A 42-year-old male presented with a stroke. He was admitted to a general ward with a right sided hemiplegia, neglect and speech deficits. The day following admission, you are called to the ward because the patient has just become drowsy, and is no longer following commands. The team has performed a CT scan of the head and this shows extensive left middle cerebral artery territory infarction, with no haemorrhage, and early evidence of raised intracranial pressure.

a) Outline your initial plan of management. The family asks if there is any surgical option to “save” the patient.

b) What is the evidence for surgery in this situation, and how would you advise the family?

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College Answer

a) The patient should be admitted to an intensive care or stroke unit for close monitoring and comprehensive treatment.

Transfer to a higher level centre is reasonable if comprehensive care and timely neurosurgical intervention is not available locally.

Maintain SpO2 >95% - any safe comments or values.

Intubate if usual concerns regarding airway protection in neurologically impaired patient.

“Safe” blood pressure (Extreme hypertension associated with haemorrhagic transformation.

Concerned about malignant brain swelling with possible temporal herniation and the need to reduce the space occupying effects of that swelling.

a) Elevate the head of the bed to 30°.

b) Do not hyperventilate PaCO2 35-40 mmHg

c) Increase levels of sedation +/- paralysis:

d) Barbiturate infusion – option, but not advocated in guidelines.

e) Osmotic therapy:

a. 3% Saline 100-200mL aliquots; Na+ ≤155mmol/L

b. Mannitol 0.5-1.0g/kg

c. Aim for serum Osm 300-320mOsm/L

f) Target normoglycaemia

g) Hypothermia- temperature 35-36.5oC

a. Prospective randomized studies are currently underway to further evaluate therapeutic hypothermia in patients with cerebral infarcts.

b) Evidence
a. Three prospective, randomized trials (i.e. DESTINY, DECIMAL and HAMLET)

  • Supratentorial infarctions treated with decompressive craniectomy, usually within 48
    hours of stroke onset. Age <60. Older populations being currently studied.
  • With hemicraniectomy compared with medical management:
    • Reduced mortality (22% versus 71% - pooled analysis)
    • No individual study showed an improvement in the percentage of survivors with good outcomes (mRS score, 0–3),
      • Only shown in a pooled analysis (43% versus 21%).
      • Only 14% of surgical survivors could look after their own affairs without assistance (mRS score, 2)

Note:
Names / excessive detail of studies not expected

Advice
I. The patient’s age <60 fits the studies’ inclusion criteria
II. Decompressive craniectomy for supratentorial infarction with swelling results in a
reproducible large reduction in mortality.

  • But mortality after large ischaemic strokes with cerebral oedema remains between 20% & 30% despite medical and surgical interventions.
  • Nearly all post-surgery survivors suffer residual permanent disabilities:
    • One half are severely disabled
    • A third are fully dependent on care
    • 50% will suffer from depression

III. There may be a discrepancy between physical disability and quality of life, with many patients and families rating a good quality of life despite severe functional handicap. Ultimate advice and decisions will be based on a balance between survival and level of disability.

Additional Examiners’ Comments:
Candidates did not accurately read the question. Answers re advice to the family were not at the required level of sophistication
.

Discussion

A systematic approach is called for.

a) is a question regarding the generic management of raised intracranial pressure, as well as the general supportive management of acute stroke, which are topics well discussed elsewhere.

The brief point-form summary of management recommendations offered below is based completly on the 2014 AHA/ASA guidelines - "Recommendations for the Management of Cerebral and Cerebellar Infarction With Swelling".

Admin) - The availability of a specialist acute stroke unit improves mortality and outcome; admission to ICU does not (perhaps the opposite)

A) - intubate them to protect from aspiration (though it does not improve outcome)

B) - Ventilate aiming for a CO2 ~35mmHg (no evidence for or against hyperventilation, but the guidelines statements tend to recommend a normal CO2)

C) - Tolerate a systolic blood pressure under 220mmHg systolic, or 120mmHg diastolic. (the evidence for this is also not very robust)

D) - There does not seem to be any point in monitoring the ICP. Rarely is the intracranial pressure raised. If it were truly raised, the usual armamentarium of methods can be deployed.

E) Control hypeglycaemia, but not aggressively - tolerate borderline-high normoglycaemia.

F) Ensure normovolaemia and good hydration.

G) Ensure adequate nutrition, preferably by the enteric route.

H) No evidence to support the use of heparin infusion.

I) no strong evidence to support the use of therapeutic hypothermia.

b) The evidence for surgery (i.e. decompressive craniectomy in malignant MCA syndrome) is discussed in detail elsewhere. In brief, the college model answer refer to three landmark studies:

A pooled analysis of the first three studies is available, including 93 patient cases.

"...after decompressive surgery the probability of survival increases from 28% to nearly 80% and the probability of survival with an mRS of ≤3 doubles."

(mRS of 3 here being the score of the modified Rankin scale, equating to a disability where one requires some help, some of the time, with some things - but is otherwise able to walk unassisted).

For advice to the family, the college quotes the AHA/ASA guidelines verbatim (see page 10):

  • "Decompressive craniectomy ... results in a reproducible large reduction in mortality, but nearly all survivors suffer residual permanent disabilities."
  • "No individual study showed an improvement in the percentage of survivors with good outcomes"
  • "Only 14% of surgical survivors could look after their own affairs without assistance"

References

References

Oh's Intensive Care manual : Chapter   51   (pp. 568)  Acute  cerebrovascular  complications by Bernard  Riley  and  Thearina  de  Beer.

Torbey, Michel T., et al. "Evidence-Based Guidelines for the Management of Large Hemispheric Infarction." Neurocritical care (2015): 1-19.

Wartenberg, Katja E. "Malignant middle cerebral artery infarction." Current opinion in critical care 18.2 (2012): 152-163.

Yang, Ming-Hao, et al. "Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: A systematic review and meta-analysis." The Surgeon (2015).

Jüttler, Eric, et al. "Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY) a randomized, controlled trial." Stroke 38.9 (2007): 2518-2525.

Jüttler, Eric, et al. "DESTINY II: DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY II." International Journal of Stroke 6.1 (2011): 79-86.

Vahedi, Katayoun, et al. "Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial)." Stroke 38.9 (2007): 2506-2517.

Hofmeijer, Jeannette, 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." The Lancet Neurology 8.4 (2009): 326-333.

Vahedi, Katayoun, et al. "Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials." The Lancet Neurology 6.3 (2007): 215-222.

Slotty, Philipp Jörg, et al. "The influence of decompressive craniectomy for major stroke on early cerebral perfusion." Journal of neurosurgery (2015): 1-6.

Barroso, Bruno. "Decompressive craniectomy for stroke after intravenous thrombolytic therapy." International Journal of Stroke 9.8 (2014): E40-E40.

Wijdicks, Eelco FM, et al. "Recommendations for the Management of Cerebral and Cerebellar Infarction With Swelling A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association." Stroke 45.4 (2014): 1222-1238.

Jüttler, Eric, et al. "Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke." New England Journal of Medicine 370.12 (2014): 1091-1100.