JOURNAL READING

Rhadezahara M. Patrisa, S.Ked (1408010068)

dr. Donny Argie , Sp. BS

SURGERY DEPARTMENT – RSUD PROF DR. W.Z JOHANNES KUPANG

FACULTY MEDICINE –NUSA CENDANA UNIVERSITY
2019
Introduction

Therefore, a decompressive
There is a clinical perception that
craniectomy is offered to relieve
The emergence of brain swelling when brain swelling occurs in the
the mass effect of the swollen
is the most troublesome and cerebral or cerebellar
hemisphere on the thalamus,
even life-threatening hemisphere, medical
brainstem, and network
consequence of a large-territory management to reduce brain
projections to the cortex,
ischemic stroke swelling is not successful in
manifested mainly by a
changing outcome
decreased level of arousal

Clinical experience has matured

This scientific statement
over the years, but there are
addresses the early approach to
uncertainties about how to
the patient with a swollen
approach a patient with
ischemic stroke in the
neuroimaging and clinical
cerebellum and cerebral
evidence of emerging brain
hemisphere
swelling after an ischemic stroke.
METHODS
Methods

The writers used systematic literature reviews

The panel reviewed the most relevant articles on

adults through computerized searches of the
medical literature using MEDLINE, EMBASE, and
Web of Science through March 2013.

The evidence is organized within the context of the

AHA framework and is classified according to the
joint AHA/American College of Cardiology and
supplementary AHA Stroke
EPIDEMIOLOGY
The prevalence of hemispheric MCA infarction by these variable definitions has been
reported to be 2% to 8% of all hospitalized ischemic stroke, 10% to 15% of all MCA
territory ischemic stroke and 18% to 31% of all ischemic stroke caused by MCA
occlusion.

A population-based study estimated that 0.3% of all ischemic stroke patients may
be eligible for decompressive craniectomy on the basis of criteria used in
randomized, controlled trials.

The actual frequency of decompressive craniectomy for malignant MCA infarction is

estimated to have increased from 0.04% of all ischemic stroke admissions in 1999 to
2000 to 0.14% of all ischemic stroke admissions in 2007 to 2008.
Epidemiology: Recommendations

■ 1. Standardized terms and ■ 2. Additional data should be

definitions for severe hemispheric collected to determine the use of
and cerebellar edema resulting decompressive craniectomy in
from infarction should be current clinical practice, including
established to facilitate multicenter whether there is variation by
and population-based studies of physician, hospital, health system,
incidence, prevalence, risk factors, or patient characteristics and
and outcomes (Class I; Level of preferences (Class I; Level of
Evidence C). Evidence C).
DEFINITION AND CLINICAL
PRESENTATION
Hemispheric Cerebellar
Stroke Stroke

Hemorrhagic
Transformation
of Strokes
Definition and Clinical Presentation:
Recommendations

Patients with or at high risk for infarction and swelling should be

identified through the use of clinical data, including vessel occlusion
status (Class I; Level of Evidence B).
NEUROIMAGING
Neuroimaging CT Imaging
■ Cerebral infarction is characterized ■ A noncontrast CT scan of the brain
by progressive cerebral edema and is the first-line diagnostic test to
mass effect, with ipsilateral sulcal exclude nonvascular, structural,
effacement, compression of the intracranial lesions as the cause of
ipsilateral ventricular system, and the focal neurological symptoms; to
then a shift of the midline differentiate between brain
structures such as the septum ischemia and hemorrhage; to
pellucidum and the pineal gland ascertain the cause and prognosis;
and to guide immediate
intervention.
MRI Imaging Other Imaging
■ MRI can be substituted for CT, but it ■ Transcranial Doppler sonography
is less widely available and there has been suggested as a
are more contraindications for use noninvasive method of monitoring
(including metal implants, cardiac elevated ICP in patients with large
pacemakers, and unstable infarctions. An increase in pulsatility
patients). indexes has been shown to
correlate with midline shift and
outcome. Transcranial Doppler
sonography provides information for
detecting cerebral herniation and
deciding on the medical or surgical
therapy.
Neuroimaging: Recommendations
1. Frank hypodensity on head CT within the first 6 hours, involvement of one third or
more of the MCA territory, and early midline shift are CT findings that are useful in
predicting cerebral edema (Class I; Level of Evidence B).

2. The measurement of MRI DWI volume within 6 hours is useful, and volumes (≥80
mL) predict rapid fulminant course (Class I; Level of Evidence B).

3. A noncontrast CT scan of the brain is a useful first- line diagnostic test and modality
of choice to monitor patients with hemispheric cerebral or cerebellar infarcts with
swelling. Serial CT findings in the first 2 days are useful to identify patients at high
risk for developing symptomatic swelling (Class I; Level of Evidence C).
TRIAGE
■ Before any intervention is undertaken, an appropriate triage should be
established.

■ If a full resuscitative status and comprehensive medical care are

warranted in a patient with a large territorial stroke, admission to a
unit with neuromonitoring capabilities is needed.

■ Neurosurgical consultation should be sought early to facilitate

planning of decompressive surgery or ventriculostomy with
decompressive surgery (in the case of cerebellar infarction) if the
patient deteriorates.

■ Early identification of patients who may experience swelling and

consequent transfer to a center with a higher level of care should be
initiated urgently if comprehensive care is agreed on and cannot be
provided.
Triage: Recommendations
1. Transfer to an intensive care or stroke unit is recommended for
patients with a large territorial stroke to plan close monitoring and
comprehensive treatment (Class I; Level of Evidence C).

2. Triage to a higher level center is reasonable if comprehensive care

and timely neurosurgical intervention are not available locally (Class
IIa; Level of Evidence C).
AIRWAY AND MECHANICAL
VENTILATION
■ The most common reason for endotracheal intubation and mechanical ventilation is
a decline in consciousness and an inability to maintain a patent airway, leading to
inadequate ventilation.
■ The mortality of mechanically ventilated patients after hemispheric ischemic stroke
is increased, but most studies were performed before decompressive craniectomy.
■ An adequate mean arterial blood pressure should be maintained at all times,
although an evidence-based target level is not established.
■ Mechanical ventilation may be needed after decompressive surgery.
■ Weaning is dependent on the alertness of the patient, among other respiratory
physiological parameters, but early extubation in patients with a decompressive
craniectomy for cerebellar infarcts can be problematic because of abnormal
oropharyngeal function, lack of strong cough, and copious thick secretions.
Airway and Mechanical Ventilation: Recommendations

1. Maintaining normocarbia is reasonable (Class IIa; Level of Evidence

C).
2. Intubation may be considered for patients with decreased levels of
consciousness resulting in poor oxygenation or impaired control of
secretions (Class IIb; Level of Evidence C).
3. Prophylactic hyperventilation is not recommended (Class III; Level of
Evidence C).
 AIRHEMODYNAMIC
SUPPORT AND BLOOD
PRESSURE MANAGEMENT
Hemodynamic Support Blood Pressure Management
■ Maintenance fluid management in ■ Acute hypertension is a frequent
patients with acute hemispheric or accompanying clinical sign in any
stroke.
cerebellar strokes includes the use
of isotonic saline and the avoidance ■ Hypotension is far less common
of hypo-osmolar fluids. and points to an associated medical
or surgical problem.
■ Fluids without dextrose are
preferred. ■ Hemispheric stroke with marked
blood pressure changes may be
■ Some groups have suggested using attributable to unusual
crystalloids and colloids to ensure circumstances such as an aortic
adequate cerebral perfusion dissection or myocardial infarction,
and further diagnostic tests might
pressure63 and normovolemia. be necessary.
Hemodynamic Support and Blood Pressure
Management: Recommendations
1. Aggressive treatment of worsening cardiac arrhythmias with appropriate
medications and continued cardiac monitoring is recommended (Class I; Level of
Evidence C).
2. 2. There are insufficient data to recommend a specific systolic or mean arterial
blood pressure target. Blood pressure–lowering drugs may be considered for the
treatment of extreme hypertension. Specific blood pressure targets are not
established (Class IIb; Level of Evidence C).
3. 3. Use of adequate fluid administration with isotonic fluids might be considered
(Class IIb; Level of Evidence C).
4. 4. Hypotonic or hypo-osmolar fluids are not recommended (Class III; Level of
Evidence C).
5. 5. Use of prophylactic osmotic diuretics before apparent swelling is not
recommended (Class III; Level of Evidence C)
 GLUCOSE
MANAGEMENT
■ Hyperglycemia is associated with increased edema in patients with
cerebral ischemia and with an increased risk of hemorrhagic
transformation.
■ The ideal glucose target after a large hemispheric stroke is unknown.
■ The European Stroke Initiative29 suggested avoiding hyperglycemia
defined as exceeding a glucose of 180 mg/dL3,4,98 or aiming for
glucose within normal ranges.
■ A recent randomized study in ischemic stroke found an increase in
infarct size with aggressive control (aiming at glucose <126 mg/dL or
<7 mmol/L).
Glucose Management: Recommendations
1. Hyperglycemia should be avoided, and glucose levels between 140
and 180 mg/dL are recommended (Class I; Level of Evidence C).
2. Tight glycemic control (glucose <110 mg/dL) is not indicated, but an
insulin infusion may be used to avoid significant hyperglycemia (Class
IIb; Level of Evidence C).
3. Hypoglycemia should be avoided at all times (Class III; Level of
Evidence C).
TEMPERATURE
MANAGEMENT
■ Fever is uncommon after ischemic stroke and may more often indicate
early infection rather than a stress response.
■ Normothermia is preferred, but therapeutic hypothermia has not been
sufficiently studied prospectively.
■ There is insufficient research to recommend early hypothermia for the
treatment of ischemic stroke.
■ Temperature management has evolved, and the use of cooling
devices has increased.
■ The development of early fever after a hemispheric or cerebellar
stroke warrants complete assessment for an infectious or a drug-
induced cause.
Temperature Management:
Recommendations
1. Temperature management is part of basic support, and a normal
temperature is reasonable (Class IIa; Level of Evidence C).
2. The effectiveness of the use of therapeutic hypothermia before brain
swelling is not known (Class IIb; Level of Evidence C)
ICP MANAGEMENT
■ Clinical deterioration is more often the result of displacement of midline structures
such as the thalamus and the brainstem than of a mechanism of globally increased
ICP.
■ There is sufficient evidence that ICP is not increased in the early days after
presentation with a hemispheric infarct.
■ There does not appear to be any value of ICP monitoring or placement of a
ventriculostomy in a patient presenting early with a large supratentorial swollen
hemispheric stroke.
■ Even in patients with deterioration from cerebral edema, ICP values may remain <20
mm Hg, suggesting that displacement from mass effect is the likely mechanism.
■ In patients with a cerebellar stroke with early swelling, acute hydrocephalus may
occur.
■ Placement of a ventriculostomy for the treatment of acute hydrocephalus in most
cases is accompanied by suboccipital decompressed craniectomy.
ICP Management: Recommendations

1. Routine ICP monitoring is not indicated in hemispheric ischemic

stroke (Class III; Level of Evidence C).
2. Ventriculostomy is recommended in obstructive hydrocephalus after a
cerebellar infarct but should be followed or accompanied by
decompressive craniectomy (Class I; Level of Evidence C).
MISCELLANEOUS
MEDICAL
■ Measures as a result of the substantial risk of hemorrhagic conversion or
development of an expanding hematoma, it is common practice to reverse an
increased international normalized ratio in a patient on warfarin, but only after
carefully judging the risks of not anticoagulating the patient.
■ There are no data indicating whether slow reversal of warfarin, for example,
discontinuation of warfarin versus use of vitamin K and fresh-frozen plasma or other
hemostatic agents, decreases the risk of hemorrhagic conversion.
■ Because of the risk of hemorrhagic transformation, the combination of aspirin and
clopidogrel is typically discontinued.
■ Intravenous heparin is avoided, but subcutaneous heparin or low-molecular-weight
heparin is necessary to prevent deep venous thrombosis, even if there is some
hemorrhagic conversion or early edema on CT scan.
■ Seizures are uncommon after a hemispheric infarct, but any patient with a
fluctuating level of consciousness may require more prolonged
electroencephalography monitoring to exclude that possibility.
■ There is no evidence of benefit in using seizure prophylaxis.
Miscellaneous Medical Measures:
Recommendations
1. Deep venous thrombosis prophylaxis with subcutaneous or low-
molecular-weight heparin should be used (Class I; Level of Evidence
C).
2. Intravenous heparin or combination antiplatelet agents are not
recommended in patients with swollen strokes (Class III; Level of
Evidence C).
3. Seizure prophylaxis in patients without seizures at presentation is not
indicated (Class III; Level of Evidence C).
RECOGNITION OF
DETERIORATION
■ The most commonly described signs in deterioration from hemispheric
supratentorial infarction are ipsilateral pupillary dysfunction, varying degrees of
mydriasis, and adduction paralysis.
■ Generally, deterioration in a supratentorial hemispheric infarct may present in 2
ways. Clinically, it may present with a gradual progressive rostrocaudal deterioration
(development of midposition pupils, worsening of motor responses, and progression
to irregular breathing and death) or more suddenly present with a unilaterally dilated
pupil progressing to bilateral pupils followed by decreasing motor response from
localization to flexion rigidity.
■ Deterioration from swelling or extension of the infarct into the brainstem cannot be
clinically distinguished, but many patients develop pupillary anisocoria, pinpoint
pupils, and loss of oculocephalic responses.
■ Further brainstem compression may lead to bradycardia, irregular breathing
patterns, and sudden apnea.
Recognition of Deterioration:
Recommendations
1. Clinicians should frequently monitor level of arousal and ipsilateral
pupillary dilation in patients with supratentorial ischemic stroke at
high risk for deterioration. Gradual development of midposition pupils
and worsening of motor response may also indicate deterioration
(Class I; Level of Evidence C).
2. Clinicians should frequently monitor for level of arousal or new
brainstem signs in patients with cerebellar stroke at high risk for
deterioration (Class I; Level of Evidence C).
MEDICAL OPTIONS IN A
DETERIORATED PATIENT
■ Several immediate measures are needed to treat a deteriorating patient.
■ In the absence of increased ICP in patients deteriorating from swelling of
supratentorial hemispheric infarcts, measures to reduce ICP may not be beneficial.
■ Osmotic therapy works mostly through an osmotic gradient and draws water out of
neurons into arteries, leading to vasoconstriction and reduced cerebrovascular
volume.
■ Mannitol has been used both as a single dose and in recurrent bolus form such as
mannitol 15 g once; 0.5 to 1 g/kg76,120; mannitol 1.0 g/kg70; and 0.5 g/kg every
4 to 6 hours.
■ Hypertonic saline has been used at a variety of doses and concentrations (3%, 7.5%,
23%).
■ Similarly, neither the dose of corticosteroids nor its efficacy has been studied
systematically, and the dose used in studies varied greatly.
■ Corticosteroids have been administered to reduce brain swelling, but a recent
Cochrane review concluded after review of 8 clinical trials that there was no benefit
on mortality or functional outcome.
Medical Options: Recommendations

1. Osmotic therapy for patients with clinical deterioration from cerebral

swelling associated with cerebral infarction is reasonable (Class IIa;
Level of Evidence C).
2. There are insufficient data on the effect of hypothermia, barbiturates,
and corticosteroids in the setting of ischemic cerebral or cerebellar
swelling, and they are not recommended (Class III; Level of Evidence
C)
NEUROSURGICAL OPTIONS
IN A DETERIORATED
PATIENT
■ Surgical treatment of the swelling associated with cerebellar or cerebral infarctions is
performed by removal of the skull and expansion of the dura to alleviate the volume
constraints of the cranial vault during the acute swelling phase of the infarction.

■ Most clinical series have used a combination of clinical and radiologic worsening when
deciding on surgery. The time interval to surgery does not seem to affect outcome.
■ The value of preemptive surgery (ie, when swelling and hydrocephalus progress on CT
scan in a clinically stable patient) and the best neurosurgical approach (ie, removal of
necrotic tissue versus decompression alone versus decompression and ventriculostomy)
are not known.
Neurosurgical Options:
Recommendations
1. In patients <60 years of age with unilateral MCA infarctions that deteriorate
neurologically within 48 hours despite medical therapy, decompressive craniectomy
with dural expansion is effective. The effect of later decompression is not known,
but it should be strongly considered (Class I; Level of Evidence B).
2. Although the optimal trigger for decompressive craniectomy is unknown, it is
reasonable to use a decrease in level of consciousness and its attribution to brain
swelling as selection criteria (Class IIa; Level of Evidence A).
3. The efficacy of decompressive craniectomy in patients >60 years of age and the
optimal timing of surgery are uncertain (Class IIb; Level of Evidence C).
4. Suboccipital craniectomy with dural expansion should be performed in patients with
cerebellar infarctions who deteriorate neurologically despite maximal medical
therapy (Class I; Level of Evidence B).
BIOMARKERS
Serum Biomarkers Other Biomarkers

■ Circulating markers that relate to ■ In addition to circulating proteins,

the BBB have been studied most other investigational biomarkers
extensively, reflecting the central include invasive intracranial
role that the integrity of the BBB monitoring with microdialysis,
may play in the development of flumazenil imaging with positron
cerebral edema. emission tomography, and
continuous electroencephalography.
■ Other reports using biomarkers to
predict edema include cellular ■ Microdialysis probe placements
fibronectin, a constituent of the adjacent to hemispheric infarcts
basal lamina. Cellular fibronectin have revealed decreases in
elevations of >16.6 μg/mL predict extracellular amino acids in
edema with 90% sensitivity and infarction compared with
100% specificity. nonmalignant edema.
Biomarkers: Recommendations

1. The usefulness of serum biomarkers as predictors of ischemic brain

swelling is not well established (Class IIb; Level of Evidence C).
2. The usefulness of electrophysiological studies as predictors of
deterioration after a hemispheric stroke is not well established (Class
IIb; Level of Evidence C).
OUTCOME AND FAMILY
DISCUSSION
■ Mortality after large ischemic strokes with cerebral edema has remained between
20% and 30% despite medical and surgical interventions.
■ Outcome assessed years after hemispheric stroke is not available, but continuously
improving quality of life has been described.
■ There is a discrepancy between physical disability and quality of life, with many
patients and families rating a good quality of life despite severe functional handicap.
■ Decision making is shared between physicians and families, and discussion is of
paramount importance. Families have the burden of predicting what the patient
would want in this situation, but that usually is the best guide for decision making.
■ In discussion with family members, it is important to discuss the possibility of
depression, lack of initiative, irritability, disinhibition, and being wheelchair-bound.
Simple designations such as “survived but handicapped,” “survived but walks with a
cane,” or “cannot tell” are ambiguous and not helpful in decision making.
Outcome and Family Discussion:
Recommendations
1. Clinicians may discuss with family members that half of the surviving
patients with massive hemispheric infarctions, even after
decompressive craniectomy, are severely disabled and a third are
fully dependent on care (Class IIb; Level of Evidence C).
2. Clinicians may discuss with family members that the outcome after
cerebellar infarct can be good after suboccipital craniectomy (Class
IIb; Level of Evidence C).
SUMMARY
 Strokes that swell require The main principles have been well
immediate close attention, and defined and involve avoidance of
medical and surgical options have permanent brainstem injury from
been proposed. brain tissue shift.

Medical options have not been In surviving patients, morbidity can be

validated well, but neurosurgical substantial in a third of the patients,
management of hemispheric but the remaining patients have good
supratentorial strokes has been potential for recovery after
tested prospectively in clinical trials. rehabilitation.
THANK YOU…