Surgical Management of Acute Stroke

Jee-Hyun Kwon

doi:10.5124/jkma.2009.52.4.375

J Korean Med Assoc > Volume 52(4); 2009 > Article

Kwon: Surgical Management of Acute Stroke

Focused Issue of This Month

Acute Management of Stroke

Journal of the Korean Medical Association

Journal of the Korean Medical Association 2009; 52(4): 375-381.

Published online: April 30, 2009

DOI: http://dx.doi.org/10.5124/jkma.2009.52.4.375

Surgical Management of Acute Stroke

Jee-Hyun Kwon, MD

Department of Neurology, Ulsan University College of Medicine, Korea. jhkwon-or@hanmail.net

Abstract

Stroke is a most common neurological disease leading to mortality and morbidity. Many clinical evidences confirm that medical treatment including thrombolytic and antithrombotic therapy may improve the clinical outcome in patients with acute ischemic stroke. However, little information exists about effectiveness and safety of reperfusion surgery such as emergency carotid endarterectomy and extracranial-intracranial bypass surgery in patients with acute ischemic stroke and limits its wide application. Recent pooled analysis of three randomized controlled clinical trials-DECIMAL (decompressive craniectomy in malignant middle cerebral artery infarcts) trial; DESTINY (decompressive surgery for the treatment of malignant infarction of the middle cerebral artery) trial; and HAMLET (hemicraniectomy after middle cerebral artery infarction with life-threatening edema trial) reported decompressive surgery undertaken within 48 hours of stroke onset in patients with malignant middle cerebral artery infarction reduced mortality and morbidity. However, decompressive surgery in patients with malignant middle cerebral artery infarction should be done according to the clinical conditions of individual patients. No clear evidences are present on that craniotomy, minimally invasive surgery, and early clot evacuation are effective on functional outcome of patients with spontaneous intracerebral hemorrhage compared with initial conservative therapy. In conclusion, a lot of well-designed studies are needed to recommend appropriate surgical management in patients with acute ischemic and hemorrhagic stroke.

Malignant middle cerebral artery infarct; Decompressive surgery; Intracerebral hemorrhage

References

1. Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EF. American Heart Association; American Stroke Association Stroke Council; Clinical Cardiology Council; Cardiovascular Radiology and Intervention Council; Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007;38:1655-1711.

2. Meyer FB, Sundt TM Jr, Piepgras DG, Sandok BA, Forbes G. Emergency carotid endarterectomy for patients with acute carotid occlusion and profound neurological deficits. Ann Surg 1986;203:82-89.

3. Kasper GC, Wladis AR, Lohr JM, Roedersheimer LR, Reed RL, Miller TJ, et al. Carotid thromboendarterectomy for recent total occlusion of the internal carotid artery. J Vasc Surg 2001;33:242-249.

4. Gay JL, Curtil A, Buffiere S, Favre JP, Barral X. Urgent carotid artery repair: retrospective study of 21 cases. Ann Vasc Surg 2002;16:401-406.

5. Heros RC. Carotid endarterectomy in patients with intraluminal thrombus. Stroke 1988;19:667-668.

6. Buchan A, Gates P, Pelz D, Barnett HJ. Intraluminal thrombus in the cerebral circulation. Implications for surgical management. Stroke 1988;19:681-687.

7. BT A. Treatment of acute traumatic internal carotid artery occlusion with extracranial-to-intracranial arterial bypass: case report. Neurosurgery 1989;25:90-92.

8. Kakinuma K, Ezuka I, Takai N, Yamamoto K, Sasaki O. The simple indicator for revascularization of acute middle cerebral artery occlusion using angiogram and ultra-early embolectomy. Surg Neurol 1999;51:332-341.

9. Linskey ME, Sekhar LN, Hecht ST. Emergency embolectomy for embolic occlusion of the middle cerebral artery after internal carotid artery balloon test occlusion. Case report. J Neurosurg 1992;77:134-138.

10. Frank JI. Large hemispheric infarction, deterioration, and intracranial pressure. Neurology 1995;45:1286-1290.

11. Qureshi AI, Suarez JI, Yahia AM, Mohammad Y, Uzun G, Suri MF, et al. Timing of neurologic deterioration in massive middle cerebral artery infarction: a multicenter review. Crit Care Med 2003;31:272-277.

12. Manno EM, Nichols DA, Fulgham JR, Wijdicks EF. Computed tomographic determinants of neurologic deterioration in patients with large middle cerebral artery infarctions. Mayo Clin Proc 2003;78:156-160.

13. Heinsius T, Bogousslavsky J, Van Melle G. Large infarcts in the middle cerebral artery territory. Etiology and outcome patterns. Neurology 1998;50:341-350.

14. Wijdicks EF, Diringer MN. Middle cerebral artery territory infarction and early brain swelling: progression and effect of age on outcome. Mayo Clin Proc 1998;73:829-836.

15. Maramattom BV, Bahn MM, Wijdicks EF. Which patient fares worse after early deterioration due to swelling from hemispheric stroke? Neurology 2004;63:2142-2145.

16. 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;53:309-315.

17. Berrouschot J, Sterker M, Bettin S, Koster J, Schneider D. Mortality of space-occupying ('malignant') middle cerebral artery infarction under conservative intensive care. Intensive Care Med 1998;24:620-623.

18. H J, vdW HB, K LJ. Treatment of space-occupying cerebral infarction. Crit Care Med 2003;31:617-625.

19. Rieke K, Schwab S, Krieger D, von Kummer R, Aschoff A, Schuchardt V, Hacke W. Decompressive surgery in space-occupying hemispheric infarction: results of an open, prospective trial. Crit Care Med 1995;23:1576-1587.

20. Schwab S, Steiner T, Aschoff A, Schwarz S, Steiner HH, Jansen O, Hacke W. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 1998;29:1888-1893.

21. Morley N, Berge E, Cruz-Flores S, Whittle I. Surgical decompression for cerebral edema in acute ischemic stroke. Stroke 2003;34:1337.

22. Gupta R, Connolly ES, Mayer S, Elkind MS. Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review. Stroke 2004;35:539-543.

23. H J, A GJ, A A, vG J, M MR, K LJ, et al. Hemicraniectomy after middle cerebral artery infarction with life-threatening Edema trial (HAMLET). Protocol for a randomised controlled trial of decompressive surgery in space-occupying hemispheric infarction. Trials 2006;7:29.

24. Jüttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, Witte S, Jenetzky E, Hacke W. DESTINY Study Group. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke 2007;38:2518-2525.

25. Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, Boutron C, Couvreur G, Rouanet F, Touzé E, Guillon B, Carpentier A, Yelnik A, George B, Payen D, Bousser MG. DECIMAL Investigators. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 2007;38:2506-2517.

26. Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A, Amelink GJ, Schmiedeck P, Schwab S, Rothwell PM, Bousser MG, van der Worp HB, Hacke W. DECIMAL, DESTINY, and HAMLET investigators. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 2007;6:215-222.

27. Hornig CR, Rust DS, Busse O, Jauss M, Laun A. Space-occupying cerebellar infarction. Clinical course and prognosis. Stroke 1994;25:372-374.

28. Mathew P, Teasdale G, Bannan A, Oluoch-Olunya D. Neurosurgical management of cerebellar haematoma and infarct. J Neurol Neurosurg Psychiatry 1995;59:287-292.

29. E JA, N-T DE, S SI. Diagnosis and initial management of cerebellar infarction. Lancet Neurol 2008;7:951-964.

30. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008;25:457-507.

31. Chen HJ, Lee TC, Wei CP. Treatment of cerebellar infarction by decompressive suboccipital craniectomy. Stroke 1992;23:957-961.

32. Broderick JP, Brott T, Tomsick T, Miller R, Huster G. Intracerebral hemorrhage more than twice as common as subarachnoid hemorrhage. J Neurosurg 1993;78:188-191.

33. Anderson CS, Chakera TM, Stewart-Wynne EG, Jamrozik KD. Spectrum of primary intracerebral haemorrhage in Perth, Western Australia, 1989-90: incidence and outcome. J Neurol Neurosurg Psychiatry 1994;57:936-940.

34. Bamford J, Dennis M, Sandercock P, Burn J, Warlow C. The frequency, causes and timing of death within 30 days of a first stroke: the Oxfordshire Community Stroke Project. J Neurol Neurosurg Psychiatry 1990;53:824-829.

35. Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, Mayberg M, Morgenstern L, Ogilvy CS, Vespa P, Zuccarello M. American Heart Association; American Stroke Association Stroke Council; High Blood Pressure Research Council; Quality of Care and Outcomes in Research Interdisciplinary Working Group. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38:2001-2023.

36. Juvela S, Heiskanen O, Poranen A, Valtonen S, Kuurne T, Kaste M, Troupp H. The treatment of spontaneous intracerebral hemorrhage. A prospective randomized trial of surgical and conservative treatment. J Neurosurg 1989;70:755-758.

37. Zuccarello M, Brott T, Derex L, Kothari R, Sauerbeck L, Tew J, Van Loveren H, Yeh HS, Tomsick T, Pancioli A, Khoury J, Broderick J. Early surgical treatment for supratentorial intracerebral hemorrhage: a randomized feasibility study. Stroke 1999;30:1833-1839.

38. Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, Karimi A, Shaw MD, Barer DH. STICH investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. The Lancet 2005;365:387-397.

39. van Loon J, Van Calenbergh F, Goffin J, Plets C. Controversies in the management of spontaneous cerebellar haemorrhage. A consecutive series of 49 cases and review of the literature. Acta Neurochir (Wien) 1993;122:187-193.

40. Firsching R, Huber M, Frowein RA. Cerebellar haemorrhage: management and prognosis. Neurosurg Rev 1991;14:191-194.

41. Da Pian R, Bazzan A, Pasqualin A. Surgical versus medical treatment of spontaneous posterior fossa haematomas: a cooperative study on 205 cases. Neurol Res 1984;6:145-151.

42. Kirollos RW, Tyagi AK, Ross SA, van Hille PT, Marks PV. Management of spontaneous cerebellar hematomas: a prospective treatment protocol. Neurosurgery 2001;49:1378-1386.

43. Morioka J, Fujii M, Kato S, Fujisawa H, Akimura T, Suzuki M, Kobayashi S. Japan Standard Stroke Registry Group (JSSR). Surgery for spontaneous intracerebral hemorrhage has greater remedial value than conservative therapy. Surg Neurol 2006;65:67-72.

44. Auer LM, Deinsberger W, Niederkorn K, Gell G, Kleinert R, Schneider G, Holzer P, Bone G, Mokry M, K_rner E, et al. Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J Neurosurg 1989;70:530-535.

45. Teernstra OP, Evers SM, Lodder J, Leffers P, Franke CL, Blaauw G. Stereotactic treatment of intracerebral hematoma by means of a plasminogen activator: a multicenter randomized controlled trial (SICHPA). Stroke 2003;34:968-974.

46. Morgan T, Zuccarello M, Narayan R, Keyl P, Lane K, Hanley D. Preliminary findings of the minimally-invasive surgery plus rtPA for intracerebral hemorrhage evacuation (MISTIE) clinical trial. Acta Neurochir Suppl 2008;105:147-151.

47. Kaneko M, Tanaka K, Shimada T, Sato K, Uemura K. Long-term evaluation of ultra-early operation for hypertensive intracerebral hemorrhage in 100 cases. J Neurosurg 1983;58:838-842.

48. Morgenstern LB, Demchuk AM, Kim DH, Frankowski RF, Grotta JC. Rebleeding leads to poor outcome in ultra-early craniotomy for intracerebral hemorrhage. Neurology 2001;56:1294-1299.

49. Tan SH, Ng PY, Yeo TT, Wong SH, Ong PL, Venketasubramanian N. Hypertensive basal ganglia hemorrhage: a prospective study comparing surgical and nonsurgical management. Surg Neurol 2001;56:287-292.

Figure 1

Distributions of the scores on the mRS and death after 12 months for patients treated with or without decompressive surgery (Adopted from Vahedi K, et al. Lancet Neurol 2007; 6: 218).

Figure 2

Absolute risk reductions and odds ratios for unfavourable outcome at 12 months (Adopted from Vahedi K, et al. Lancet Neurol 2007; 6: 218).