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1.  Surgical Management of Massive Cerebral Infarction 
The aim of this study was to analyze the treatment results and prognostic factors in patients with massive cerebral infarction who underwent decompressive craniectomy.
From January 2000 to December 2005, we performed decompressive craniectomy in 24 patients with massive cerebral infarction. We retrospectively reviewed the medical records, radiological findings, initial clinical assessment using the Glasgow Coma Scale, serial computerized tomography (CT) with measurement of midline and septum pellucidum shift, and cerebral infarction territories. Patients were evaluated based on the following factors : the pre- and post-operative midline shifting on CT scan, infarction area or its dominancy, consciousness level, pupillary light reflex and Glasgow Outcome Scale.
All 24 patients (11 men, 13 women; mean age, 63 years; right middle cerebral artery (MCA) territory, 17 patients; left MCA territory, 7 patients) were treated with large decompressive craniectomy and duroplasty. The average time interval between the onset of symptoms and surgical decompression was 2.5 days. The mean Glasgow Coma Scale was 12.4 on admission and 8.3 preoperatively. Of the 24 surgically treated patients, the good outcome group (Group 2 : GOS 4-5) comprised 9 cases and the poor outcome group (Group1 : GOS 1-3) comprised 15 cases.
We consider decompressive craniectomy for large hemispheric infarction as a life-saving procedure. Good preoperative GCS, late clinical deterioration, small size of the infarction area, absence of anisocoria, and preoperative midline shift less than 11mm were considered to be positive predictors of good outcome. Careful patient selection based on the above-mentioned factors and early operation may improve the functional outcome of surgical management for large hemispheric infarction.
PMCID: PMC2588216  PMID: 19096565
Acute cerebral infarction; Brain edema; Brain herniation; Decompressive craniectomy; Intracranial pressure
2.  Decompressive craniectomy for malignant middle cerebral artery infarction: Impact on mortality and functional outcome 
Malignant middle cerebral artery (MCA) infarction is a devastating clinical entity affecting about 10% of stroke patients. Decompressive craniectomy has been found to reduce mortality rates and improve outcome in patients.
A retrospective case review study was conducted to compare patients treated with medical therapy and decompressive surgery for malignant MCA infarction in Hospital Kuala Lumpur over a period of 5 years (from January 2007 to December 2012). A total of 125 patients were included in this study; 90 (72%) patients were treated with surgery, while 35 (28%) patients were treated with medical therapy. Outcome was assessed in terms of mortality rate at 30 days, Glasgow Outcome Score (GOS) on discharge, and modified Rankin scale (mRS) at 3 and 6 months.
Decompressive craniectomy resulted in a significant reduction in mortality rate at 30 days (P < 0.05) and favorable GOS outcome at discharge (P < 0.05). Good functional outcome based on mRS was seen in 48.9% of patients at 3 months and in 64.4% of patients at 6 months (P < 0.05). Factors associated with good outcome include infarct volume of less than 250 ml, midline shift of less than 10 mm, absence of additional vascular territory involvement, good preoperative Glasgow Coma Scale (GCS) score, and early surgical intervention (within 24 h) (P < 0.05). Age and dominant hemisphere infarction had no significant association with functional outcome.
Decompressive craniectomy achieves good functional outcome in, young patients with good preoperative GCS score and favorable radiological findings treated with surgery within 24 h of ictus.
PMCID: PMC4123249  PMID: 25101197
Decompressive craniectomy; malignant cerebral infarction; middle cerebral artery infarction
3.  Outcome Following Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction in Patients Older Than 70 Years Old 
Malignant middle cerebral artery (MCA) infarction occurs in 10% of all ischemic strokes and these severe strokes are associated with high mortality rates. Recent clinical trials demonstrated that early decompressive craniectomy reduce mortality rates and improves functional outcomes in healthy young patients (less than 61 years of age) with a malignant infarction. The purpose of this study was to assess the efficacy of decompressive craniectomy in elderly patients (older than 70 years of age) with a malignant MCA infarction.
Between February 2008 and October 2011, 131 patients were diagnosed with malignant MCA infarctions. We divided these patients into two groups: patients who underwent decompressive craniectomy (n = 58) and those who underwent conservative care (n = 73). A cut-off point of 70 years of age was set, and the study population was segregated into those who fell above or below this point. Mortality rates and functional outcome scores were assessed, and a modified Rankin Scale (mRS) score of > 3 was considered to represent a poor outcome.
Mortality rates were significantly lower at 29.3% (one-month mortality rate) and 48.3% (six-month mortality rate) in the craniectomy group as compared to 58.9% and 71.2%, respectively, in the conservative care group (p < 0.001, p = 0.007). Age (≥70 years vs. < 70 years) did not statistically differ between groups for the six-month mortality rate (p = 0.137). However, the pre-operative National Institutes of Health Stroke Scale (NIHSS) score did contribute to the six-month mortality rate (p = 0.047).
Decompressive craniectomy is effective for patients with a malignant MCA infarction regardless of their age. Therefore, factors other than age should be considered and the treatment should be individualized in elderly patients with malignant infarctions.
PMCID: PMC3471258  PMID: 23210030
Age; Mortality; Middle cerebral artery; Cerebral infarction; Decompressive craniectomy
4.  Is decompressive craniectomy for malignant middle cerebral artery infarction of any worth?*  
Objective: Malignant middle cerebral artery (MCA) infarction is characterized by mortality rate of up to 80%. The aim of this study was to determine the value of decompressive craniectomy in patients presenting malignant MCA infarction compared with those receiving medical treatment alone. Methods: Patients with malignant MCA infarction treated in our hospital between January 1996 and March 2004 were included in this retrospective analysis. The National Institute of Health Stroke Scale (NIHSS) was used to assess neurological status on admission and at one week after surgery. All patients were followed up for assessment of functional outcome by the Barthel index (BI) and modified Rankin Scale (RS) at 3 months after infarction. Results: Ten out of 24 patients underwent decompressive craniectomy. The mean interval between stroke onset and surgery was 62.10 h. The mortality was 10.0% compared with 64.2% in patients who received medical treatment alone (P<0.001). The mean NIHSS score before surgery was 26.0 and 15.4 after surgery (P<0.001). At follow up, patients who underwent surgery had significantly better outcome with mean BI of 53.3, RS of 3.3 as compared to only 16.0 and 4.60 in medically treated patients. Speech function also improved in patients with dominant hemispherical infarction. Conclusion: Decompressive craniectomy in patients with malignant MCA infarction improves both survival rates and functional outcomes compared with medical treatment alone. A randomized controlled trial is required to substantiate those findings.
PMCID: PMC1389798  PMID: 15973766
Decompressive craniectomy; Cerebral infarction; Middle cerebral artery (MCA)
5.  Outcome and prognostic factors of hemicraniectomy for space occupying cerebral infarction 
Objective: To determine long term functional outcome and length of survival of patients undergoing decompressive craniectomy for space occupying infarction of the middle cerebral artery (MCA), and to identify risk factors associated with death and unfavourable outcomes
Methods: Databases of patients undergoing decompressive craniectomy for space occupying MCA infarction compiled at eight neurosurgical departments (1996–2001) were merged, and 188 patients were evaluated. Mortality was calculated by the Kaplan–Meier method. Clinical outcome was rated using the Glasgow outcome scale (GOS). The prognostic impact of patient related covariates on length of survival and the GOS was analysed multivariately.
Results: The unadjusted 3, 6, and 12 month mortality rates were 7.9%, 37.6%, and 43.8%, respectively (median follow up, 26 weeks). In the "best" multivariate model, age >50 years (p<0.02) and the involvement of two or more additional vascular territories (p<0.01) had an unfavourable impact on length of survival. The adjusted six month mortality was as low as 20.0% (no risk factor) and as high as 59.7% (two risk factors). A GOS score of ⩽3 was significantly associated with age >50 years (p<0.0003): 34.9% of the patients ⩽50 years of age achieved a GOS score of >3, as compared with 12.0% of the elderly subpopulation. The side of the infarct did not have prognostic relevance.
Conclusions: Results of surgical treatment in patients <50 years of age undergoing decompressive craniectomy are encouraging. The effectiveness of decompressive craniectomy for patients >50 years remains questionable and should be analysed in the framework of a prospective randomised study.
PMCID: PMC1738890  PMID: 14742603
6.  Outcome of decompressive craniectomy in comparison to nonsurgical treatment in patients with malignant MCA infarction 
SpringerPlus  2014;3:115.
Malignant cerebral infarction is a well-recognized disease, comprising 10-15% of all cases with cerebral infarction and causing herniation and death in 80% of cases. In this study, we compare the effects of decompressive craniectomy versus conventional medical treatment on mortality rate and functional and neurological outcome in patients with malignant MCA infarction.
We performed a prospective case–control study on 60 patients younger than 80years of age suffering malignant MCA cerebral infarction. The case group underwent decompressive craniectomy in addition to routine aggressive medical care; while the control group received routine medical treatment. Patient outcome was assessed using Glasgow outcome scale and modified Rankin scale within three months of follow-up. The data were analyzed by SPSS version 16.0 software using Chi Square, One-way ANOVA and Mann–Whitney tests.
There were 27 male and 33 female patients with a mean age of 60.6 years (SD = 12.3). Glasgow outcome scale score averaged 2.93 in the surgical versus 1.53 in the medical group; this difference was significant (p = 0.001). Outcome in modified Rankin scale was also significantly lower in the surgical (3.27) versus medical (5.27) group (p < 0.001). Surgery could decrease the mortality rate about 47%.
In this study, decompressive craniectomy could decrease mortality rate, and improve neurological and functional outcome, and decrease long-term disability in patients with malignant MCA infarction.
PMCID: PMC3977016  PMID: 24711983
Cerebral infarction; Decompressive craniectomy; Middle cerebral artery
7.  Fluid-Attenuated Inversion Recovery Hyperintense Vessels in Posterior Cerebral Artery Infarction 
Fluid-attenuated inversion recovery hyperintense vessels (FHVs) are known to reflect stagnant or slow blood flow within the cerebral artery. FHVs are frequently observed in patients with acute cerebral infarction accompanied by arterial occlusion or significant stenosis of the anterior cerebral circulation. However, FHVs have not been studied in the context of posterior cerebral circulation. Thus, we investigated the prevalence of FHVs and its clinical significance in patients with acute posterior cerebral artery (PCA) territory infarction.
In this retrospective study, consecutive patients with PCA territory infarction who underwent MRI within 1 week after symptom onset were enrolled. Two neurologists who were blinded to the angiographic findings read the images and determined the presence of FHVs. Afterwards, FHVs were graded according to the extent (subtle or prominent) and location (proximal or distal) of the hyperintense vessels. Neurologic deficits of the patients were assessed by the National Institutes of Health Stroke Scale (NIHSS) upon admission and after 5 days. The clinical outcome between patient groups based on FHVs grading was compared using the NIHSS. Among the patients with PCA occlusion, infarction volume on the diffusion-weighted image was compared between the two groups with and without distal FHVs.
FHVs were observed in 25 of the 87 patients (28.7%) with PCA territory infarction and in 65.7% of the 35 patients with significant arterial stenosis (10 patients) or occlusion (25 patients) in the posterior cerebral circulation. Among the 18 patients with PCA occlusion, the NIHSS score was significantly improved in patients with distal FHVs compared to the others (2.00 ± 2.18 vs. 0.56 ± 1.01, p = 0.04). The infarction volume was smaller in the distal FHV group than in the others (8.3 ± 8.7 vs. 16.8 ± 17.6 ml), but the difference was not statistically significant.
FHVs are detected in patients with PCA territory infarction, especially in those with an occlusive lesion in the PCA. FHVs can be used as an imaging marker of PCA occlusion. Although this study showed a better clinical improvement in patients with distal FHVs, further study is needed to elucidate the clinical meaning of FHVs in PCA infarction.
PMCID: PMC3776708  PMID: 24052794
Fluid-attenuated inversion recovery MRI; Hyperintense vessel; Posterior cerebral artery infarction

8.  Endovascular Treatment of Tandem Internal Carotid and Middle Cerebral Artery Occlusions 
Extracranial internal carotid artery (ICA) angioplasty and intracranial thrombectomy may be a safe and efficacious therapeutic option for recanalization of a subset of arterial occlusions termed tandem occlusions of Internal carotid artery and Middle cerebral artery (TIM).
Approximately 25% of patients with middle cerebral artery (MCA) occlusion will have a concomitant ICA occlusion and 50% of patients with an ICA occlusion will have a proximal MCA occlusion. Cervical ICA occlusion with MCA embolic occlusion is associated with a low rate of recanalization and poor outcome after intravenous thrombolysis. We report our experience on acute ischemic stroke patients with TIM occlusion treated with extracranial ICA angioplasty/stenting and intracranial thrombectomy and/or standard intravenous thrombolysis.
A retrospective analysis of 7 patients from our stroke database was done. 6 patients of the 7 patients were treated with extracranial ICA angioplasty and intracranial thrombectomy and/or intravenous thrombolysis. We examined early neurological improvement (defined by a reduction of National Institutes of Health Stroke Scale (NIHSS) > 8 points). We also evaluated the rate of successful recanalization based on thrombolysis in cerebral infarction (TICI) score of 2b or 3.
All but one of the 6 treated patients achieved a TICI score of 2b or 3 signifying successful recanalization. In addition, treated patients had an early reduction of their NIHSS by greater than 8 points. The 1 patient who did not to achieve TICI 2b or 3 also failed to show early neurological improvement. Four of the treated patients had a follow up NIHSS at 90 days of 1 or less and mRS at 90 days of 0.
In cases of tandem occlusions of ICA and MCA, multimodal therapy consistent of intravenous thrombolysis and/or extracranial ICA stenting and intracranial thrombectomy to achieve recanalization may be a safe and efficacious therapeutic option for recanalization. Further prospective studies are warranted.
PMCID: PMC4241412  PMID: 25422711
9.  Mouse Model of Middle Cerebral Artery Occlusion 
Stroke is the most common fatal neurological disease in the United States 1. The majority of strokes (88%) result from blockage of blood vessels in the brain (ischemic stroke) 2. Since most ischemic strokes (~80%) occur in the territory of middle cerebral artery (MCA) 3, many animal stroke models that have been developed have focused on this artery. The intraluminal monofilament model of middle cerebral artery occlusion (MCAO) involves the insertion of a surgical filament into the external carotid artery and threading it forward into the internal carotid artery (ICA) until the tip occludes the origin of the MCA, resulting in a cessation of blood flow and subsequent brain infarction in the MCA territory 4. The technique can be used to model permanent or transient occlusion 5. If the suture is removed after a certain interval (30 min, 1 h, or 2 h), reperfusion is achieved (transient MCAO); if the filament is left in place (24 h) the procedure is suitable as a model of permanent MCAO. This technique does not require craniectomy, a neurosurgical procedure to remove a portion of skull, which may affect intracranial pressure and temperature 6. It has become the most frequently used method to mimic permanent and transient focal cerebral ischemia in rats and mice 7,8. To evaluate the extent of cerebral infarction, we stain brain slices with 2,3,5-triphenyltetrazolium chloride (TTC) to identify ischemic brain tissue 9. In this video, we demonstrate the MCAO method and the determination of infarct size by TTC staining.
PMCID: PMC3197421  PMID: 21372780
10.  Surgical Treatment for Acute, Severe Brain Infarction 
Stroke is the most prevalent disease involving the central nervous system. Since medical modalities are sometimes ineffective for the acute edema following massive infarction, surgical decompression may be an effective option when medical treatments fail. The present study was undertaken to assess the outcome and prognostic factors of decompressive surgery in life threatening acute, severe, brain infarction.
We retrospectively analyzed twenty-six patients (17 males and 9 females; average age, 49.7yrs) who underwent decompressive surgery for severe cerebral or cerebellar infarction from January 2003 to December 2006. Surgical indication was based on the clinical signs such as neurological deterioration, pupillary reflex, and radiological findings. Clinical outcome was assessed by Glasgow Outcome Scale (GOS).
Of the 26 patients, 5 (19.2%) showed good recovery, 5 (19.2%) showed moderate disability, 2 (7.7%) severe disability, 6 (23.1%) persistent experienced vegetative state, and 8 (30.8%) death. In this study, the surgical decompression improved outcome for cerebellar infarction, but decompressive surgery did not show a good result for MCA infarction (30.8% overall mortality vs 100% mortality). The dominant-hemisphere infarcts showed worse prognosis, compared with nondominant-hemisphere infarcts (54.5% vs 70%). Poor prognostic factors were diabetes mellitus, dominant-hemisphere infarcts and low preoperative Glasgow Coma Scale (GCS) score.
The patients who exhibit clinical deterioration despite aggressive medical management following severe cerebral infarction should be considered for decompressive surgery. For better outcome, prompt surgical treatment is mandatory. We recommend that patients with severe cerebral infarction should be referred to neurosurgical department primarily in emergency setting or as early as possible for such prompt surgical treatment.
PMCID: PMC2588211  PMID: 19096564
Cerebral infarct; Brain edema; Decompression; Surgery; Craniectomy
11.  Emergency Carotid Artery Stent Insertion for Acute ICA Occlusion 
An effective intervention has not yet been established for patients with acute occlusion of the internal carotid artery (ICA). The aim of our study was to investigate the feasibility, safety, and efficacy of emergent stent placement of carotid artery to improve neurologic symptoms and clinical outcome.
Of 84 consecutive patients with severe ICA stenosis who were admitted to our institution from March 2006 to May 2009, 10 patients with acute ICA occlusion (11.9%) underwent emergency carotid artery stent placement. We reviewed their records for neurologic outcome using the National Institutes of Health Stroke Scale (NIHSS) score, before and at 7 days after stent placement; clinical outcome using the modified Rankin Scale score (mRS) and Glasgow Outcome Scale (GOS); frequency of procedure-related complications; and recurrence rate of ipsilateral ischemic stroke within 90 days.
Carotid lesions were dilated completely in all patients. Median NIHSS scores before emergency stent placement and at 7 days were 16.6 and 6, respectively, showing significant improvement. Eight patients (80%) had favorable outcomes (mRS score 0-2 and GOS 4-5). Complications occurred in two patients (20%): stent insertion failed in one and an intracerebral hemorrhage occurred in the other. Ipsilateral ischemic stroke did not recur within 3 months.
Emergency carotid artery stent placement can improve the 7-day neurologic outcome and the 90-day clinical outcome in selected patients with acute cerebral infarction.
PMCID: PMC2899029  PMID: 20617087
Cerebral infarction; Carotid stenosis; Stent
12.  Predicting the Long-Term Outcome after Subacute Stroke within the Middle Cerebral Artery Territory 
Background and Purpose
The National Institutes of Health Stroke Scale (NIHSS) score is known to be effective in predicting the likelihood of recovery after stroke. However, the baseline NIHSS score predicts long-term outcomes rather crudely because early changes in stroke scores may influence the stroke outcomes. Therefore, a precise prognostic algorithm or a cutoff point for predicting long-term outcomes based on data from serial NIHSS scores is needed.
We serially assessed 437 patients with acute symptomatic ischemic stroke within the middle cerebral artery territory who presented with nonlacunar stroke and were followed-up for at least 6 months after symptom onset. The NIHSS score was serially checked at 0, 1, 3, 7, and 14 days after admission. In all patients, the Barthel index (BI) and the modified Rankin Scale (mRS) score were checked, with a poor outcome defined as any of the following endpoints: death, modified mRS score of >3, or BI of <60.
A marked neurological improvement or worsening (i.e., a change in the NIHSS score of at least 4) was seen in 13.5% or 5.5% of the patients, respectively, during the first 7 days after admission. About 25% of the 437 patients had poor long-term outcomes. Analysis of receiver operating characteristic curves showed that the NIHSS score at day 7 after admission was better for predicting poor long-term outcomes than was the baseline score (P=0.003). In addition, we analyzed the cutoff point of the 7th-day NIHSS score for predicting a poor outcome at 6 months after symptom onset. An NIHSS score of at least 6 at day 7 after admission predicted poor long-term outcomes with a sensitivity of 84% [95% confidence interval (CI), 76-90%], a specificity of 92% (95% CI, 88-94%), and positive and negative predictive values of 77% and 95%, respectively. A logistic regression analysis revealed that age, diffusion-weighted imaging lesion volume, stroke history, and 7th-day NIHSS score were independently associated with poor outcome. However, no score used in addition to the 7th-day NIHSS score improved the prediction of a poor outcome.
An NIHSS score of at least 6 on day 7 after admission accurately forecasts a poor long-term outcome after stroke. Our data may be helpful in predicting the long-term prognosis as well as in making decisions regarding novel therapeutic applications in subacute-stroke trials.
PMCID: PMC2854920  PMID: 20396462
Ischemic stroke; Outcome; Stroke scale
13.  Guidelines for the use of carotid endarterectomy: current recommendations from the Canadian Neurosurgical Society 
OBJECTIVE: To develop guidelines on the suitability of patients for carotid endarterectomy (CEA). OPTIONS: For atherosclerotic carotid stenosis that has resulted in retinal or cerebral ischemia: antiplatelet drugs or CEA. For asymptomatic carotid stenosis: CEA or no surgery. OUTCOMES: Risk of stroke and death. EVIDENCE: Trials comparing CEA with nonsurgical management of carotid stenosis. VALUES: Greatest weight was given to findings that were highly significant both statistically and clinically. BENEFITS, HARMS AND COSTS: Benefit: reduction in the risk of stroke. Major harms: iatrogenic stroke, cardiac complications and death secondary to surgical manipulations of the artery or the systemic stress of surgery. Costs were not considered. RECOMMENDATIONS: CEA is clearly recommended for patients with surgically accessible internal carotid artery (ICA) stenoses equal to or greater than 70% of the more distal, normal ICA lumen diameter, providing: (1) the stenosis is symptomatic, causing transient ischemic attacks or nondisabling stroke (including retinal infarction); (2) there is no worse distal, ipsilateral, carotid distribution arterial disease; (3) the patient is in stable medical condition; and (4) the rates of major surgical complications (stroke and death) among patients of the treating surgeon are less than 6%. Surgery is not recommended for asymptomatic stenoses of less than 60%. Symptomatic stenoses of less than 70% and asymptomatic stenoses of greater than 60% are uncertain indications. For these indications, consideration should be given to (1) patient presentation, age and medical condition; (2) plaque characteristics such as degree of narrowing, the presence of ulceration and any documented worsening of the plaque over time; (3) other cerebral arterial stenoses or occlusions, or cerebral infarcts identified through neuroimaging; and (4) surgical complication rates at the institution. CEA should not be considered for asymptomatic stenoses unless the combined stroke and death rate among patients of the surgeon is less than 3%. VALIDATION: These guidelines generally agree with position statements prepared by other organizations in recent years, and with a January 1995 consensus statement by a group of experts assembled by the American Heart Association.
PMCID: PMC1228103  PMID: 9307551
14.  Outcomes in Severe Middle Cerebral Artery Ischemic Stroke 
Neurocritical care  2014;21(1):20-26.
Severe middle cerebral artery stroke (MCA) is associated with a high rate of morbidity and mortality. We assessed the hypothesis that patient specific variables may be associated with outcomes. We also sought to describe under-recognized patient-centered outcomes.
A consecutive, multi-institution, retrospective cohort of adult patients (≤70 years) was established from 2009-2011. We included patients with NIHSS score ≥ 15 and infarct volume ≥ 60 mL measured within 48 hours of symptom onset. Malignant edema was defined as the development of midline brain shift of ≥ 5 mm in the first 5 days. Exclusion criterion was enrollment in any experimental trial. A univariate and multivariate logistic regression analysis was performed to model and predict the factors related to outcomes.
46 patients (29 female, 17 male; mean age 57.3±1.5 years) met study criteria. The mortality rate was 28% (n=13). In a multivariate analysis, only concurrent anterior cerebral artery (ACA) involvement was associated with mortality (OR 9.78, 95% CI 1.15, 82.8, p=0.04). In the malignant edema subgroup (n=23, 58%), 4 died (17%), 7 underwent decompressive craniectomy (30%), 7 underwent tracheostomy (30%), and 15 underwent gastrostomy (65%).
Adverse outcomes after severe stroke are common. Concurrent ACA involvement predicts mortality in severe MCA stroke. It is useful to understand the incidence of life sustaining procedures, such as tracheostomy and gastrostomy, as well as factors that contribute to their necessity.
PMCID: PMC3880600  PMID: 23839704
Brain injuries; Brain edema; Intracranial pressure; Stroke; Fatal outcome; Tracheostomy; Gastrostomy; Decompressive craniectomy
15.  Hemicraniectomy and Durotomy Upon Deterioration From Infarction-Related Swelling Trial (HeADDFIRST): A Randomized Pilot Clinical Trial 
Background and Purpose
HeADDFIRST was a randomized pilot study to obtain information necessary to design a Phase III trial to evaluate the benefit of surgical decompression for brain swelling from large supratentorial cerebral hemispheric infarction (LSCHI).
All stroke patients were screened for eligibility [age 18–75, NIHSS ≥ 18 with Item 1a < 2 (responsive to minor stimulation), and CT demonstrating unilateral, complete MCA territory infarction by specific imaging criteria]. All enrolled patients were treated using a standardized medical treatment protocol. Those with both ≥ 4 mm of pineal shift and deterioration in level of arousal or ≥ 7.5 mm of anteroseptal shift within 96 hours of stroke onset were randomized to continued Medical Treatment Only (MTO) or Medical Treatment plus Surgery (MTS). Death at 21 days was the primary outcome measure.
Among 4,909 screened patients, only 66 (1.3%) were eligible for HeADDFIRST. Forty patients were enrolled, and 26 developed the requisite brain swelling for randomization. All who failed to meet randomization criteria were alive at 21 days. Mortality at 21 and 180 days was 40% (4/10) in the MTO and 21% (3/14) and 36% (5/14) in the MTS arms, respectively.
HeADDFIRST randomization criteria effectively distinguished low from high risk of death from LSCHI. Lower mortality in the MTO group than in other published trials suggests a possible benefit to standardizing medical management. These results can inform the interpretation of recently completed European trials regarding patient selection and medical management.
PMCID: PMC4033520  PMID: 24425122
stroke; cerebral edema; craniectomy; standardized medical management
16.  Decompressive Surgery in Patients with Poor-grade Aneurysmal Subarachnoid Hemorrhage: Clipping with Simultaneous Decompression Versus Coil Embolization Followed by Decompression 
In addition to obliterating the aneurysm using clipping or coiling, decompressive surgery for control of rising intracranial pressure (ICP) is thought to be crucial to prevention of adverse outcomes in patients with poor grade aneurysmal subarachnoid hemorrhage (aSAH). We evaluated the clinical characteristics of patients with poor-grade aSAH, and compared outcomes of aneurysmal clipping with simultaneous decompressive surgery to those of coil embolization followed by decompression.
Materials and Methods
In 591 patients with aSAH, 70 patients with H-H grade IV and V underwent decompressive surgery including craniectomy, lobectomy, and hematoma removal. We divided the patients into two groups according to clipping vs. coil embolization (clip group vs. coil group), and analyzed outcomes and mortality.
Aneurysmal clipping was performed in 40 patients and coil embolization was performed in 30 patients. No significant differences in demographics were observed between the two groups. Middle cerebral artery and posterior circulation aneurysms were more frequent in the clip group. Among 70 patients, mortality occurred in 29 patients (41.4%) and 61 patients (87.1%) had a poor score on the Glasgow outcome scale (scores I-III). No significant difference in mortality was observed between the two groups, but a favorable outcome was more frequent in the coil group (p < 0.05).
In this study, despite aggressive surgical and endovascular management for elevated ICP, there were high rates of adverse outcomes and mortality in poor-grade aSAH. Despite poor outcomes overall, early coil embolization followed by decompression surgery could lead to more favorable outcomes in patients with poor-grade aSAH.
PMCID: PMC4205252  PMID: 25340028
Subarachnoid hemorrhage; Intracranial aneurysm; Decompressive craniectomy; Endovascular; Microsurgery; Intracranial hypertension
17.  Study of the Long-Term Results of Decompressive Craniectomy after Severe Traumatic Brain Injury Based on a Series of 60 Consecutive Cases 
The Scientific World Journal  2014;2014:207585.
Background. Decompressive craniectomy can be proposed in the management of severe traumatic brain injury. Current studies report mixed results, preventing any clear conclusions on the place of decompressive craniectomy in traumatology. Methods. The objective of this retrospective study was to evaluate the results of all decompressive craniectomies performed between 2005 and 2011 for refractory intracranial hypertension after severe traumatic brain injury. Sixty patients were included. Clinical parameters (Glasgow scale, pupillary examination) and radiological findings (Marshall CT scale) were analysed. Complications, clinical outcome, and early and long-term Glasgow Outcome Scale (GOS) were evaluated after surgery. Finally, the predictive value of preoperative parameters to guide the clinician's decision to perform craniectomy was studied. Results. Craniectomy was unilateral in 58 cases and the mean bone flap area was 100 cm2. Surgical complications were observed in 6.7% of cases. Mean followup was 30 months and a favourable outcome was obtained in 50% of cases. The initial Glasgow Scale was the only statistically significant predictive factor for long-term outcome. Conclusion. Despite the discordant results in the literature, this study demonstrates that decompressive craniectomy is useful for the management of refractory intracranial hypertension after severe traumatic brain injury.
PMCID: PMC3956416  PMID: 24719566
18.  Hemicraniectomy for large middle cerebral artery territory infarction: outcome in 19 patients 
Methods: Between June 1997 and June 2000, 19 patients who fulfilled the clinical and imaging criteria for large middle cerebral artery infarction underwent hemicraniectomy because of impending herniation despite best medical therapy. The National Institute of Health Stroke Scale (NIHSS) assessed neurological status on admission and at one week after surgery. At 3 month follow up, The Barthel Index (BI) and Rankin Scale (RS) were used to assess the functional outcome among survivors.
Results: There were 15 males and 4 females with a mean age of 46.5 years (range 27–76 years). Ten patients (53%) had dominant hemisphere stroke. The mean interval between stroke onset and surgery was 60.3 hours (range 20–103 hours). The mean NIHSS score before surgery was 20.5 (range 17–26) and 10.5 (range 6–22) after surgery. One patient (5.2%) died due to post-operative meningitis. At follow up, mean BI was 56.4 (range 25–90) and RS revealed severe handicap in 4 patients (21%). Patients under 50 years of age had a significantly better outcome with mean BI of 60.7 as compared to only 41.3 (p=<0.048) in older patients. Speech function, especially comprehension improved in all patients with dominant hemisphere infarction.
Conclusion: These findings add to previous studies suggesting hemicraniectomy may be a useful procedure in patients with large middle cerebral artery territory infarction. The functional outcome is good in younger patients. A randomised controlled trial is required to substantiate these findings.
PMCID: PMC1738467  PMID: 12754357
19.  Anterior choroidal artery ischaemic patterns predict outcome of carotid occlusion 
To investigate whether anterior choroidal artery (AChA) territory sparing or AChA infarction restricted to the medial temporal lobe (MT), implying good collateral status, predicts good outcome, defined as modified Rankin Scale 0–2, at discharge in acute internal carotid artery (ICA) occlusion.
The authors studied consecutive patients with acute ICA occlusion admitted to an academic medical centre between January 2002 and August 2010, who underwent MRI followed by conventional angiography. The pattern of AChA involvement on initial diffusion-weighted imaging was dichotomised as spared or MT only versus other partial or full. The association of AChA infarct patterns and good outcome at discharge was calculated by multivariate logistic regression with adjustment.
For the 60 patients meeting entry criteria, mean age was 68.3 years and median admission NIH Stroke Scale score was 19. AChA territory was spared or restricted to the MT in 27 patients and other partially involved or fully involved in 33 patients. AChA territory spared or ischaemia restricted to MT only, compared with other partial infarct patterns or full infarct, was independently associated with good discharge outcome (44.4% vs 12.1%, OR 7.24, 95% CI 1.32 to 39.89, p=0.023).
In acute ICA occlusion, the absence of AChA infarction or restriction to the MT is an independent predictor of good discharge outcome. Analysis of AChA infarct patterns may improve early prognostication and decision-making.
PMCID: PMC4157912  PMID: 22492212
20.  Granulocyte colony-stimulating factor for acute ischemic stroke: a randomized controlled trial 
Because granulocyte colony-stimulating factor (G-CSF) has anti-inflammatory and neuroprotective properties and is known to mobilize stem cells, it may be useful in the treatment of acute ischemic stroke. We sought to examine the feasibility, safety and efficacy of using G-CSF to treat acute stroke.
We conducted a randomized, blinded controlled trial involving 10 patients with acute cerebral infarction (middle cerebral artery territory as documented by the admission MRI) who presented within 7 days of onset and whose scores on the National Institutes of Health Stroke Scale (NIHSS) were between 9 and 20. Patients were assigned to either G-CSF therapy or usual care. The G-CSF group (n = 7) received subcutaneous G-CSF injections (15 μg/kg per day) for 5 days. The primary outcome was percentage changes between baseline and 12-month follow-up in mean group scores on 4 clinical scales: the NIHSS, European Stroke Scale (ESS), ESS Motor Subscale (EMS) and Barthel Index (BI). We also assessed neurologic functioning using PET to measure cerebral uptake of fluorodeoxyglucose in the cortical areas surrounding the ischemic core.
All of the patients completed the 5-day course of treatment, and none were lost to follow-up. No severe adverse effects were seen in patients receiving G-CSF. There was greater improvement in neurologic functioning between baseline and 12-month follow-up in the G-CSF group than in the control group (NIHSS: 59% change in the mean G-CSF group score v. 36% in the mean control group score, ESS: 33% v. 20%, EMS: 106% v. 58%, BI: 120% v. 60%). Although at 12 months there was no difference between the 2 groups in cerebral uptake of fluorodeoxyglucose in the ischemic core, uptake in the area surrounding the core was significantly improved in the G-CSF group compared with the control group. There was positive correlation between metabolic activity and EMS score following simple linear correlation analysis.
Our preliminary evidence suggests that using G-CSF as therapy for acute stroke is safe and feasible and leads to improved neurologic outcomes.
PMCID: PMC1405861  PMID: 16517764
21.  Early Single Center Experience with the Solitaire Thrombectomy Device for the Treatment of Acute Ischemic Stroke 
Interventional Neuroradiology  2011;17(2):235-240.
We report the immediate technical and clinical outcome of a new self-expanding fully retrievable stent in the treatment of acute ischemic stroke.
Eleven consecutive patients with acute intracerebral artery occlusions were treated with a self-expandable fully retrievable intracranial stent (Solitaire AB). Four patients had an occlusion of the basilar artery, five had a middle cerebral artery occlusion and two had terminal carotid artery occlusions. Recanalization results were assessed by follow-up angiography immediately after the procedure. Neurologic status was evaluated before and after treatment (90-day follow-up) according to the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scales (mRS).
Successful revascularization (TICI 2a/b and 3) was achieved in 11 of 11 (100%) patients, a TICI 3 state was accomplished in two (18%) patients, and partial recanalization or slow distal branch filling with filling of more than two-thirds of the vessel territory (TICI 2a/2b) was achieved in nine (82%) patients. The stent was removed in all patients. The mean time from stroke symptom onset to recanalization was 339 minutes (+/– 114.3 minutes). NIHSS on admission was 16.09 (+/– 4.7). Almost two-thirds of the patients (61.2%) improved by >6 points on the NIHSS at discharge, and 30% showed a mRS of <2 at 90 days. Mortality was 9%. One patient with a BA occlusion had a massive brain stem infarction and died two days after the procedure. There were no intracranial hemorrhages.
The use of the Solitaire in ischemic stroke patients shows encouraging results. However, further prospective large randomized trials are mandatory to confirm these early results.
PMCID: PMC3287277  PMID: 21696665
mechanical thrombectomy, acute ischemic stroke, retrievable stent
22.  How often are ischemic stroke patients eligible for decompressive hemicraniectomy? 
Background and Purpose
Malignant middle cerebral artery (MCA) infarction is estimated to occur in 10% of ischemic strokes, but few patients undergo decompressive hemicraniectomy, a proven therapy. We determined the proportion of ischemic stroke patients without significant baseline disability with large MCA infarction who would have been potentially eligible for hemicraniectomy in an era before publication of recent hemicraniectomy trials.
Ischemic stroke cases that occurred in 2005 among residents of the five-county Greater Cincinnati/Northern Kentucky area were ascertained. Two study physicians reviewed all clinical and neuroimaging data for patients with baseline modified Rankin Score (mRS) <2, age ≥18 years with NIHSS ≥10. Large MCA infarction was defined as >50% of the MCA territory or >145mL on diffusion-weighted MRI. Other eligibility criteria for hemicraniectomy, based on the pooled analysis of recent clinical trials, were age 18–60 years and NIHSS >15.
Of 2227 ischemic strokes, 39(1.8%) with baseline mRS <2 had large MCA infarction. None underwent hemicraniectomy, and 16(41.0%) died within 30 days. Six patients (0.3% of all ischemic strokes) were potentially eligible for hemicraniectomy; one died within 30 days.
Based on criteria from clinical trials, only 0.3% of cases were eligible for hemicraniectomy. Given the survival and functional outcome benefit in treated patients, future studies should determine whether additional subgroups of ischemic stroke patients may benefit from hemicraniectomy.
PMCID: PMC3265663  PMID: 22034001
decompressive surgery; stroke care; epidemiology
23.  The effect of craniectomy size on mortality, outcome, and complications after decompressive craniectomy at a rural trauma center 
Decompressive craniectomy (DC) has increasing support with current studies suggesting an improvement in both survival rates and outcomes with this intervention. However, questions surround this procedure; specifically, no evidence has indicated the optimal craniectomy size. Larger craniectomy is thought to better decrease intracranial pressure, but with a possible increase in complication rates. Our hypothesis is that a larger craniectomy may improve mortality and outcome, but may increase complication rates.
Materials and Methods:
A retrospective observational therapeutic study was undertaken to determine if craniectomy size is related to complication rates, mortality, or outcome. Our institution's Trauma Registry was searched for patients undergoing DC. Craniectomy size was measured by antero-posterior (AP) diameter. Mortality, outcome (through admission and discharge Glasgow Coma Score and Glasgow Outcome Scale), and complications (such as re-bleeding, re-operation, hygroma, hydrocephalus, infection, and syndrome of the trephined) were noted. Complications, mortality, and outcome were then compared to craniectomy size, to determine if any relation existed to support our hypothesis.
20 patients met criteria for inclusion in this study. Craniectomy size as measured by AP diameter was correlated with a statistically significant improvement in mortality within the group. All patients with a craniectomy size less than 10 cm died. However, outcome was not significantly related to craniectomy size in the group. Similarly, complication rates did not differ significantly compared to craniectomy size.
This study provides Level 3 evidence that craniectomy size may be significantly related to improved mortality within our group, supporting our initial hypothesis; however, no significant improvement in outcome was seen. Similarly, in contrast to our hypothesis, complication rates did not significantly correlate with craniectomy size.
PMCID: PMC4078603  PMID: 25002758
Craniectomy; neurotrauma; traumatic brain injury
24.  Preoperative 123I-iomazenil SPECT imaging predicts cerebral hyperperfusion following endarterectomy for unilateral cervical internal carotid artery stenosis 
Cerebral hyperperfusion following carotid endarterectomy (CEA) occurs in patients with preoperative impairments in cerebral hemodynamics. The aim of the present study was to determine whether late images/early images on preoperative brain 123I-iomazenil (IMZ) single-photon emission computed tomography (SPECT), which correlate with oxygen extraction fraction images on positron emission tomography, could identify patients at risk for cerebral hyperperfusion following endarterectomy for unilateral cervical internal carotid artery (ICA) stenosis.
In 80 patients, preoperative brain SPECT scans were initiated immediately after (early images) and 180 min after (late images) administration of 123I-IMZ. A region of interest (ROI) was automatically placed in the middle cerebral artery territory in both the cerebral hemispheres using a three-dimensional stereotaxic ROI template. Transcranial regional cerebral oxygen saturation (rSO2) was monitored using near-infrared spectroscope throughout carotid endarterectomy, and a patient was defined as having cerebral hyperperfusion when a ratio of rSO2 at the end of the surgery to rSO2 before ICA clamping was ≥ 1.1.
Cerebral hyperperfusion was observed on intraoperative rSO2 monitoring in eight patients (10%). Preoperative increase in affected side-to-contralateral side asymmetry on late/early 123I-IMZ value was the only significant independent predictor of cerebral hyperperfusion (95% confidence interval [CI], 1.606 to 8.710; P = 0.0010). The preoperative late/early 123I-IMZ asymmetry corresponded to an 88% sensitivity and 89% specificity, with 47% positive- and 98% negative-predictive values for the development of cerebral hyperperfusion.
Preoperative late/early 123I-IMZ images can identify patients at risk for cerebral hyperperfusion following endarterectomy for unilateral cervical ICA stenosis.
PMCID: PMC3478115  PMID: 23133803
123I-iomazenil; brain SPECT; hyperperfusion; carotid endarterectomy
25.  Selective neuronal damage and Wisconsin Card Sorting Test performance in atherosclerotic occlusive disease of the major cerebral artery 
In atherosclerotic internal carotid artery (ICA) or middle cerebral artery (MCA) disease, selective neuronal damage can be detected as a decrease in central benzodiazepine receptors (BZRs) in the normal-appearing cerebral cortex. This study aimed to determine whether a decrease in the BZRs in the non-infarcted cerebral cortex is associated with poor performance on the Wisconsin Card Sorting Test (WCST), which assesses executive functions.
The authors measured the BZRs using positron emission tomography and 11C-flumazenil in 60 non-disabled patients with unilateral atherosclerotic ICA or MCA disease and no cortical infarction. Using three-dimensional stereotactic surface projections, the abnormally decreased BZR index (extent (%) of pixels with Z score >2 compared with controls×average Z score in those pixels) in the cerebral cortex of the anterior cerebral artery (ACA) or MCA territory was calculated and found to be correlated with the patient's score on the WCST.
On the basis of the WCST results, 39 patients were considered abnormal (low categories achieved) for their age. The BZR index of the ACA territory in the hemisphere affected by arterial disease was significantly higher in abnormal patients than in normal patients. The BZR index of the MCA territory differed significantly between the two groups when patients with left arterial disease (n=28) were analysed separately.
In atherosclerotic ICA or MCA disease, selective neuronal damage that is manifested as a decrease in BZRs in the non-infarcted cerebral cortex may contribute to the development of executive dysfunction.
PMCID: PMC3022362  PMID: 20802218
Carotid artery disease; middle cerebral artery disease; positron emission tomography; Wisconsin Card Sorting test; benzodiazepine receptor; cerebrovascular disease; cognition; pet; ligand studies; stroke

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