DECIMAL, DESTINY, and HAMLET investigators: Earlydecompressivesurgery in malignantinfarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials
Department of Neurology, Assistance Publique, Hôpitaux de Paris, Lariboisière Hospital, Paris, France. The Lancet Neurology
(Impact Factor: 21.9).
03/2007; 6(3):215-22. DOI: 10.1016/S1474-4422(07)70036-4
Malignant infarction of the middle cerebral artery (MCA) is associated with an 80% mortality rate. Non-randomised studies have suggested that decompressive surgery reduces this mortality without increasing the number of severely disabled survivors. To obtain sufficient data as soon as possible to reliably estimate the effects of decompressive surgery, results from three European randomised controlled trials (DECIMAL, DESTINY, HAMLET) were pooled. The trials were ongoing when the pooled analysis was planned.
Available from: Daniela Kasprowska
- "Ponadto wykazano, że u chorych do 60 roku życia ze złośliwym zawałem półkuli mózgu obejmującym cały obszar unaczynienia tętnicy środkowej mózgu lub rozległym zawałem móżdżku, istotnie zmniejsza śmiertelność odpowiednio wcześnie wykonana dekompresja chirurgiczna (do 48 godz.) . W prewencji wtórnej potwierdzono skuteczność doustnych leków antykoagulacyjnych u chorych z migotaniem przedsionków, endarterektomii tętnicy szyjnej wewnętrznej, leków przeciwpłytkowych i inhibitorów reduktazy 3-hydroksy- -3-metylo-glutarylokoenzymu A (statyn) . "
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ABSTRACT: Ischemic stroke is one of the leading causes of adult death and disability worldwide. Present applied therapeutic strategies do not give satisfactory results. It is often emphasized that pharmacological actions aimed at reducing the area of ischemic brain injury should protect astrocytes forming together with neurons and the endothelium neurovascular unit. Astrocytes contribute importantly to proper neuronal function during both physiological and pathological conditions. In ischemic stroke, astrocytes are involved in regulation of water and ion homeostasis, cerebral blood flow, maintenance of the blood-brain barrier, and control of the extracellular level of glutamate, as well as being a source of neuroprotectants. On the other hand, astrocytes may also contribute to enlarged ischemic area due to their participation in inflammatory processes and production of potential neurotoxic substances. Herein we review experimental and clinical data concerning adaptive and pathological roles of astrocytes during both early and late phases of ischemia. Especially, we emphasize specific features of astrocytes that might become a potential target of therapeutic strategies for ischemic stroke.
Available from: Yoshua Esquenazi
- "Decompressive hemicraniectomy is now widely used for the management of malignant middle cerebral artery infarctions . It prevents intracranial herniation, and the reduction of ICP via HC rapidly restores perfusion pressure to the ischemic penumbra through lepto-meningeal collaterals, and reduces infarction size in animal models   . "
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ABSTRACT: The management of patients with supra-tentorial intracerebral hemorrhage (ICH) remains controversial. Here we critically evaluate the safety, feasibility, and outcomes following decompressive hemicraniectomy (HC) with or without clot evacuation in the management of patients with large ICHs.
We analyzed data from 73 consecutive patients managed with a HC for a spontaneous ICH. All relevant patient variables at initial presentation and management were compiled. Variables were modeled as independent regressors against the three-month Glasgow Outcome Score using a multivariate logistic regression model.
Over 7 years, HC was performed in 73 patients with clot evacuation in 86% and HC alone in 14%. The average ICH volume was 81cc and the median HC surface area was 105cm(2). 26 patients were comatose at initial presentation. Three-month functional outcomes were favorable in 29%, unfavorable in 44% and 27% of patients expired. Admission Glasgow Coma Scale (p=0.003), dominant hemisphere ICH location (p=0.01) and hematoma volume (p=0.002) contributed significantly to the outcome, as estimated by a multivariate analysis. Eight surgical complications occurred.
Early HC with or without clot evacuation is feasible and safe for managing spontaneous ICH. Our experience in this uncontrolled retrospective series, the largest such series in the modern era, suggests that it may be of particular benefit in patients with large non-dominant hemisphere ICH who are not moribund at presentation. Our findings suggest that a prospective randomized trial of HC vs. craniotomy for ICH be conducted.
Copyright © 2014 Elsevier B.V. All rights reserved.
Available from: Stephen Honeybul
- "Numerous studies have demonstrated that the procedure can reduce mortality and this was most clearly demonstrated by the pooled analysis of the three European stroke trials that compared decompressive hemicraniectomy with standard medical management in patients who clinically deteriorated following cerebral swelling secondary to ischemic stroke. The results of this analysis confirmed a dramatic reduction in mortality in those patients treated surgically and this provides unequivocal support for the use of the procedure as a lifesaving intervention. However, evidence that outcome is actually improved is less forthcoming. "
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There continues to be considerable interest in the use of decompressive craniectomy in the management of neurological emergencies. The procedure is technically straightforward; however, it is becoming increasingly apparent that it is associated with significant complications. One complication that has received relatively little attention is the neurological dysfunction that can occur due to the absence of the bone flap and the subsequent distortion of the brain under the scalp as cerebral swelling subsides. The aim of this narrative review was to examine the literature available regarding the clinical features described, outline the proposed pathophysiology for these clinical manifestations and highlight the implications that this may have for rehabilitation of patients with a large skull defect.
A literature search was performed in the MEDLINE database (1966 to June 2012). The following keywords were used: Hemicraniectomy, decompressive craniectomy, complications, syndrome of the trephined, syndrome of the sinking scalp flap, motor trephined syndrome. The bibliographies of retrieved reports were searched for additional references.
Various terms have been used to describe the different neurological signs and symptoms with which patients with a skull defect can present. These include; syndrome of the trephined, posttraumatic syndrome, syndrome of the sinking scalp flap, and motor trephined syndrome. There is, however, considerable overlap between the conditions described and a patient's individual clinical presentation.
It is becoming increasingly apparent that certain patients are particularly susceptible to the presence of a large skull defect. The term “Neurological Susceptibility to a Skull Defect” (NSSD) is therefore suggested as a blanket term to describe any neurological change attributable to the absence of cranial coverage.
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