Removing Part of the Skull Saves Older Stroke Patients

A new study reveals that hemicraniectomy in stroke patients older than 60 with life-threatening brain edema cuts mortality rate by more than half compared with conservative treatment.

Researchers at the University of Heidelberg (Germany) randomly assigned 112 patients 61 years of age or older (median age 70 years) with malignant middle-cerebral-artery infarction, with brain imaging results indicating that ischemia had affected at least two-thirds of the brain served by the artery. In all, 49 patients were randomized to hemicraniectomy (removal of skull bone at least 12 cm in diameter), and 63 to conservative treatment, which consisted of usual intensive care unit (ICU) support with osmotherapy, sedation, and ventilation. Assignments were made within 48 hours after the onset of symptoms. The primary end point was survival without severe disability according to the modified Rankin scale.

The results showed that the proportion of patients who survived without severe disability was 38% in the hemicraniectomy group, compared to 18% in the control group. The difference resulted largely from lower mortality in the surgery group (33% vs. 70%). No patients had a modified Rankin scale score of 0–2 (survival with no disability or slight disability); 7% of patients in the surgery group and 3% of patients in the control group had a score of 3 (moderate disability); 32% and 15%, respectively, had a score of 4 (moderately severe disability) and 28% and 13%, respectively, had a score of 5 (severe disability). Infections were more frequent in the hemicraniectomy group, and herniation was more frequent in the control group. The study was published in the March 20, 2014, issue of the New England Journal of Medicine.

“Seventy percent survive with surgery, only 30% without,” concluded lead author professor Werner Hacke, MD, PhD, chairman of the department of neurology, and colleagues. “You may survive a usually deadly stroke, but the quality of life is not always good afterwards. Patients and relatives must be involved in the decision-making, and it helps to know what the patient's preference would be.”

Hemicraniectomy is one of the most effective ways of relieving massive brain swelling and the resulting increase in intracranial pressure (ICP), which prevents blood from flowing into most of the brain, resulting in a rapid progression to brain death. The procedure consists of temporarily removing a portion of the skull (sometimes up to one half or more) in order to allow the swollen brain to expand, without causing further elevations in ICP. The part of the skull bone that is removed is typically frozen until the swelling has resolved, at which point it can be sutured back.

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