Monday, March 31, 2014

Journal Club: Surveillance neuroimaging and neurologic examinations affect care for intracerebral hemorrhage

Journal Club: Surveillance neuroimaging and neurologic examinations affect care for intracerebral hemorrhage
Neurology current issue

The article "Surveillance neuroimaging and neurologic examinations affect care for intracerebral hemorrhage"1 is reviewed. This review focuses on the methods, results, and limitations and merits of the original article.



Original Article: http://www.neurology.org/cgi/content/short/82/13/e108?rss=1
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Saturday, March 29, 2014

[Articles] Safety and efficacy of suvorexant during 1-year treatment of insomnia with subsequent abrupt treatment discontinuation: a phase 3 randomised, double-blind, placebo-controlled trial

[Articles] Safety and efficacy of suvorexant during 1-year treatment of insomnia with subsequent abrupt treatment discontinuation: a phase 3 randomised, double-blind, placebo-controlled trial
The Lancet Neurology

Our findings show that suvorexant was generally safe and well tolerated over 1 year of nightly treatment in patients with insomnia, with efficacy noted for subjective measures of sleep onset and maintenance.

Original Article: http://www.thelancet.com/journals/laneur/article/PIIS1474-4422(14)70053-5/abstract?rss=yes
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Chronic brain deficits may be prevented by blood-brain barrier repair after stroke

Chronic brain deficits may be prevented by blood-brain barrier repair after stroke
Neurology News & Neuroscience News from Medical News Today

Following ischemic stroke, the integrity of the blood-brain barrier (BBB), which prevents harmful substances such as inflammatory molecules from entering the brain, can be impaired in cerebral areas distant from initial ischemic insult. This disruptive condition, known as diaschisis, can lead to chronic post-stroke deficits, University of South Florida researchers report.

Original Article: http://www.medicalnewstoday.com/releases/274600.php
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MRI tracking of genes to offer insights into memory and learning

MRI tracking of genes to offer insights into memory and learning
Neurology News & Neuroscience News from Medical News Today

Doctors normally use MRI to look inside the body to examine organs and tissue, for instance to find tumors and other abnormalities. Now, biological engineers in the US want to adapt the scanning technology to work on a much smaller scale.

Original Article: http://www.medicalnewstoday.com/articles/274703.php
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Anxiolytic, Hypnotic Medications May Triple Mortality Risk

Anxiolytic, Hypnotic Medications May Triple Mortality Risk
Medscape Today- Medscape

Use of anxiolytic or hypnotic medications may triple mortality risk.
Medscape Medical News

Original Article: http://www.medscape.com/viewarticle/822716?src=rss
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ECT: Electrode Placement, Age Influence Depression Outcomes

ECT: Electrode Placement, Age Influence Depression Outcomes
Medscape Today- Medscape

In individuals with severe depression who are treated with ECT, electrode placement and patient age may have a significant influence on treatment outcomes.
Medscape Medical News

Original Article: http://www.medscape.com/viewarticle/822714?src=rss
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AANS and NREF Focus on Increasing Awareness About Traumatic Brain Injury ... - Newswise (press release)

AANS and NREF Focus on Increasing Awareness About Traumatic Brain Injury ... - Newswise (press release)
neurosurgery - Google News


AANS and NREF Focus on Increasing Awareness About Traumatic Brain Injury ...
Newswise (press release)
The spokesorganization for neurosurgery and the Neurosurgery Research and Education Foundation look to educate the public on the importance of traumatic brain injury research. Released: 3/27/2014 6:00 PM EDT Embargo expired: 3/28/2014 7:00 AM ...
Aurora Spine to Participate at American Association of Neurological Surgeons ...



Original Article: http://news.google.com/news/url?sa=t&fd=R&ct2=us&usg=AFQjCNFmzdq_rCuw4XFXDbbeOpVJs27y9A&clid=c3a7d30bb8a4878e06b80cf16b898331&cid=43982360467419&ei=r4w1U-CnEoSymQKn9gE&url=http://newswise.com/articles/aans-and-nref-focus-on-increasing-awareness-about-traumatic-brain-injury-for-2014-national-neurosurgery-awareness-week
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AHA/ASA Guideline on Palliative Care in Stroke

AHA/ASA Guideline on Palliative Care in Stroke
Medscape NeurologyHeadlines

The 'first of its kind' statement emphasizes the importance of a well-coordinated medical team to personalize care, optimize quality of life, and minimize suffering for patients with a major stroke.
Medscape Medical News

Original Article: http://www.medscape.com/viewarticle/822723?src=rss
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FDA Okays First Drug for Migraine Prevention in Adolescents

FDA Okays First Drug for Migraine Prevention in Adolescents
Medscape NeurologyHeadlines

The FDA has approved topiramate for prophylaxis of migraine in adolescents aged 12 to 17, the first such approval for this age group.
FDA Approvals

Original Article: http://www.medscape.com/viewarticle/822748?src=rss
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Mild head injuries linked to risk of death years later - Reuters UK

Mild head injuries linked to risk of death years later - Reuters UK
neurosurgery - Google News


Mild head injuries linked to risk of death years later
Reuters UK
High rates of death in the year following a severe head injury have been well documented, McMillan and his colleagues write in the Journal of Neurology, Neurosurgery and Psychiatry. But little is known about risk of death after mild head injuries and ...



Original Article: http://news.google.com/news/url?sa=t&fd=R&ct2=us&usg=AFQjCNH6REiwNJIIxg0hHImoVe9uBP6blw&clid=c3a7d30bb8a4878e06b80cf16b898331&cid=43982360848479&ei=U1Y2U7DXMYf8mAK-8wE&url=http://uk.reuters.com/article/2014/03/28/us-head-injuries-idUKBREA2R1V820140328
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Wednesday, March 26, 2014

Teaching NeuroImages: Snowball-like lesions with sudden hearing loss

Teaching NeuroImages: Snowball-like lesions with sudden hearing loss
Neurology current issue

A 53-year-old man presented with abrupt hearing loss, followed by a 4-week course of recurrent vertigo, headaches, and ataxia. Brain MRI revealed multiple punctate ischemic foci on corpus callosum (figure). Cerebral angiogram and echocardiogram were unremarkable. Susac syndrome was diagnosed following findings of branch retinal artery occlusion from fluorescein angiography (figure).



Original Article: http://www.neurology.org/cgi/content/short/82/12/e100?rss=1
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Restarting anticoagulation after intracranial hemorrhage: A risky decision with no recipe

Restarting anticoagulation after intracranial hemorrhage: A risky decision with no recipe
Neurology current issue

The decision to restart anticoagulation after an intracranial hemorrhage (ICH) always poses a challenge. It is a complex problem that we are encountering with increasing frequency because of the growing use of anticoagulants in an aging population. Many factors must be considered when making the decision and current guidelines provide little guidance on how to make it.1 Few studies address this topic and they only provide low levels of evidence.



Original Article: http://www.neurology.org/cgi/content/short/82/12/1016?rss=1
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DESTINY II: Benefit of Surgery for Stroke With Swelling

DESTINY II: Benefit of Surgery for Stroke With Swelling
Medscape NeurologyHeadlines

Final published results of the trial show that decompressive hemicraniectomy almost halved mortality rates in patients with brain edema after a large stroke.
Medscape Medical News

Original Article: http://www.medscape.com/viewarticle/822472?src=rss
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New AAN Guideline on Cannabis, Alternative Medicine in MS

New AAN Guideline on Cannabis, Alternative Medicine in MS
Medscape NeurologyHeadlines

The guideline gives some support to cannabis products but emphasizes there is little evidence for most complementary and alternative medicine in multiple sclerosis.
Medscape Medical News

Original Article: http://www.medscape.com/viewarticle/822496?src=rss
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Low Back Pain Leading Cause of Disability Worldwide: Study - Philly.com

Low Back Pain Leading Cause of Disability Worldwide: Study - Philly.com
neurosurgery - Google News


Philly.com
Low Back Pain Leading Cause of Disability Worldwide: Study
Philly.com
"Back pain is the number one cause of lost work days in the U.S," said Dr. Anders Cohen, chief of neurosurgery and spine surgery at the Brooklyn Hospital Center, in New York City. For the first study, Hoy and his colleagues reviewed 117 published ...



Original Article: http://news.google.com/news/url?sa=t&fd=R&ct2=us&usg=AFQjCNFYcfetD7JVxh_VwbGmGGaQgscyxw&clid=c3a7d30bb8a4878e06b80cf16b898331&cid=43982357273603&ei=XesxU9D3B6n2mQKP9AE&url=http://www.philly.com/philly/health/HealthDay686113_20140325_Low_Back_Pain_Leading_Cause_of_Disability_Worldwide__Study.html
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Marijuana for Epilepsy: Weighing the Evidence

Marijuana for Epilepsy: Weighing the Evidence
Medscape NeurologyHeadlines

Andrew Wilner dusts off his 2011 opinions about the use of medical marijuana and finds that, in the absence of further evidence, they are still valid today.
Medscape Neurology

Original Article: http://www.medscape.com/viewarticle/822445?src=rss
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USPSTF: No to Routine Screening for Cognitive Impairment

USPSTF: No to Routine Screening for Cognitive Impairment
Medscape NeurologyHeadlines

There is insufficient evidence to recommend routine screening for cognitive decline in older adults in the primary care setting, according to a new review by the US Preventive Services Task Force.
Medscape Medical News

Original Article: http://www.medscape.com/viewarticle/822581?src=rss
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Evaluation of Common Structural Brain Changes in Aging and Alzheimer Disease with the Use of an MRI-Based Brain Atrophy and Lesion Index: A Comparison Between T1WI and T2WI at 1.5T and 3T

Evaluation of Common Structural Brain Changes in Aging and Alzheimer Disease with the Use of an MRI-Based Brain Atrophy and Lesion Index: A Comparison Between T1WI and T2WI at 1.5T and 3T
AJNR Blog

Editor's Choice

March 2014

(2 of 3)

This study assesses the usefulness of a set of established structural findings in Alzheimer disease with various MRI sequences at 2 different field strengths in 127 subjects. Scores of atrophy and lesion burden were reliable across sequences and unit strength and were lowest in individuals with cognitive impairment, higher in those with Alzheimer disease, and also correlated with age, cognitive performance, and amyloid-β test. Although the results were slightly better at 3T, the authors concluded that even at 1.5T scores were reliable.

EIC signature

Abstract

BACKGROUND AND PURPOSE
The Brain Atrophy and Lesion Index combines several common, aging-related structural brain changes and has been validated for high-field MR imaging. In this study, we evaluated measurement properties of the Brain Atrophy and Lesion Index by use of T1WI and T2WI at 1.5T and 3T MR imaging to comprehensively assess the usefulness of the lower field-strength testing.

MATERIALS AND METHODS
Data were obtained from the Alzheimer's Disease Neuroimaging Initiative. Images of subjects (n = 127) who had T1WI and T2WI at both 3T and 1.5T on the same day were evaluated, applying the Brain Atrophy and Lesion Index rating. Criterion and construct validity and interrater agreement were tested for each field strength and image type.

RESULTS
Regarding reliability, the intraclass correlation coefficients for the Brain Atrophy and Lesion Index score were consistently high (>0.81) across image type and field strength. Regarding construct validity, the Brain Atrophy and Lesion Index score differed among diagnostic groups, being lowest in people without cognitive impairment and highest in those with Alzheimer disease (F > 5.14; P < .007). Brain Atrophy and Lesion Index scores correlated with age (r > 0.37, P < .001) and cognitive performance (r > 0.38, P < .001) and were associated with positive amyloid-β test (F > 3.96, P < .050). The T1WI and T2WI Brain Atrophy and Lesion Index scores were correlated (r > 0.93, P < .001), with the T2WI scores slightly greater than the T1WI scores (F > 4.25, P < .041). Regarding criterion validation of the 1.5T images, the 1.5T scores were highly correlated with the 3T Brain Atrophy and Lesion Index scores (r > 0.93, P < .001).

CONCLUSIONS
The higher field and T2WI more sensitively detect subtle changes in the deep white matter and perivascular spaces in particular. Even so, 1.5T Brain Atrophy and Lesion Index scores are similar to those obtained by use of 3T images. The Brain Atrophy and Lesion Index may have use in quantifying the impact of dementia on brain structures.

Full text

The post Evaluation of Common Structural Brain Changes in Aging and Alzheimer Disease with the Use of an MRI-Based Brain Atrophy and Lesion Index: A Comparison Between T1WI and T2WI at 1.5T and 3T appeared first on AJNR Blog.



Original Article: http://www.ajnrblog.org/2014/03/26/evaluation-common-structural-brain-changes-aging-alzheimer-disease-use-mri-based-brain-atrophy-lesion-index-comparison-t1wi-t2wi-1-5t-3t/
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Sunday, March 23, 2014

Do No Harm: Stories of Life, Death and Brain Surgery review - The Guardian

Do No Harm: Stories of Life, Death and Brain Surgery review - The Guardian
neurosurgery - Google News


The Guardian
Do No Harm: Stories of Life, Death and Brain Surgery review
The Guardian
I worked as a junior neurosurgical trainee once, at the bottom of what he calls "the strict medical hierarchy", and realised then that living with such responsibility is not just onerous, it utterly transforms the lives of those who bear it. It's ...



Original Article: http://news.google.com/news/url?sa=t&fd=R&usg=AFQjCNEmAeRyvHYU0FtzNQ1dEH6ruKSuPw&cid=c3a7d30bb8a4878e06b80cf16b898331&url=http://www.theguardian.com/books/2014/mar/19/do-no-harm-brain-surgery-henry-marsh-review
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Preconditioning Effect on Cerebral Vasospasm in Patients With Aneurysmal Subarachnoid Hemorrhage

Preconditioning Effect on Cerebral Vasospasm in Patients With Aneurysmal Subarachnoid Hemorrhage
Neurosurgery - Current Issue

imageBACKGROUND: Recent experimental evidence indicates that endogenous mechanisms against cerebral vasospasm can be induced via preconditioning. OBJECTIVE: To determine whether these vascular protective mechanisms are also present in vivo in humans with aneurysmal subarachnoid hemorrhage. METHODS: A multicenter retrospective cohort of patients with aneurysmal subarachnoid hemorrhage was examined for ischemic preconditioning stimulus: preexisting steno-occlusive cerebrovascular disease (CVD) and/or previous cerebral infarct. Generalized estimating equation models were performed to determine the effect of the preconditioning stimulus on the primary end points of radiographic vasospasm, symptomatic vasospasm, and vasospasm-related delayed cerebral infarction and the secondary end point of discharge modified Rankin Scale score. RESULTS: Of 1043 patients, 321 (31%) had preexisting CVD and 437 (42%) had radiographic vasospasm. Patients with preexisting CVD were less likely to develop radiographic vasospasm (odds ratio = 0.67; 95% confidence interval = 0.489-0.930; P = .02) but had no differences in other end points. In terms of the secondary end point, patients with preexisting CVD did not differ significantly from patients without preexisting CVD in mortality or unfavorable outcome in multivariate analyses, although patients with preexisting CVD were marginally more likely to die (P = .06). CONCLUSION: This retrospective case-control study suggests that endogenous protective mechanisms against cerebral vasospasm—a preconditioning effect—may exist in humans, although these results could be the effect of atherosclerosis or some combination of preconditioning and atherosclerosis. Additional studies investigating the potential of preconditioning in aneurysmal subarachnoid hemorrhage are warranted. ABBREVIATIONS: aSAH, aneurysmal subarachnoid hemorrhage CI, confidence interval CVD, cerebrovascular disease mRS, modified Rankin Scale OR, odds ratio VCI, vasospasm-related delayed cerebral infarction

Original Article: http://journals.lww.com/neurosurgery/Fulltext/2014/04000/Preconditioning_Effect_on_Cerebral_Vasospasm_in.10.aspx
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Intraobserver and Interobserver Agreement in Visual Inspection for Xanthochromia: Implications for Subarachnoid Hemorrhage Diagnosis, Computed Tomography Validation Studies, and the Walton Rule

Intraobserver and Interobserver Agreement in Visual Inspection for Xanthochromia: Implications for Subarachnoid Hemorrhage Diagnosis, Computed Tomography Validation Studies, and the Walton Rule
Neurosurgery - Current Issue

BACKGROUND: Visual inspection for xanthochromia is used to diagnose subarachnoid hemorrhage (SAH), to validate computed tomography subarachnoid hemorrhage diagnosis and was used to determine the Walton rule. No study has assessed the reliability of xanthochromia. OBJECTIVE: To determine intraobserver and interobserver xanthochromia agreement. METHODS: Mock cerebrospinal fluid samples contained increasing concentrations of human oxyhemoglobin, bilirubin, and albumin. Non-color-blind observers randomly assessed samples against a white background twice under significantly differing illumination. Specimens were recorded as red, orange, yellow, or clear. RESULTS: Results were obtained for 26 observers (11 male, 15 female observers). We found that 19.2% of samples were misclassified: red, 11.7%; orange, 28.5%; yellow, 29.6%; and clear, 22.1% (χ2 = 213.2; P < .001). Of the yellow misclassifications, 88% were misclassified as clear. Female observers correctly classified samples significantly more frequently than male observers (P = .03). Intraobserver agreement differed significantly from expected for both male (χ2 = 105.6; P < .001) and female (χ2 = 99.9; P < .001) observers regardless of illumination. Interobserver agreement was poor regardless of sex (χ2 for male observers = 176.96, P < .001; χ2 for female observers = 182.69, P < .001) or illumination (χ2 for bright = 125.64, P < .001; χ2 for dark = 148.48, P < .001). Overall, there was 75% agreement in 46% of the tests and 90% agreement in only 36% of the tests. CONCLUSION: This simple laboratory study would be expected to maximize agreement relative to clinical practice. Although non-color-blind female observers significantly outperformed non-color-blind male observers, both intraobserver agreement and interobserver agreement for xanthochromia were prohibitively poor regardless of sex or illumination. Yellow was most frequently misclassified, 88% as clear (ie, true positives were commuted to false negatives). Xanthochromia is therefore highly unreliable for subarachnoid hemorrhage diagnosis and computed tomography validation. The Walton rule requires urgent clinical revalidation. Abbreviation: SAH, subarachnoid hemorrhage

Original Article: http://journals.lww.com/neurosurgery/Fulltext/2014/04000/Intraobserver_and_Interobserver_Agreement_in.15.aspx
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The Dentate Nucleus and Its Projection System in the Human Cerebellum: The Dentate Nucleus Microsurgical Anatomical Study

The Dentate Nucleus and Its Projection System in the Human Cerebellum: The Dentate Nucleus Microsurgical Anatomical Study
Neurosurgery - Current Issue

imageBACKGROUND: Neurosurgical management of cerebellar lesions remains challenging. Thus, it is important to have sound knowledge of the microsurgical anatomy of the cerebellum and dentate nucleus (DN) and to define different types of exposure in a variety of surgical interventions. OBJECTIVE: To examine the anatomy of the DN from a neurosurgical viewpoint using fiber tracking techniques. METHODS: Ten formalin-fixed human hemispheres were dissected with the Ludwig and Klingler fiber dissection technique under × 6 to × 40 magnification. Anatomic images were created with 3-dimensional diffusion tensor imaging. The relationships of the DN to tentorium and suboccipital and lateral surfaces of the cerebellum and its spatial positioning relative to different surgical approaches in the cerebellum and fourth ventricle were examined. The fiber tracts terminating at and surrounding the DN were defined. RESULTS: The DN is at greater risk of being injured in the transvermian and supratonsillar approaches to the cerebellum and fourth ventricle, with lesser risk in the telovelar and subtonsillar approaches. Superior approaches are safer compared with other approaches. CONCLUSION: The DN represents an important anatomic structure in surgical interventions involving the posterior fossa, particularly in the elderly because of the common occurrence of atrophy-related problems in this age group. Functionally and anatomically, the DN is closely related to the superior and middle cerebellar peduncles. The inferior cerebellar peduncle poses positional risks because it follows an anterior and superior course relative to the DN. The telovelar approach is a safer procedure for interventions involving the pathological lesions of the fourth ventricle floor. ABBREVIATIONS: DN, dentate nucleus DTI, diffusion tensor imaging

Original Article: http://journals.lww.com/neurosurgery/Fulltext/2014/04000/The_Dentate_Nucleus_and_Its_Projection_System_in.16.aspx
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High Rate of Inappropriate Imaging for Headache

High Rate of Inappropriate Imaging for Headache
Medscape NeurologyHeadlines

Around $1 billion per year is spent on neuroimaging for headaches in the United States, despite the fact that this is not recommended practice, a new study has found.
Medscape Medical News

Original Article: http://www.medscape.com/viewarticle/822199?src=rss
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Quality of life changes during the pre- to postdiagnosis period and treatment-related recovery time in older women with breast cancer

Quality of life changes during the pre- to postdiagnosis period and treatment-related recovery time in older women with breast cancer
Cancer

BACKGROUND

Health care providers have little population-based evidence about health-related quality of life (HRQOL) changes, from the pre- to postdiagnosis period, and treatment-related recovery time for women aged 65 years and older diagnosed with breast cancer.

METHODS

Older women with and without breast cancer completed self-reports of HRQOL at baseline and 2 years later as part of annual Medicare Health Outcomes Surveys (MHOS). MHOS was linked to Surveillance, Epidemiology, and End Results registries, which were used to categorize women with breast cancer by treatment type (breast-conserving surgery, breast-conserving surgery plus radiation, mastectomy) and time since diagnosis at follow-up. Each cancer case diagnosed in 1998 through 2007 (N = 542) was matched to 5 women without cancer (N = 2710) using propensity score matching. Analysis of covariance models examined changes in HRQOL, adjusting for demographics and initial functioning.

RESULTS

Older women within 6 months of diagnosis had greater declines than women without cancer in SF-36 Physical (−5.8 vs −1.8) and Mental (−3.6 vs −0.7) Component Summary scores, General Health (−12.3 vs −4.6), Vitality (−11.0 vs −2.2), Bodily Pain (−8.5 vs −2.1), Social Functioning (−15.1 vs −3.3), Role-Physical (−26.5 vs −3.9), and Role-Emotional (−13.1 vs −3.1) scores (all P < .05). By approximately 1 year, women with and without breast cancer had similar HRQOL. Comparable declines in Physical Component Summary and Role-Physical occurred across treatment types.

CONCLUSIONS

Women aged 65 years and older diagnosed with breast cancer should be counseled that survivors within 6 months of diagnosis are vulnerable to HRQOL declines, compared to women without breast cancer, but that decrements generally wane after 12 months. Cancer 2014. © 2014 American Cancer Society.



Original Article: http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1002/cncr.28649
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New Guidelines Extend Statins to 13M More Americans

New Guidelines Extend Statins to 13M More Americans
Medscape Today- Medscape

Of the 12.8 million Americans who would be eligible under the new ACC/AHA cholesterol guidelines, more than 10 million new prescriptions would be for patients in primary prevention.
Heartwire

Original Article: http://www.medscape.com/viewarticle/822210?src=rss
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Indications and Usefulness of Nerve Biopsy

Indications and Usefulness of Nerve Biopsy
Neurosurgery Blog

Progress in neurophysiology and neurogenetics as well as previous neuropathological findings have all improved our knowledge of the pathophysiological characteristics of peripheral nerve disorders.1- 3 Thanks to these improvements, the indications of nerve biopsy have decreased during the past decade, making this invasive procedure unnecessary in the vast majority of patients with peripheral neuropathy.

However, a recent prospective study has shown that nerve biopsy improves treatment in an estimated 60% of patients,4 a figure close to that of an earlier retrospective study.5 The yield of nerve biopsy depends on a number of factors, including selection of patients, expertise of the laboratory, and techniques used. In this article, I will briefly review the main indications and factors that can increase the usefulness of nerve biopsy.

The post Indications and Usefulness of Nerve Biopsy appeared first on NEUROSURGERY BLOG.



Original Article: http://neurocirurgiabr.com/indications-and-usefulness-of-nerve-biopsy/?utm_source=rss&utm_medium=rss&utm_campaign=indications-and-usefulness-of-nerve-biopsy
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Learning and memory: Don't forget the CA2

Learning and memory: Don't forget the CA2
Nature Reviews Neuroscience - Issue - nature.com science feeds

Nature Reviews Neuroscience 15, 204 (2014). doi:10.1038/nrn3719

Author: Sian Lewis

The CA2 region of the hippocampus is a disynaptic gateway between the entorhinal cortex and CA1. This study showed that in adult mice, selective inactivation of CA2 pyramidal cell output resulted in the loss of memory of a previously encountered conspecific but had no effect



Original Article: http://feeds.nature.com/~r/nrn/rss/current/~3/M_n_b4iNhLI/nrn3719
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Saturday, March 22, 2014

DESTINY II: Hemicraniectomy in Older Patients with Extensive Middle-Cerebral-Artery Stroke

DESTINY II: Hemicraniectomy in Older Patients with Extensive Middle-Cerebral-Artery Stroke
Neurosurgery Blog

Hemicraniectomy in Older Patients with Extensive Middle-Cerebral-Artery Stroke

Eric Jüttler, M.D., Ph.D., Andreas Unterberg, M.D., Ph.D., Johannes Woitzik, M.D., Ph.D., Julian Bösel, M.D., Hemasse Amiri, M.D., Oliver W. Sakowitz, M.D., Ph.D., Matthias Gondan, Ph.D., Petra Schiller, Ph.D., Ronald Limprecht, Steffen Luntz, M.D., Hauke Schneider, M.D., Ph.D., Thomas Pinzer, M.D., Ph.D., Carsten Hobohm, M.D., Jürgen Meixensberger, M.D., Ph.D., and Werner Hacke, M.D., Ph.D. for the DESTINY II Investigators

N Engl J Med 2014; 370:1091-1100March 20, 2014DOI: 10.1056/NEJMoa1311367

Background

Early decompressive hemicraniectomy reduces mortality without increasing the risk of very severe disability among patients 60 years of age or younger with complete or subtotal space-occupying middle-cerebral-artery infarction. Its benefit in older patients is uncertain.

Methods

We randomly assigned 112 patients 61 years of age or older (median, 70 years; range, 61 to 82) with malignant middle-cerebral-artery infarction to either conservative treatment in the intensive care unit (the control group) or hemicraniectomy (the hemicraniectomy group); assignments were made within 48 hours after the onset of symptoms. The primary end point was survival without severe disability (defined by a score of 0 to 4 on the modified Rankin scale, which ranges from 0 [no symptoms] to 6 [death]) 6 months after randomization.

Results

Hemicraniectomy improved the primary outcome; the proportion of patients who survived without severe disability was 38% in the hemicraniectomy group, as compared with 18% in the control group (odds ratio, 2.91; 95% confidence interval, 1.06 to 7.49; P=0.04). This difference resulted from lower mortality in the surgery group (33% vs. 70%). No patients had a modified Rankin scale score of 0 to 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 [requirement for assistance with most bodily needs]); 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.

Conclusions

Hemicraniectomy increased survival without severe disability among patients 61 years of age or older with a malignant middle-cerebral-artery infarction. The majority of survivors required assistance with most bodily needs. (Funded by the Deutsche Forschungsgemeinschaft; DESTINY II Current Controlled Trials number, ISRCTN21702227.)

http://www.nejm.org/doi/full/10.1056/NEJMoa1311367?query=featured_home

 

 

The post DESTINY II: Hemicraniectomy in Older Patients with Extensive Middle-Cerebral-Artery Stroke appeared first on NEUROSURGERY BLOG.



Original Article: http://neurocirurgiabr.com/destiny-ii-hemicraniectomy-in-older-patients-with-extensive-middle-cerebral-artery-stroke/?utm_source=rss&utm_medium=rss&utm_campaign=destiny-ii-hemicraniectomy-in-older-patients-with-extensive-middle-cerebral-artery-stroke
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