Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
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Safety and Efficacy of Hypothermia (34℃) after Hemicraniectomy for Malignant MCA Infarction

  • Park, Hyun-Seok (Department of Neurosurgery, Busan-Ulsan Regional Cardio-Cerebrovascular Center, Medical Science Research Center, Dong-A University College of Medicine) ;
  • Choi, Jae-Hyung (Department of Neurosurgery, Busan-Ulsan Regional Cardio-Cerebrovascular Center, Medical Science Research Center, Dong-A University College of Medicine)
  • Received : 2016.11.17
  • Accepted : 2017.07.31
  • Published : 2018.03.01
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Abstract

Objective : The beneficial effect of hypothermia after hemicraniectomy in malignant middle cerebral artery (MCA) infarction has been controversial. We aim to investigate the safety and clinical efficacy of hypothermia after hemicraniectomy in malignant MCA infarction. Methods : From October 2012 to February 2016, 20 patients underwent hypothermia (Blanketrol III, Cincinnati Sub-Zero, Cincinnati, OH, USA) at $34^{\circ}C$ after hemicraniectomy in malignant MCA infarction (hypothermia group). The indication of hypothermia included acute cerebral infarction >2/3 of MCA territory and a Glasgow coma scale (GCS) score <11 with a midline shift >10 mm or transtentorial herniation sign (a fixed and dilated pupil). We retrospectively collected 27 patients, as the control group, who had undergone hemicraniectomy alone and simultaneously met the inclusion criteria of hypothermia between January 2010 and September 2012, before hypothermia was implemented as a treatment strategy in Dong-A University Hospital. We compared the mortality rate between the two groups and investigated hypothermia-related complications, such as postoperative bleeding, pneumonia, sepsis and arrhythmia. Results : The age, preoperative infarct volume, GCS score, National institutes of Health Stroke Scale score, and degree of midline shift were not significantly different between the two groups. Of the 20 patients in the hypothermia group, 11 patients were induced with hypothermia immediately after hemicraniectomy and hypothermia was initiated in 9 patients after the decision of hypothermia during postoperative care. The duration of hypothermia was $4{\pm}2days$ (range, 1 to 7 days). The side effects of hypothermia included two patients with arrhythmia, one with sepsis, one with pneumonia, and one with hypotension. Three cases of hypothermia were discontinued due to these side effects (one sepsis, one hypotension, and one bradycardia). The mortality rate of the hypothermia group was 15.0% and that of the control group was 40.7% (p=0.056). On the basis of the logistic regression analysis, hypothermia was considered to contribute to the decrease in mortality rate (odds ratio, 6.21; 95% confidence interval, 1.04 to 37.05; p=0.045). Conclusion : This study suggests that hypothermia after hemicraniectomy is a viable option when the progression of patients with malignant MCA infarction indicate poor prognosis.

Keywords

References

  1. Bernard SA, Buist M : Induced hypothermia in critical care medicine: a review. Crit Care Med 31 : 2041-2051, 2003 https://doi.org/10.1097/01.CCM.0000069731.18472.61
  2. Bernard SA, Jones BM, Horne MK : Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest. Ann Emerg Med 30 : 146-153, 1997 https://doi.org/10.1016/S0196-0644(97)70133-1
  3. Berrouschot J, Sterker M, Bettin S, Koster J, Schneider D : Mortality of spaceoccupying ('malignant') middle cerebral artery infarction under conservative intensive care. Intensive Care Med 24 : 620-623, 1998 https://doi.org/10.1007/s001340050625
  4. Clark DL, Penner M, Orellana-Jordan IM, Colbourne F : Comparison of 12, 24 and 48 h of systemic hypothermia on outcome after permanent focal ischemia in rat. Exp Neurol 212 : 386-392, 2008 https://doi.org/10.1016/j.expneurol.2008.04.016
  5. De Georgia MA, Krieger DW, Abou-Chebl A, Devlin TG, Jauss M, Davis SM, et al. : Cooling for acute ischemic brain damage (COOL AID): a feasibility trial of endovascular cooling. Neurology 63 : 312-317, 2004 https://doi.org/10.1212/01.WNL.0000129840.66938.75
  6. Den Hertog HM, van der Worp HB, Tseng MC, Dippel DW : Cooling therapy for acute stroke. Cochrane Database Syst Rev (1) : CD001247, 2009
  7. Els T, Oehm E, Voigt S, Klisch J, Hetzel A, Kassubek J : Safety and therapeutical benefit of hemicraniectomy combined with mild hypothermia in comparison with hemicraniectomy alone in patients with malignant ischemic stroke. Cerebrovasc Dis 21 : 79-85, 2006 https://doi.org/10.1159/000090007
  8. Frank JI : Large hemispheric infarction, deterioration, and intracranial pressure. Neurology 45 : 1286-1290, 1995 https://doi.org/10.1212/WNL.45.7.1286
  9. Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R : 'Malignant' middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol 53 : 309-315, 1996 https://doi.org/10.1001/archneur.1996.00550040037012
  10. Heiss WD : Malignant MCA Infarction: pathophysiology and imaging for early diagnosis and management decisions. Cerebrovasc Dis 41 : 1-7, 2016 https://doi.org/10.1159/000446380
  11. Hemmen TM, Raman R, Guluma KZ, Meyer BC, Gomes JA, Cruz-Flores S, et al. : Intravenous thrombolysis plus hypothermia for acute treatment of ischemic stroke (ICTuS-L): final results. Stroke 41 : 2265-2270, 2010 https://doi.org/10.1161/STROKEAHA.110.592295
  12. Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp HB, et al. : Surgical decompression for space-occupying cerebral infarction (the hemicraniectomy after middle cerebral artery infarction with life-threatening edema trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol 8 : 326-333, 2009 https://doi.org/10.1016/S1474-4422(09)70047-X
  13. Juttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, et al. : Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY): a randomized, controlled trial. Stroke 38 : 2518-2525, 2007 https://doi.org/10.1161/STROKEAHA.107.485649
  14. Juttler E, Unterberg A, Woitzik J, Bosel J, Amiri H, Sakowitz OW, et al. : Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 370 : 1091-1100, 2014 https://doi.org/10.1056/NEJMoa1311367
  15. Kammersgaard LP, Rasmussen BH, Jorgensen HS, Reith J, Weber U, Olsen TS : Feasibility and safety of inducing modest hypothermia in awake patients with acute stroke through surface cooling: a case-control study: the copenhagen stroke study. Stroke 31 : 2251-2256, 2000 https://doi.org/10.1161/01.STR.31.9.2251
  16. Kollmar R, Blank T, Han JL, Georgiadis D, Schwab S : Different degrees of hypothermia after experimental stroke: short- and long-term outcome. Stroke 38 : 1585-1589, 2007 https://doi.org/10.1161/STROKEAHA.106.475897
  17. Kollmar R, Schabitz WR, Heiland S, Georgiadis D, Schellinger PD, Bardutzky J, et al. : Neuroprotective effect of delayed moderate hypothermia after focal cerebral ischemia: an MRI study. Stroke 33 : 1899-1904, 2002 https://doi.org/10.1161/01.STR.0000019603.29818.9C
  18. Krieger DW, De Georgia MA, Abou-Chebl A, Andrefsky JC, Sila CA, Katzan IL, et al. : Cooling for acute ischemic brain damage (cool aid): an open pilot study of induced hypothermia in acute ischemic stroke. Stroke 32 : 1847-1854, 2001 https://doi.org/10.1161/01.STR.32.8.1847
  19. Lyden PD, Allgren RL, Ng K, Akins P, Meyer B, Al-Sanani F, et al. : Intravascular cooling in the treatment of stroke (ICTuS): early clinical experience. J Stroke Cerebrovasc Dis 14 : 107-114, 2005 https://doi.org/10.1016/j.jstrokecerebrovasdis.2005.01.001
  20. Martin-Schild S, Hallevi H, Shaltoni H, Barreto AD, Gonzales NR, Aronowski J, et al. : Combined neuroprotective modalities coupled with thrombolysis in acute ischemic stroke: a pilot study of caffeinol and mild hypothermia. J Stroke Cerebrovasc Dis 18 : 86-96, 2009 https://doi.org/10.1016/j.jstrokecerebrovasdis.2008.09.015
  21. Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, et al. : Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest. N Engl J Med 369 : 2197-2206, 2013 https://doi.org/10.1056/NEJMoa1310519
  22. Park CK, Jun SS, Kim MC, Kang JK : Effects of systemic hypothermia and selective brain cooling on ischemic brain damage and swelling. Acta Neurochir Suppl 71 : 225-228, 1998
  23. Poca MA, Benejam B, Sahuquillo J, Riveiro M, Frascheri L, Merino MA, et al. : Monitoring intracranial pressure in patients with malignant middle cerebral artery infarction: is it useful? J Neurosurg 112 : 648-657, 2010 https://doi.org/10.3171/2009.7.JNS081677
  24. Schwab S, Georgiadis D, Berrouschot J, Schellinger PD, Graffagnino C, Mayer SA : Feasibility and safety of moderate hypothermia after massive hemispheric infarction. Stroke 32 : 2033-2035, 2001 https://doi.org/10.1161/hs0901.095394
  25. Schwab S, Schwarz S, Spranger M, Keller E, Bertram M, Hacke W : Moderate hypothermia in the treatment of patients with severe middle cerebral artery infarction. Stroke 29 : 2461-2466, 1998 https://doi.org/10.1161/01.STR.29.12.2461
  26. Shaw CM, Alvord EC Jr, Berry RG : Swelling of the brain following ischemic infarction with arterial occlusion. Arch Neurol 1 : 161-177, 1959 https://doi.org/10.1001/archneur.1959.03840020035006
  27. Silver FL, Norris JW, Lewis AJ, Hachinski VC : Early mortality following stroke: a prospective review. Stroke 15 : 492-496, 1984 https://doi.org/10.1161/01.STR.15.3.492
  28. Tahir RA, Pabaney AH : Therapeutic hypothermia and ischemic stroke: a literature review. Surg Neurol Int 7(Suppl 14) : S381-S386, 2016 https://doi.org/10.4103/2152-7806.183492
  29. Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A, et al. : Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 6 : 215-222, 2007 https://doi.org/10.1016/S1474-4422(07)70036-4
  30. Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, et al. : Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 38 : 2506-2517, 2007 https://doi.org/10.1161/STROKEAHA.107.485235
  31. van der Worp HB, Macleod MR, Kollmar R; European Stroke Research Network for Hypothermia (EuroHYP) : Therapeutic hypothermia for acute ischemic stroke: ready to start large randomized trials? J Cereb Blood Flow Metab 30 : 1079-1093, 2010 https://doi.org/10.1038/jcbfm.2010.44
  32. van der Worp HB, Sena ES, Donnan GA, Howells DW, Macleod MR : Hypothermia in animal models of acute ischaemic stroke: a systematic review and meta-analysis. Brain 130(Pt 12) : 3063-3074, 2007 https://doi.org/10.1093/brain/awm083
  33. Wijdicks EF, Sheth KN, Carter BS, Greer DM, Kasner SE, Kimberly WT, et al. : Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the american heart association/american stroke association. Stroke 45 : 1222-1238, 2014 https://doi.org/10.1161/01.str.0000441965.15164.d6
  34. Yanamoto H, Nagata I, Niitsu Y, Zhang Z, Xue JH, Sakai N, et al. : Prolonged mild hypothermia therapy protects the brain against permanent focal ischemia. Stroke 32 : 232-239, 2001 https://doi.org/10.1161/01.STR.32.1.232

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