University of Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany

    Hauke Schneider

Authors
  1. Jan Rahmig
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sigrid Wöpking
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Eric Jüttler
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Lorenz Uhlmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ronald Limprecht
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jessica Barlinn
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Gabriele Schackert
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Heinz Reichmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Hauke Schneider
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

JR has acquired, analyzed and interpreted data. SW has acquired and interpreted data. EJ has provided data and interpreted data. LU has analyzed and interpreted data. RL has analyzed and interpreted data. JB has acquired and interpreted data. GS has interpreted data and provided administrative support. HR has interpreted data and provided administrative support. HS has designed and coordinated the study, has acquired, analyzed and interpreted data, and drafted the manuscript. All authors critically revised the manuscript for important intellectual content. All authors read and approved the final version of the manuscript.

Corresponding author

Correspondence to Hauke Schneider.

Ethics declarations

Conflict of interest

All authors declare that they have no conflict of interests.

Ethical Approval

The study was approved by the institutional review board (Ethikkommission an der TU Dresden; IRB00001473). Written informed consent was obtained from patients or their legal representatives.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 25 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rahmig, J., Wöpking, S., Jüttler, E. et al. Decompressive Hemicraniectomy in Elderly Patients With Space-Occupying Infarction (DECAP): A Prospective Observational Study. Neurocrit Care 31, 97–106 (2019). https://doi.org/10.1007/s12028-018-0660-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12028-018-0660-3

Keywords

Search

Navigation