World Neurosurgery News
recurrent glioblastoma and its risk for neurological morbidity. J Neurosurg 120:846-853, 2014. 5. Sanai N, Polley MY, McDermott MW, Parsa AT, Berger MS: An extent of resection threshold for newly diagnosed glioblastomas. J Neurosurg 115: 3-8, 2011. 6. Stummer W, Novotny A, Stepp H, Goetz C, Bise K, Reulen HJ: Fluorescence-guided resection of glioblastoma multiforme by using 5-aminolevulinic acidinduced porphyrins: a prospective study in 52 consecutive patients. J Neurosurg 93:1003-1013, 2000. 7. Stummer W, Reulen HJ, Meinel T, Pichlmeier U, Schumacher W, Tonn JC, Rohde V, Oppel F,
Turowski B, Woiciechowsky C, Franz K, Pietsch T; ALA-Glioma Study Group: Extent of resection and survival in glioblastoma multiforme: identification of and adjustment for bias. Neurosurgery 62: 564-576; discussion 564-576, 2008. 8. Stupp R, Mason WP, van den Bent MJ, Weller M, Fisher B, Taphoorn MJ, Belanger K, Brandes AA, Marosi C, Bogdahn U, Curschmann J, Janzer RC, Ludwin SK, Gorlia T, Allgeier A, Lacombe D, Cairncross JG, Eisenhauer E, Mirimanoff RO; European Organisation for Research and Treatment of Cancer Brain Tumor and Radiotherapy Groups, National Cancer Institute of Canada Clinical Trials Group: Radiotherapy plus concomitant
and adjuvant temozolomide for glioblastoma. N Engl J Med 352:987-996, 2005. 9. Toennis W, Walter W: Glioblastoma multiforme (report on 2611 cases) [in German]. Acta Neurochir Suppl (Wien) (Suppl 6):40-62, 1959.
From the Departments of 1Neurological Surgery and 2Radiology, University of Washington School of Medicine, Seattle, Washington, USA 1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.wneu.2014.10.006
Hemicraniectomy for Acute Stroke in Patients Older than Age 60: Neurosurgeons on the Frontlines of Multidisciplinary Stroke Therapy Youssef J. Hamade, Samer G. Zammar, Najib E. El Tecle, Tarek Y. El Ahmadieh, Byron K. Yip, Timothy R. Smith, Bernard R. Bendok
Malignant middle cerebral artery (MCA) infarction is a lifethreatening condition that results from space-occupying brain swelling with subsequent herniation and possibly early death (2). This morbid entity constitutes about 10% of all ischemic strokes and is associated with significant mortality affecting 80% of patients (2, 7). Prior randomized controlled trials, mainly HAMLET (Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial), DECIMAL (Early Decompressive Craniectomy In Malignant Middle Cerebral Artery Infarction), and DESTINY (DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY), demonstrated survival and functional benefit of decompressive hemicraniectomy in patients with malignant MCA infarction (1, 3-6, 8, 9). However, these trials involved only patients 60 years who presented with extensive MCA stroke. Results of the DESTINY II trial were published in the March 2014 issue of New England Journal of Medicine. The study comprised 112 patients and was conducted at 13 German sites between August 2009 and May 2013. Patients were eligible if they presented within 48 hours with clinical symptoms of acute unilateral MCA infarction with an National Institutes of Health Stroke Scale score >14 (for nondominant hemisphere) or >19 (for dominant hemisphere) with reduced levels of consciousness or ischemic infarction with involvement of at least two thirds of the MCA territory and basal ganglia on brain imaging. Patients were excluded if they had preexisting disability defined by a modified Rankin scale (mRS) score of >1, impending symptoms (absence of pupillary reflex, reduced levels of consciousness), previous hemorrhagic
WORLD NEUROSURGERY 82 [6]: 928-935, DECEMBER 2014
episodes, other brain lesions, contraindications for surgery, or an estimated life expectancy of 60 years with malignant MCA infarction. This trial arms neurosurgeons and other stroke specialists with data that enrich the informed consent process. Hemicraniectomy has a dramatic impact on mortality, but survival is associated with moderate disability. This outcome may or may not be consistent with patient wishes. The trend toward surviving with a mRS score of 5 should be weighed carefully during the informed consent process, and health care professionals should try to put this survival in perspective. It is our hope that further advances in acute stroke therapy and rehabilitation science including robotics and brain stimulation may result in further improvements in outlook for this most “malignant” of stroke subtypes. These data reinforce the potential for neurosurgeons to enhance stroke care and outcomes.
poor functional outcome. J Neurol Neurosurg Psychiatry 70:226-228, 2001. 5. Juttler 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 38:2518-2525, 2007. 6. Jüttler E, Unterberg A, Woitzik J, Bösel J, Amiri H, Sakowitz OW, Gondan M, Schiller P, Limprecht R, Luntz S, Schneider H, Pinzer T, Hobohm C, Meixensberger J, Hacke W; DESTINY II Investigators: Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 370:1091-1100, 2014. 7. Silver FL, Norris JW, Lewis AJ, Hachinski VC: Early mortality following stroke: a prospective review. Stroke 15:492-496, 1984. 8. 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 6:215-222, 2007. 9. 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 38:2506-2517, 2007.
Departments of Neurological Surgery and Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA 1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.wneu.2014.10.005
82 [6]: 928-935, DECEMBER 2014 WORLD NEUROSURGERY
recurrent glioblastoma and its risk for neurological morbidity. J Neurosurg 120:846-853, 2014. 5. Sanai N, Polley MY, McDermott MW, Parsa AT, Berger MS: An extent of resection threshold for newly diagnosed glioblastomas. J Neurosurg 115: 3-8, 2011. 6. Stummer W, Novotny A, Stepp H, Goetz C, Bise K, Reulen HJ: Fluorescence-guided resection of glioblastoma multiforme by using 5-aminolevulinic acidinduced porphyrins: a prospective study in 52 consecutive patients. J Neurosurg 93:1003-1013, 2000. 7. Stummer W, Reulen HJ, Meinel T, Pichlmeier U, Schumacher W, Tonn JC, Rohde V, Oppel F,
Turowski B, Woiciechowsky C, Franz K, Pietsch T; ALA-Glioma Study Group: Extent of resection and survival in glioblastoma multiforme: identification of and adjustment for bias. Neurosurgery 62: 564-576; discussion 564-576, 2008. 8. Stupp R, Mason WP, van den Bent MJ, Weller M, Fisher B, Taphoorn MJ, Belanger K, Brandes AA, Marosi C, Bogdahn U, Curschmann J, Janzer RC, Ludwin SK, Gorlia T, Allgeier A, Lacombe D, Cairncross JG, Eisenhauer E, Mirimanoff RO; European Organisation for Research and Treatment of Cancer Brain Tumor and Radiotherapy Groups, National Cancer Institute of Canada Clinical Trials Group: Radiotherapy plus concomitant
and adjuvant temozolomide for glioblastoma. N Engl J Med 352:987-996, 2005. 9. Toennis W, Walter W: Glioblastoma multiforme (report on 2611 cases) [in German]. Acta Neurochir Suppl (Wien) (Suppl 6):40-62, 1959.
From the Departments of 1Neurological Surgery and 2Radiology, University of Washington School of Medicine, Seattle, Washington, USA 1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.wneu.2014.10.006
Hemicraniectomy for Acute Stroke in Patients Older than Age 60: Neurosurgeons on the Frontlines of Multidisciplinary Stroke Therapy Youssef J. Hamade, Samer G. Zammar, Najib E. El Tecle, Tarek Y. El Ahmadieh, Byron K. Yip, Timothy R. Smith, Bernard R. Bendok
Malignant middle cerebral artery (MCA) infarction is a lifethreatening condition that results from space-occupying brain swelling with subsequent herniation and possibly early death (2). This morbid entity constitutes about 10% of all ischemic strokes and is associated with significant mortality affecting 80% of patients (2, 7). Prior randomized controlled trials, mainly HAMLET (Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial), DECIMAL (Early Decompressive Craniectomy In Malignant Middle Cerebral Artery Infarction), and DESTINY (DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY), demonstrated survival and functional benefit of decompressive hemicraniectomy in patients with malignant MCA infarction (1, 3-6, 8, 9). However, these trials involved only patients 60 years who presented with extensive MCA stroke. Results of the DESTINY II trial were published in the March 2014 issue of New England Journal of Medicine. The study comprised 112 patients and was conducted at 13 German sites between August 2009 and May 2013. Patients were eligible if they presented within 48 hours with clinical symptoms of acute unilateral MCA infarction with an National Institutes of Health Stroke Scale score >14 (for nondominant hemisphere) or >19 (for dominant hemisphere) with reduced levels of consciousness or ischemic infarction with involvement of at least two thirds of the MCA territory and basal ganglia on brain imaging. Patients were excluded if they had preexisting disability defined by a modified Rankin scale (mRS) score of >1, impending symptoms (absence of pupillary reflex, reduced levels of consciousness), previous hemorrhagic
WORLD NEUROSURGERY 82 [6]: 928-935, DECEMBER 2014
episodes, other brain lesions, contraindications for surgery, or an estimated life expectancy of 60 years with malignant MCA infarction. This trial arms neurosurgeons and other stroke specialists with data that enrich the informed consent process. Hemicraniectomy has a dramatic impact on mortality, but survival is associated with moderate disability. This outcome may or may not be consistent with patient wishes. The trend toward surviving with a mRS score of 5 should be weighed carefully during the informed consent process, and health care professionals should try to put this survival in perspective. It is our hope that further advances in acute stroke therapy and rehabilitation science including robotics and brain stimulation may result in further improvements in outlook for this most “malignant” of stroke subtypes. These data reinforce the potential for neurosurgeons to enhance stroke care and outcomes.
poor functional outcome. J Neurol Neurosurg Psychiatry 70:226-228, 2001. 5. Juttler 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 38:2518-2525, 2007. 6. Jüttler E, Unterberg A, Woitzik J, Bösel J, Amiri H, Sakowitz OW, Gondan M, Schiller P, Limprecht R, Luntz S, Schneider H, Pinzer T, Hobohm C, Meixensberger J, Hacke W; DESTINY II Investigators: Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 370:1091-1100, 2014. 7. Silver FL, Norris JW, Lewis AJ, Hachinski VC: Early mortality following stroke: a prospective review. Stroke 15:492-496, 1984. 8. 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 6:215-222, 2007. 9. 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 38:2506-2517, 2007.
Departments of Neurological Surgery and Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA 1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.wneu.2014.10.005
82 [6]: 928-935, DECEMBER 2014 WORLD NEUROSURGERY
