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

Eric Jüttler; Andreas Unterberg; Johannes Woitzik; Julian Bösel; Hemasse Amiri; Oliver W. Sakowitz; Matthias Gondan; Petra Schiller; Ronald Limprecht; Steffen Luntz; Hauke Schneider; Thomas Pinzer; Carsten Hobohm; Jürgen Meixensberger; Werner Hacke

doi:10.1056/nejmoa1311367

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

Eric Jüttler, Andreas Unterberg, Johannes Woitzik, Julian Bösel, Hemasse Amiri, Oliver W. Sakowitz, Matthias Gondan, Petra Schiller, Ronald Limprecht, Steffen Luntz, Hauke Schneider, Thomas Pinzer, Carsten Hobohm, Jürgen Meixensberger, Werner Hacke

339 Citations (Scopus)

Abstract

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.

Original language	English
Journal	New England Journal of Medicine
Volume	370
Issue number	12
Pages (from-to)	1091-1100
Number of pages	10
ISSN	0028-4793
DOIs	https://doi.org/10.1056/nejmoa1311367
Publication status	Published - 2014

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10.1056/nejmoa1311367

https://www.nejm.org/doi/pdf/10.1056/NEJMoa1311367?articleTools=true

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Jüttler, E., Unterberg, A., Woitzik, J., Bösel, J., Amiri, H., Sakowitz, O. W., Gondan, M., Schiller, P., Limprecht, R., Luntz, S., Schneider, H., Pinzer, T., Hobohm, C., Meixensberger, J., & Hacke, W. (2014). Hemicraniectomy in Older Patients with Extensive Middle-Cerebral-Artery Stroke. New England Journal of Medicine, 370(12), 1091-1100. https://doi.org/10.1056/nejmoa1311367

Jüttler, E, Unterberg, A, Woitzik, J, Bösel, J, Amiri, H, Sakowitz, OW, Gondan, M, Schiller, P, Limprecht, R, Luntz, S, Schneider, H, Pinzer, T, Hobohm, C, Meixensberger, J & Hacke, W 2014, 'Hemicraniectomy in Older Patients with Extensive Middle-Cerebral-Artery Stroke', New England Journal of Medicine, vol. 370, no. 12, pp. 1091-1100. https://doi.org/10.1056/nejmoa1311367

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title = "Hemicraniectomy in Older Patients with Extensive Middle-Cerebral-Artery Stroke",

abstract = "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.",

author = "Eric J{\"u}ttler and Andreas Unterberg and Johannes Woitzik and Julian B{\"o}sel and Hemasse Amiri and Sakowitz, {Oliver W.} and Matthias Gondan and Petra Schiller and Ronald Limprecht and Steffen Luntz and Hauke Schneider and Thomas Pinzer and Carsten Hobohm and J{\"u}rgen Meixensberger and Werner Hacke",

year = "2014",

doi = "10.1056/nejmoa1311367",

language = "English",

volume = "370",

pages = "1091--1100",

journal = "New England Journal of Medicine",

issn = "0028-4793",

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T1 - Hemicraniectomy in Older Patients with Extensive Middle-Cerebral-Artery Stroke

AU - Jüttler, Eric

AU - Unterberg, Andreas

AU - Woitzik, Johannes

AU - Bösel, Julian

AU - Amiri, Hemasse

AU - Sakowitz, Oliver W.

AU - Gondan, Matthias

AU - Schiller, Petra

AU - Limprecht, Ronald

AU - Luntz, Steffen

AU - Schneider, Hauke

AU - Pinzer, Thomas

AU - Hobohm, Carsten

AU - Meixensberger, Jürgen

AU - Hacke, Werner

PY - 2014

Y1 - 2014

N2 - 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.

AB - 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.

U2 - 10.1056/nejmoa1311367

DO - 10.1056/nejmoa1311367

M3 - Journal article

C2 - 24645942

SN - 0028-4793

VL - 370

SP - 1091

EP - 1100

JO - New England Journal of Medicine

JF - New England Journal of Medicine

IS - 12

ER -

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

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