VIENNA – Decompressive hemicraniectomy for malignant middle cerebral artery infarction was associated with high rates of in-hospital and late complications in a clinical practice setting, according to research reported at the annual European Stroke Conference.
The retrospective findings showed that 88.1% of the 48 patients who underwent the surgery experienced complications such as intracranial hemorrhage (ICH) or symptomatic epilepsy while hospitalized, and 89.5% experienced complications in the later months of their recovery.
While these complication rates are higher than those seen in the randomized controlled clinical studies, the operation still proved life saving for many, with in-hospital and overall mortality rates of 12.5% and 14.6%, respectively, which is similar to the mortality rate seen in the DESTINY trial (Stroke 2007;38:2518-25) after 6 months.
Dr. Hans-Werner Pledl
“Patients who underwent [decompressive hemicraniectomy] are a complication-prone collective”, said Dr. Hans-Werner Pledl, resident physician at the department of neurology, UniversitätsMedizin Mannheim, University of Heidelberg (Germany). “Especially in the elderly, recovery stays limited in relevant factors such as ambulation and conversation for self-sufficiency,” he added.
To date, four clinical trials – DECIMAL (Stroke 2007;38:2506-17), HAMLET (Lancet Neurol 2009;8:326-33) and DESTINY and DESTINY II (Int J Stroke 2011;6:79-86) – have looked at the efficacy and safety of DHC in small numbers of patients with life-threatening middle cerebral artery (MCA) infarction. Of these, only DESTINY II included patients over 60 years of age so while there was evidence that the pressure-relieving surgery reduced mortality if performed early, albeit with an increase in functional disability, experience in older patients was less clear. To look at the complication rates in a real-world practice setting, Dr. Pledl of University Hospital Mannheim’s stroke unit, examined the medical records of 48 patients with MCA infarction who underwent DHC between 2008 and 2014. At the time of admission, the 21 male and 27 female patients were aged 28 to 70 years, with the mean age being 57 years. Dr. Pledl noted that two out of every five (41.7%) patients was over the age of 60 years.
On average, patients were referred to the stroke unit within 3 hours and 44 minutes of the incident event, but some were seen within 30 minutes and others within 5 days. A total of 43.8% of patients had an MCA infarction involving the dominant hemisphere and just under 60% received thrombolytic therapy with rtPA. The median time to surgery was 1.3 days, with just over one-fifth (21.7%) of patients undergoing DHC more than 48 hours after their stroke.
The median National Institutes of Health Stroke Scale scores at admission and discharge were 19 and 18, respectively, while the modified Rankin Scale (mRS) score was 5 at both time points. The Barthel Index was 0 at admission, signifying that the patient was heavily dependent on a carer to perform basic living activities, and 7.5 at discharge, indicating some only marginal improvement in patients’ independence.
The majority (75%) of patients achieved reasonable recovery with early (phase B) rehabilitation, 44% with continued poststroke (phase C) rehabilitation, and 6% were able to become self-sufficient and some even returning to work (phase D). “Remarkably, nearly half (48.9%) of patients return home after rehabilitation and do not stay in a clinical or institutional care facility,” Dr. Pledl said.
In-hospital neurological or psychiatric complications included ICH (seven patients), symptomatic epilepsy (six patients), and delirium (five patients). Perioperative complications included meningitis (three patients), wound healing disorders (three patients), and two patients had epidural hemorrhage (EDH). Common infections included pneumonia (13 patients) and urinary tract infections (UTI, eight patients), and other complications included anemia (14 patients) and cardiac complications (nine patients).
During the recovery phase, the most common neurological or psychiatric complications were central pain syndrome and symptomatic epilepsy, affecting nine patients each. Patients again experienced EDH (five patients), with some cases of hydrocephalus (four patients) and wound-healing problems (three patients). UTIs were the most common type of infection, seen in 14 patients. Other late complications included dysphagia (41.7%) and tracheostomy (35.4%), and post-rehab depression (54.2%).
Dr. Pledl suggested that the findings could be used to help better inform patients and their carers so they can have “realistic expectations” of the procedure’s likely outcomes and decide whether or not to have the surgery performed. These “real world” data could also help physicians to be more aware of the likely complications and perhaps address them in some way so that they have minimal impact on patients’ quality of life.
Although patients who experienced complications in this study were not asked if they regretted the decision to undergo the surgery, there is evidence to show that patients and carers can accept a significant level of disability without having significantly impaired quality of life. Nevertheless, the decision on whether DHC should be performed should be made on an individual case basis, especially in older patients, Dr. Pledl concluded.