Preliminary clinical trials suggest that therapeutic hypothermia might improve the outcomes of pa... more Preliminary clinical trials suggest that therapeutic hypothermia might improve the outcomes of patients with acute stroke. Definitive trials are under way.
Based on empirical experience, hypothermia has long been known to be a potent putative neuroprote... more Based on empirical experience, hypothermia has long been known to be a potent putative neuroprotectant. Recent insights into the mechanisms of central ischemia and reperfusion suggest reasons why hypothermia may be an ideal modality for extending the time window for thrombolytic stroke therapy. Hypothermia protects brain tissue from the effects of ischemia in multiple ways. It retards energy depletion, reduces intracellular acidosis, and lessens the ischemic overdose of excitatory neurotransmitters. This attenuates the influx of intracellular calcium, the herald of subsequent neuronal death. Additionally, hypothermia suppresses synthesis of oxygen free radicals involved in secondary damage associated with reperfusion. It also suppresses the mechanisms related to blood-brain barrier degeneration and post-ischemic remodeling. Animal and human data show that deep hypothermia is primarily protective and is used in several cardiothoracic and neurosurgical applications, and that mild hypo...
Background Stroke is the fifth leading cause of death in young individuals globally. Data on the ... more Background Stroke is the fifth leading cause of death in young individuals globally. Data on the burden of sudden death by stroke are sparse in the young. Aims The aim of this study was to report mortality rates, cause of death, stroke subtype, and symptoms in children and young adults who suffered sudden death by stroke. Methods We conducted a retrospective, nationwide study including all deaths within Danish borders between 2000–2009 and 2007–2009 in persons aged 1–35 years and 36–49 years, respectively. Two physicians identified all sudden death cases through review of all death certificates. All available autopsy reports and records from hospitals and general practitioners were retrieved and a neurologist identified all sudden death by stroke cases. Results Of the 14,567 deaths in the 10-year period, there were 1,698 sudden death cases, of which 52 (3%) were sudden death by stroke. There was a male predominance (56%) and the median age was 33 years. The incidence of sudden death...
ImportanceThere is increasing interest in heart rhythm monitoring and technologies to detect subc... more ImportanceThere is increasing interest in heart rhythm monitoring and technologies to detect subclinical atrial fibrillation (AF), which may lead to incidental diagnosis of bradyarrhythmias.ObjectiveTo assess bradyarrhythmia prevalence and prognostic significance in persons screened for AF using implantable loop recorder (ILR) compared with unscreened persons.Design, Setting, and ParticipantsThis was a post hoc analysis of the Implantable Loop Recorder Detection of Atrial Fibrillation to Prevent Stroke (LOOP) randomized clinical trial, which took place in 4 sites in Denmark. Participants were 70 years or older without known AF but diagnosed with at least 1 of the following: hypertension, diabetes, heart failure, or prior stroke. Participants were recruited by letter invitation between January 31, 2014, and May 17, 2016. The median (IQR) follow-up period was 65 (59-70) months. Analysis took place between February and June 2022.InterventionsILR screening for AF with treatment of any b...
Background Erenumab is a calcitonin gene-related peptide (CGRP)-receptor antibody inhibiting CGRP... more Background Erenumab is a calcitonin gene-related peptide (CGRP)-receptor antibody inhibiting CGRP function. CGRP is prominently involved in the pathophysiology of migraine through nociceptive modulation in the trigeminovascular system. This study aims to explore the treatment effect of erenumab in a real-life setting. Methods In this retrospective observational study, we analyzed the data of 91 patients with migraine receiving at least three consecutive monthly injections of erenumab and followed up for 3–12 months. The primary objective was to describe the reduction in monthly migraine days throughout the follow-up period. To identify patients who responded to treatment, we analyzed the association between different patient characteristics and their treatment outcomes. Results Seventy-three patients (80.2%) responded to erenumab treatment, defined as ≥50% reduction of migraine days per month, across all migraine types. It was noted that ethnicity (p-value = 0.015) and older age (p-...
P60 Background and Purpose: Fluid-attenuated inversion-recovery (FLAIR)imaging sequences are gene... more P60 Background and Purpose: Fluid-attenuated inversion-recovery (FLAIR)imaging sequences are generally thought to provide superior lesion contrast over T2-weighted sequences in MR imaging of nonacute ischemic infarcts. To evaluate whether this applies to lesions in the posterior fossa in particular, we compared the conspicuity of posterior fossa infarcts negative on diffusion-weighted imaging between FLAIR and T2-weighted sequences. Methods: Administrative and Radiology databases were used to identify neurology outpatients at a tertiary care center who underwent brain MRs in 1999 demonstrating brainstem infarcts. Contrast-to-Noise Ratios (CNR = (S lesion - S background )/SD air ))were computed for the lesions on the axial fast spin echo T2-weighted and FLAIR images. Lesion conspicuity was qualitatively compared between the two imaging sequences by two stroke neurologists unaware of the study question. Results: There were 8 pontine and 13 cerebellar infarcts identified on 19 brain MR...
P233 Background Large MCA ischemic stroke when associated with extensive mass effect can result i... more P233 Background Large MCA ischemic stroke when associated with extensive mass effect can result in brain herniation and death. As yet there are no guidelines to aid the selection of patients for decompressive therapies, such as hemicraniectomy. Methods This was a multicentre retrospective study of large MCA infarction requiring neurocritical care. The repeat CT scans performed within 120 hours of stroke onset were assessed for horizontal displacement of septum pellucidum and pineal gland, the size of MCA infarction, involvement of other vascular territories and hydrocephalus. The primary outcome measure was death within 30 days. Results A total of 251 patients fulfilled entry criteria into the study of which 201 received conventional medical therapy alone. Univariate analysis identified the following predictors of early death: NIHSS >16 (P<0.03, OR 2.17 95% CI 1.12–4.2), anteroseptal shift >7 mm (P<0.001, OR 9.2 95% CI 4.1–20.63), pineal shift >3 mm (P<0.001, OR 12...
P241 Background and objective: Patients with massive hemispheric strokes are threatened by cardia... more P241 Background and objective: Patients with massive hemispheric strokes are threatened by cardiac arrhythmias secondary to autonomic dysregulation. We evaluated ECG abnormalities in patients with massive MCA infarction to identify patients at risk for cardiac complications. Methods: From the placebo arm of the LUB-INT-9 study we identified a group of 144 patients with massive anterior circulation stroke. Patients with a history of myocardial infarction, atrial fibrillation or with febrile infection within 96h after admission where excluded. 52 patients remained and were assigned according to presence or absence of temporal lobe involvement, multiple territory involvement, brainswelling in CT scan and according to outcome (death due to neurological deterioration) and side of infarction. A groupwise comparison of ECG findings between patients with presence or absence of the previous findings was performed using Wilcoxon rank sum test and considered significant with a p-value < 0.0...
Background and Purpose— Many patients with acute ischemic stroke are not eligible for thrombolysi... more Background and Purpose— Many patients with acute ischemic stroke are not eligible for thrombolysis or mechanical reperfusion therapies due to contraindications, inaccessible vascular occlusions, late presentation, or large infarct core. Sphenopalatine ganglion (SPG) stimulation to enhance collateral flow and stabilize the blood-brain barrier offers an alternative, potentially more widely deliverable, therapy. Methods— In a randomized, sham-controlled, double-masked trial at 41 centers in 7 countries, patients with anterior circulation ischemic stroke not treated with reperfusion therapies within 24 hours of onset were randomly allocated to active SPG stimulation or sham control. The primary efficacy outcome was improvement beyond expectations on the modified Rankin Scale of global disability at 90 days (sliding dichotomy), assessed in the modified intention-to-treat population. The initial planned sample size was 660 patients, but the trial was stopped early when technical improveme...
In patients with intracranial large vessel arterial occlusion, ipsilateral extracranial carotid a... more In patients with intracranial large vessel arterial occlusion, ipsilateral extracranial carotid artery occlusions or near-occlusions pose a significant hurdle in endovascular management of acute ischaemic stroke. Stenting of the carotid lesion may be beneficial in this situation to provide a stable access for introducing catheters through the carotid lesion into the intracranial vasculature and the target occlusion. Furthermore, carotid stenting may ensure ample blood flow for wash-out of clot material and reperfusion of the ischaemic penumbral tissue. However, antiplatelet therapy administered to prevent stent thrombosis and sudden increase in blood flow after reopening of the carotid lesion may increase the risk for intracranial haemorrhagic complications. This review aims to assess the benefits and harms of carotid stenting vs. no stenting assisting thrombectomy for acute ischaemic stroke. International and regional electronic databases will be searched to identify eligible rando...
Journal of nuclear medicine : official publication, Society of Nuclear Medicine, 2014
This study provides the first comprehensive quantification of translocator protein (TSPO) binding... more This study provides the first comprehensive quantification of translocator protein (TSPO) binding using SPECT and 6-chloro-2-(4'-(123)I-iodophenyl)-3-(N,N-diethyl)-imidazo[1,2-a]pyridine-3-acetamide ((123)I-CLINDE) in neurologic patients. (123)I-CLINDE is structurally related to well-known PET ligands such as (18)F-PBR111 and (18)F-DPA-714. Six patients with cerebral stroke and 4 patients with glioblastoma multiforme (GBM) underwent 150-min dynamic SPECT scans with arterial blood sampling. Four of the patients were rescanned. All patients were genotyped for the rs6971 polymorphism. Volumes of interest were delineated on the individual SPECT scans and the coregistered MR images. Compartmental and graphical models using arterial input or the cerebellum as a reference region were used to quantify (123)I-CLINDE binding. Among the 6 models investigated, the 2-tissue-compartment model with arterial input described the time-activity data best. Time-stability analyses suggested that acq...
The identification of strategies by which the central nervous system (CNS) can transform itself i... more The identification of strategies by which the central nervous system (CNS) can transform itself in response to injury has incited the systematic exploration of methods to enhance neurological recovery after CNS injury. Several pharmaceuticals have been shown to promote such recovery; however, more rigorous clinical trials are necessary to establish their clinical relevance. The major impediment for these strategies in the clinical arena is the astounding heterogeneity surrounding neuroplasticity and regeneration. Tolerance to injury and varied rates of recovery are likely governed by genetic and environmental factors that remain largely elusive. The extraordinary complexity of the neural networks in the CNS impedes the assessment of 'plain' pharmacological interventions in therapeutic trials. 'Proof-of-principle' studies of pharmacological interventions enhancing neuroplasticity or regeneration may therefore at first focus on surrogate markers, such as functional MRI...
Stroke is a leading cause of long-term disability with early accelerated followed by gradual reco... more Stroke is a leading cause of long-term disability with early accelerated followed by gradual recovery during the first 6 months after the ictus. The most important mechanism concerning early recovery is thought to be brain plasticity provided by anatomical and functional reorganization of the central nervous system after injury. Recent advances in noninvasive, functional brain imaging techniques provided some insight indicating the contribution of ipsilateral uncrossed corticospinal tracts in motor recovery after stroke. Since motor tracts vary considerably among subjects, the ratio of contralateral corticospinal tract fibers and their interhemispheric control versus the amount and function of ipsilateral corticospinal tract fibers may affect the scale of motor recovery after stroke. Further studies are needed to clarify the mechanisms of motor recovery after stroke in humans.
Background and Purpose— Hemicraniectomy and Durotomy Upon Deterioration From Infarction-Related S... more Background and Purpose— Hemicraniectomy and Durotomy Upon Deterioration From Infarction-Related Swelling Trial (HeADDFIRST) was a randomized pilot study to obtain information necessary to design a Phase III trial to evaluate the benefit of surgical decompression for brain swelling from large supratentorial cerebral hemispheric infarction. Methods— All patients with stroke were screened for eligibility (age 18–75 years, National Institutes of Health Stroke Scale ≥18 with Item 1a<2 [responsive to minor stimulation], and CT demonstrating unilateral, complete middle cerebral artery territory infarction by specific imaging criteria). All enrolled patients were treated using a standardized medical treatment protocol. Those with both ≥4 mm of pineal shift and deterioration in level of arousal or ≥7.5 mm of anteroseptal shift within 96 hours of stroke onset were randomized to continued medical treatment only or medical treatment plus surgery. Death at 21 days was the primary outcome meas...
The high early case fatality among patients with massive hemispheric strokes calls for effective ... more The high early case fatality among patients with massive hemispheric strokes calls for effective treatments. Release of the restriction created by the dura mater and bony skull to allow the infarcted brain tissue to swell has been successfully adopted by some while considered controversial by others. A recent pooled analysis provides estimates for the efficacy of decompressive surgery. Further analyses of current trial data suggest that in particular patient age and timing of surgery determine outcome. Nonetheless, in order to guide the management of individual patients, carefully adjusted medical care, ongoing futility analysis, and simultaneous caregiver meetings should be conducted to reach a joint decision addressing any ethical concerns. In conclusion, decompressive surgery increases the probability of survival but produces patients with moderate or moderately severe disability (albeit not severe disability). Currently, the decision to perform decompressive surgery should remain an individual one in each and every patient.
Preliminary clinical trials suggest that therapeutic hypothermia might improve the outcomes of pa... more Preliminary clinical trials suggest that therapeutic hypothermia might improve the outcomes of patients with acute stroke. Definitive trials are under way.
Based on empirical experience, hypothermia has long been known to be a potent putative neuroprote... more Based on empirical experience, hypothermia has long been known to be a potent putative neuroprotectant. Recent insights into the mechanisms of central ischemia and reperfusion suggest reasons why hypothermia may be an ideal modality for extending the time window for thrombolytic stroke therapy. Hypothermia protects brain tissue from the effects of ischemia in multiple ways. It retards energy depletion, reduces intracellular acidosis, and lessens the ischemic overdose of excitatory neurotransmitters. This attenuates the influx of intracellular calcium, the herald of subsequent neuronal death. Additionally, hypothermia suppresses synthesis of oxygen free radicals involved in secondary damage associated with reperfusion. It also suppresses the mechanisms related to blood-brain barrier degeneration and post-ischemic remodeling. Animal and human data show that deep hypothermia is primarily protective and is used in several cardiothoracic and neurosurgical applications, and that mild hypo...
Background Stroke is the fifth leading cause of death in young individuals globally. Data on the ... more Background Stroke is the fifth leading cause of death in young individuals globally. Data on the burden of sudden death by stroke are sparse in the young. Aims The aim of this study was to report mortality rates, cause of death, stroke subtype, and symptoms in children and young adults who suffered sudden death by stroke. Methods We conducted a retrospective, nationwide study including all deaths within Danish borders between 2000–2009 and 2007–2009 in persons aged 1–35 years and 36–49 years, respectively. Two physicians identified all sudden death cases through review of all death certificates. All available autopsy reports and records from hospitals and general practitioners were retrieved and a neurologist identified all sudden death by stroke cases. Results Of the 14,567 deaths in the 10-year period, there were 1,698 sudden death cases, of which 52 (3%) were sudden death by stroke. There was a male predominance (56%) and the median age was 33 years. The incidence of sudden death...
ImportanceThere is increasing interest in heart rhythm monitoring and technologies to detect subc... more ImportanceThere is increasing interest in heart rhythm monitoring and technologies to detect subclinical atrial fibrillation (AF), which may lead to incidental diagnosis of bradyarrhythmias.ObjectiveTo assess bradyarrhythmia prevalence and prognostic significance in persons screened for AF using implantable loop recorder (ILR) compared with unscreened persons.Design, Setting, and ParticipantsThis was a post hoc analysis of the Implantable Loop Recorder Detection of Atrial Fibrillation to Prevent Stroke (LOOP) randomized clinical trial, which took place in 4 sites in Denmark. Participants were 70 years or older without known AF but diagnosed with at least 1 of the following: hypertension, diabetes, heart failure, or prior stroke. Participants were recruited by letter invitation between January 31, 2014, and May 17, 2016. The median (IQR) follow-up period was 65 (59-70) months. Analysis took place between February and June 2022.InterventionsILR screening for AF with treatment of any b...
Background Erenumab is a calcitonin gene-related peptide (CGRP)-receptor antibody inhibiting CGRP... more Background Erenumab is a calcitonin gene-related peptide (CGRP)-receptor antibody inhibiting CGRP function. CGRP is prominently involved in the pathophysiology of migraine through nociceptive modulation in the trigeminovascular system. This study aims to explore the treatment effect of erenumab in a real-life setting. Methods In this retrospective observational study, we analyzed the data of 91 patients with migraine receiving at least three consecutive monthly injections of erenumab and followed up for 3–12 months. The primary objective was to describe the reduction in monthly migraine days throughout the follow-up period. To identify patients who responded to treatment, we analyzed the association between different patient characteristics and their treatment outcomes. Results Seventy-three patients (80.2%) responded to erenumab treatment, defined as ≥50% reduction of migraine days per month, across all migraine types. It was noted that ethnicity (p-value = 0.015) and older age (p-...
P60 Background and Purpose: Fluid-attenuated inversion-recovery (FLAIR)imaging sequences are gene... more P60 Background and Purpose: Fluid-attenuated inversion-recovery (FLAIR)imaging sequences are generally thought to provide superior lesion contrast over T2-weighted sequences in MR imaging of nonacute ischemic infarcts. To evaluate whether this applies to lesions in the posterior fossa in particular, we compared the conspicuity of posterior fossa infarcts negative on diffusion-weighted imaging between FLAIR and T2-weighted sequences. Methods: Administrative and Radiology databases were used to identify neurology outpatients at a tertiary care center who underwent brain MRs in 1999 demonstrating brainstem infarcts. Contrast-to-Noise Ratios (CNR = (S lesion - S background )/SD air ))were computed for the lesions on the axial fast spin echo T2-weighted and FLAIR images. Lesion conspicuity was qualitatively compared between the two imaging sequences by two stroke neurologists unaware of the study question. Results: There were 8 pontine and 13 cerebellar infarcts identified on 19 brain MR...
P233 Background Large MCA ischemic stroke when associated with extensive mass effect can result i... more P233 Background Large MCA ischemic stroke when associated with extensive mass effect can result in brain herniation and death. As yet there are no guidelines to aid the selection of patients for decompressive therapies, such as hemicraniectomy. Methods This was a multicentre retrospective study of large MCA infarction requiring neurocritical care. The repeat CT scans performed within 120 hours of stroke onset were assessed for horizontal displacement of septum pellucidum and pineal gland, the size of MCA infarction, involvement of other vascular territories and hydrocephalus. The primary outcome measure was death within 30 days. Results A total of 251 patients fulfilled entry criteria into the study of which 201 received conventional medical therapy alone. Univariate analysis identified the following predictors of early death: NIHSS >16 (P<0.03, OR 2.17 95% CI 1.12–4.2), anteroseptal shift >7 mm (P<0.001, OR 9.2 95% CI 4.1–20.63), pineal shift >3 mm (P<0.001, OR 12...
P241 Background and objective: Patients with massive hemispheric strokes are threatened by cardia... more P241 Background and objective: Patients with massive hemispheric strokes are threatened by cardiac arrhythmias secondary to autonomic dysregulation. We evaluated ECG abnormalities in patients with massive MCA infarction to identify patients at risk for cardiac complications. Methods: From the placebo arm of the LUB-INT-9 study we identified a group of 144 patients with massive anterior circulation stroke. Patients with a history of myocardial infarction, atrial fibrillation or with febrile infection within 96h after admission where excluded. 52 patients remained and were assigned according to presence or absence of temporal lobe involvement, multiple territory involvement, brainswelling in CT scan and according to outcome (death due to neurological deterioration) and side of infarction. A groupwise comparison of ECG findings between patients with presence or absence of the previous findings was performed using Wilcoxon rank sum test and considered significant with a p-value < 0.0...
Background and Purpose— Many patients with acute ischemic stroke are not eligible for thrombolysi... more Background and Purpose— Many patients with acute ischemic stroke are not eligible for thrombolysis or mechanical reperfusion therapies due to contraindications, inaccessible vascular occlusions, late presentation, or large infarct core. Sphenopalatine ganglion (SPG) stimulation to enhance collateral flow and stabilize the blood-brain barrier offers an alternative, potentially more widely deliverable, therapy. Methods— In a randomized, sham-controlled, double-masked trial at 41 centers in 7 countries, patients with anterior circulation ischemic stroke not treated with reperfusion therapies within 24 hours of onset were randomly allocated to active SPG stimulation or sham control. The primary efficacy outcome was improvement beyond expectations on the modified Rankin Scale of global disability at 90 days (sliding dichotomy), assessed in the modified intention-to-treat population. The initial planned sample size was 660 patients, but the trial was stopped early when technical improveme...
In patients with intracranial large vessel arterial occlusion, ipsilateral extracranial carotid a... more In patients with intracranial large vessel arterial occlusion, ipsilateral extracranial carotid artery occlusions or near-occlusions pose a significant hurdle in endovascular management of acute ischaemic stroke. Stenting of the carotid lesion may be beneficial in this situation to provide a stable access for introducing catheters through the carotid lesion into the intracranial vasculature and the target occlusion. Furthermore, carotid stenting may ensure ample blood flow for wash-out of clot material and reperfusion of the ischaemic penumbral tissue. However, antiplatelet therapy administered to prevent stent thrombosis and sudden increase in blood flow after reopening of the carotid lesion may increase the risk for intracranial haemorrhagic complications. This review aims to assess the benefits and harms of carotid stenting vs. no stenting assisting thrombectomy for acute ischaemic stroke. International and regional electronic databases will be searched to identify eligible rando...
Journal of nuclear medicine : official publication, Society of Nuclear Medicine, 2014
This study provides the first comprehensive quantification of translocator protein (TSPO) binding... more This study provides the first comprehensive quantification of translocator protein (TSPO) binding using SPECT and 6-chloro-2-(4'-(123)I-iodophenyl)-3-(N,N-diethyl)-imidazo[1,2-a]pyridine-3-acetamide ((123)I-CLINDE) in neurologic patients. (123)I-CLINDE is structurally related to well-known PET ligands such as (18)F-PBR111 and (18)F-DPA-714. Six patients with cerebral stroke and 4 patients with glioblastoma multiforme (GBM) underwent 150-min dynamic SPECT scans with arterial blood sampling. Four of the patients were rescanned. All patients were genotyped for the rs6971 polymorphism. Volumes of interest were delineated on the individual SPECT scans and the coregistered MR images. Compartmental and graphical models using arterial input or the cerebellum as a reference region were used to quantify (123)I-CLINDE binding. Among the 6 models investigated, the 2-tissue-compartment model with arterial input described the time-activity data best. Time-stability analyses suggested that acq...
The identification of strategies by which the central nervous system (CNS) can transform itself i... more The identification of strategies by which the central nervous system (CNS) can transform itself in response to injury has incited the systematic exploration of methods to enhance neurological recovery after CNS injury. Several pharmaceuticals have been shown to promote such recovery; however, more rigorous clinical trials are necessary to establish their clinical relevance. The major impediment for these strategies in the clinical arena is the astounding heterogeneity surrounding neuroplasticity and regeneration. Tolerance to injury and varied rates of recovery are likely governed by genetic and environmental factors that remain largely elusive. The extraordinary complexity of the neural networks in the CNS impedes the assessment of 'plain' pharmacological interventions in therapeutic trials. 'Proof-of-principle' studies of pharmacological interventions enhancing neuroplasticity or regeneration may therefore at first focus on surrogate markers, such as functional MRI...
Stroke is a leading cause of long-term disability with early accelerated followed by gradual reco... more Stroke is a leading cause of long-term disability with early accelerated followed by gradual recovery during the first 6 months after the ictus. The most important mechanism concerning early recovery is thought to be brain plasticity provided by anatomical and functional reorganization of the central nervous system after injury. Recent advances in noninvasive, functional brain imaging techniques provided some insight indicating the contribution of ipsilateral uncrossed corticospinal tracts in motor recovery after stroke. Since motor tracts vary considerably among subjects, the ratio of contralateral corticospinal tract fibers and their interhemispheric control versus the amount and function of ipsilateral corticospinal tract fibers may affect the scale of motor recovery after stroke. Further studies are needed to clarify the mechanisms of motor recovery after stroke in humans.
Background and Purpose— Hemicraniectomy and Durotomy Upon Deterioration From Infarction-Related S... more Background and Purpose— Hemicraniectomy and Durotomy Upon Deterioration From Infarction-Related Swelling Trial (HeADDFIRST) was a randomized pilot study to obtain information necessary to design a Phase III trial to evaluate the benefit of surgical decompression for brain swelling from large supratentorial cerebral hemispheric infarction. Methods— All patients with stroke were screened for eligibility (age 18–75 years, National Institutes of Health Stroke Scale ≥18 with Item 1a<2 [responsive to minor stimulation], and CT demonstrating unilateral, complete middle cerebral artery territory infarction by specific imaging criteria). All enrolled patients were treated using a standardized medical treatment protocol. Those with both ≥4 mm of pineal shift and deterioration in level of arousal or ≥7.5 mm of anteroseptal shift within 96 hours of stroke onset were randomized to continued medical treatment only or medical treatment plus surgery. Death at 21 days was the primary outcome meas...
The high early case fatality among patients with massive hemispheric strokes calls for effective ... more The high early case fatality among patients with massive hemispheric strokes calls for effective treatments. Release of the restriction created by the dura mater and bony skull to allow the infarcted brain tissue to swell has been successfully adopted by some while considered controversial by others. A recent pooled analysis provides estimates for the efficacy of decompressive surgery. Further analyses of current trial data suggest that in particular patient age and timing of surgery determine outcome. Nonetheless, in order to guide the management of individual patients, carefully adjusted medical care, ongoing futility analysis, and simultaneous caregiver meetings should be conducted to reach a joint decision addressing any ethical concerns. In conclusion, decompressive surgery increases the probability of survival but produces patients with moderate or moderately severe disability (albeit not severe disability). Currently, the decision to perform decompressive surgery should remain an individual one in each and every patient.
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