Hemicraniectomy for Malignant Middle Cerebral Artery Syndrome

A Review of Functional Outcomes in Two High-Volume Stroke Centers

Abhi Pandhi, Georgios Tsivgoulis, Nitin Goyal, Muhammad F. Ishfaq, Shailesh Male, Efstathios Boviatsis, Jason J. Chang, Ramin Zand, Konstantinos Voumvourakis, Lucas Elijovich, Anne Alexandrov, Marc Malkoff, Daniel Hoit, Adam Arthur, Andrei Alexandrov

Research output: Contribution to journalArticle

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Abstract

Background and Purpose: Despite recent landmark randomized controlled trials showing significant benefits for hemicraniectomy (HCT) compared with medical therapy (MT) in patients with malignant middle cerebral artery infarction (MMCAI), HCT rates have not substantially increased in the United States. We sought to evaluate early outcomes in patients with MMCAI who were treated with HCT (cases) in comparison to patients treated with MT due to the perception of procedural futility by families (controls). Methods: We retrospectively evaluated consecutive patients with acute MMCAI treated in 2 tertiary care centers during a 7-year period. Pretreatment National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 3 months were documented. Functional independence (FI) and survival without severe disability (SWSD) were defined as mRS of 0-2 and 0-4, respectively. Results: A total of 66 patients (37 cases and 29 controls) fulfilled the study inclusion criteria (mean age 59 ± 15 years, 52% men, median admission NIHSS score: 19 points [interquartile range {IQR}: 16-22]). Cases were younger (51 ± 11 versus 68 ± 13 years; P < .001) and tended to have lower median admission NIHSS than controls (18 [IQR:16-20] versus 20 [IQR:18-23]; P = .072). The rates of FI and SWSD at 3 months were higher in cases than controls (16% versus 0% [P = .031] and 62% versus 0% [P < .001]), while 3-month mortality was lower (24% versus 77%; P < .001). Multivariable Cox regression analyses adjusting for potential confounders identified HCT as the most important predictor of lower risk of 3-month mortality (hazard ratio: .02, 95% confidence interval: .01-0.10; P < .001). Conclusions: HCT is a critical and effective therapy for patients with MMCAI but cannot provide a guarantee of functional recovery.

Original languageEnglish (US)
Pages (from-to)2405-2410
Number of pages6
JournalJournal of Stroke and Cerebrovascular Diseases
Volume27
Issue number9
DOIs
StatePublished - Sep 1 2018

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Middle Cerebral Artery Infarction
Stroke Volume
National Institutes of Health (U.S.)
Stroke
Medical Futility
Survival
Mortality
Tertiary Care Centers
Therapeutics
Randomized Controlled Trials
Regression Analysis
Confidence Intervals

All Science Journal Classification (ASJC) codes

  • Surgery
  • Rehabilitation
  • Clinical Neurology
  • Cardiology and Cardiovascular Medicine

Cite this

Hemicraniectomy for Malignant Middle Cerebral Artery Syndrome : A Review of Functional Outcomes in Two High-Volume Stroke Centers. / Pandhi, Abhi; Tsivgoulis, Georgios; Goyal, Nitin; Ishfaq, Muhammad F.; Male, Shailesh; Boviatsis, Efstathios; Chang, Jason J.; Zand, Ramin; Voumvourakis, Konstantinos; Elijovich, Lucas; Alexandrov, Anne; Malkoff, Marc; Hoit, Daniel; Arthur, Adam; Alexandrov, Andrei.

In: Journal of Stroke and Cerebrovascular Diseases, Vol. 27, No. 9, 01.09.2018, p. 2405-2410.

Research output: Contribution to journalArticle

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title = "Hemicraniectomy for Malignant Middle Cerebral Artery Syndrome: A Review of Functional Outcomes in Two High-Volume Stroke Centers",
abstract = "Background and Purpose: Despite recent landmark randomized controlled trials showing significant benefits for hemicraniectomy (HCT) compared with medical therapy (MT) in patients with malignant middle cerebral artery infarction (MMCAI), HCT rates have not substantially increased in the United States. We sought to evaluate early outcomes in patients with MMCAI who were treated with HCT (cases) in comparison to patients treated with MT due to the perception of procedural futility by families (controls). Methods: We retrospectively evaluated consecutive patients with acute MMCAI treated in 2 tertiary care centers during a 7-year period. Pretreatment National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 3 months were documented. Functional independence (FI) and survival without severe disability (SWSD) were defined as mRS of 0-2 and 0-4, respectively. Results: A total of 66 patients (37 cases and 29 controls) fulfilled the study inclusion criteria (mean age 59 ± 15 years, 52{\%} men, median admission NIHSS score: 19 points [interquartile range {IQR}: 16-22]). Cases were younger (51 ± 11 versus 68 ± 13 years; P < .001) and tended to have lower median admission NIHSS than controls (18 [IQR:16-20] versus 20 [IQR:18-23]; P = .072). The rates of FI and SWSD at 3 months were higher in cases than controls (16{\%} versus 0{\%} [P = .031] and 62{\%} versus 0{\%} [P < .001]), while 3-month mortality was lower (24{\%} versus 77{\%}; P < .001). Multivariable Cox regression analyses adjusting for potential confounders identified HCT as the most important predictor of lower risk of 3-month mortality (hazard ratio: .02, 95{\%} confidence interval: .01-0.10; P < .001). Conclusions: HCT is a critical and effective therapy for patients with MMCAI but cannot provide a guarantee of functional recovery.",
author = "Abhi Pandhi and Georgios Tsivgoulis and Nitin Goyal and Ishfaq, {Muhammad F.} and Shailesh Male and Efstathios Boviatsis and Chang, {Jason J.} and Ramin Zand and Konstantinos Voumvourakis and Lucas Elijovich and Anne Alexandrov and Marc Malkoff and Daniel Hoit and Adam Arthur and Andrei Alexandrov",
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T1 - Hemicraniectomy for Malignant Middle Cerebral Artery Syndrome

T2 - A Review of Functional Outcomes in Two High-Volume Stroke Centers

AU - Pandhi, Abhi

AU - Tsivgoulis, Georgios

AU - Goyal, Nitin

AU - Ishfaq, Muhammad F.

AU - Male, Shailesh

AU - Boviatsis, Efstathios

AU - Chang, Jason J.

AU - Zand, Ramin

AU - Voumvourakis, Konstantinos

AU - Elijovich, Lucas

AU - Alexandrov, Anne

AU - Malkoff, Marc

AU - Hoit, Daniel

AU - Arthur, Adam

AU - Alexandrov, Andrei

PY - 2018/9/1

Y1 - 2018/9/1

N2 - Background and Purpose: Despite recent landmark randomized controlled trials showing significant benefits for hemicraniectomy (HCT) compared with medical therapy (MT) in patients with malignant middle cerebral artery infarction (MMCAI), HCT rates have not substantially increased in the United States. We sought to evaluate early outcomes in patients with MMCAI who were treated with HCT (cases) in comparison to patients treated with MT due to the perception of procedural futility by families (controls). Methods: We retrospectively evaluated consecutive patients with acute MMCAI treated in 2 tertiary care centers during a 7-year period. Pretreatment National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 3 months were documented. Functional independence (FI) and survival without severe disability (SWSD) were defined as mRS of 0-2 and 0-4, respectively. Results: A total of 66 patients (37 cases and 29 controls) fulfilled the study inclusion criteria (mean age 59 ± 15 years, 52% men, median admission NIHSS score: 19 points [interquartile range {IQR}: 16-22]). Cases were younger (51 ± 11 versus 68 ± 13 years; P < .001) and tended to have lower median admission NIHSS than controls (18 [IQR:16-20] versus 20 [IQR:18-23]; P = .072). The rates of FI and SWSD at 3 months were higher in cases than controls (16% versus 0% [P = .031] and 62% versus 0% [P < .001]), while 3-month mortality was lower (24% versus 77%; P < .001). Multivariable Cox regression analyses adjusting for potential confounders identified HCT as the most important predictor of lower risk of 3-month mortality (hazard ratio: .02, 95% confidence interval: .01-0.10; P < .001). Conclusions: HCT is a critical and effective therapy for patients with MMCAI but cannot provide a guarantee of functional recovery.

AB - Background and Purpose: Despite recent landmark randomized controlled trials showing significant benefits for hemicraniectomy (HCT) compared with medical therapy (MT) in patients with malignant middle cerebral artery infarction (MMCAI), HCT rates have not substantially increased in the United States. We sought to evaluate early outcomes in patients with MMCAI who were treated with HCT (cases) in comparison to patients treated with MT due to the perception of procedural futility by families (controls). Methods: We retrospectively evaluated consecutive patients with acute MMCAI treated in 2 tertiary care centers during a 7-year period. Pretreatment National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 3 months were documented. Functional independence (FI) and survival without severe disability (SWSD) were defined as mRS of 0-2 and 0-4, respectively. Results: A total of 66 patients (37 cases and 29 controls) fulfilled the study inclusion criteria (mean age 59 ± 15 years, 52% men, median admission NIHSS score: 19 points [interquartile range {IQR}: 16-22]). Cases were younger (51 ± 11 versus 68 ± 13 years; P < .001) and tended to have lower median admission NIHSS than controls (18 [IQR:16-20] versus 20 [IQR:18-23]; P = .072). The rates of FI and SWSD at 3 months were higher in cases than controls (16% versus 0% [P = .031] and 62% versus 0% [P < .001]), while 3-month mortality was lower (24% versus 77%; P < .001). Multivariable Cox regression analyses adjusting for potential confounders identified HCT as the most important predictor of lower risk of 3-month mortality (hazard ratio: .02, 95% confidence interval: .01-0.10; P < .001). Conclusions: HCT is a critical and effective therapy for patients with MMCAI but cannot provide a guarantee of functional recovery.

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