Decompressive surgery at an ischemic insult

[cherry@fosta.ge]

Mortality at extensive polusharnom an infarct of a brain about 80 % (in the Russian Federation, I I think, more). From 30 up to 50 % within the first month perish from a wet brain. Medicamental treatment actually is absent. Surgical decompression (gemikraniektomija) can be zhiznespasajushchej operation, but at the same time can increase or enlarge quantity or amount survived with serious physical inability. Three RKI proceed, one is finished, but results are not published. (http: // www.strokecenter.org/trials/InterventionDetail.asp? therapyName=ints/intPage69.htm) whether there Is an experience of surgical decompression at extensive polusharnyh infarcts of a brain to Russia and what attitude or relation to this intervention in the world?

Yours faithfully.

[monky2004]

Three RKI proceed, one is finished, but results are not published. [/URL] whether there Is an experience of surgical decompression at extensive polusharnyh infarcts of a brain to Russia and what attitude or relation to this intervention in the world?

Yours faithfully.



In the world you have written what opinion - go RKI, which (my opinion, by experience previous:)) will not give any *quot; ??aON?y?u*quot; result.



In Russia experience I think that small. At me in Institute we sometimes use decompression in similar situations - naprime at SAK - klippirovanii aneurysms - the expressed vasospasm - a secondary ischemia. Results - to put it mildly not strongly please, functional survival rate bad though the general or common is better.



Experience (not so randomizirovannyj) speaks Japanese that the survival rate grows, and here *quot; fuktsionalnaja oU??oaN??Oy*quot; is not present - i.e. it is similar to ours.



PS - by experience of results up to these on spent RKI in surgery and neurosurgery in particular - it seems to me that in difference from therapy (a cardiology, a neurology, etc., etc.) - RKI in surgery while look or appear *quot; a deadlock branch Yo????*quot;, so-called *quot; ON?O?yOaOU*quot; usually: first do not give the final answer; secondly variability of surgeons (we shall recollect hotjaby CEA trials where among conclusions separation of surgeons dominated over complications, etc.) very or very much influences; in the third - surgery all the same it *quot; Y?????o*quot; and *quot; ??n??o*quot; in high comprehension of this word:)

[kitten]

Experience (not so randomizirovannyj) speaks Japanese that the survival rate grows, and here *quot; fuktsionalnaja oU??oaN??Oy*quot; is not present - i.e. it is similar to ours.

It not absolutely so. Here, for example: (http: // www.ncbi.nlm.nih.gov/entrez/query.fcgi? cmd=Retrieve*amp; db=pubmed*amp; dopt=Abstract*amp; list_uids=15518850)

Mori K, Nakao Y, Yamamoto T, Maeda M. Early external decompressive craniectomy with duroplasty improves functional recovery in patients with massive hemispheric embolic infarction: timing and indication of decompressive surgery for malignant cerebral infarction. Surg Neurol. 2004 Nov; 62 (5):420-9



Department of Neurosurgery, Juntendo University, Izunagaoka Hospital, Shizuoka, Japan.



BACKGROUND: Extensive cerebral hemispheric infarction associated with massive brain swelling is known as malignant infarction because of the rapid clinical deterioration and mortality as high as 80 % unless appropriate treatment is performed. Decompressive craniectomy is an effective treatment, but patient selection, timing, functional recovery, and complications remain unclear. METHODS: Seventy-one patients with massive embolic hemispheric infarctions (infarct volume *gt; 200 cm (3)) associated with brain swelling were retrospectively divided into 3 groups according to the therapeutic modalities: 21 patients were treated conservatively (conservative group); 50 patients were treated by external decompressive craniectomy with duroplasty in 2 groups; 29 patients treated after the appearance of clinical and radiologic findings of brain herniation (late surgery group); and 21 patients treated before the onset of brain herniation (early surgery group). RESULTS: The mortality at 1 and 6 months in the conservative group were 61.9 % and 71.4 %, respectively. The mortality at 1 and 6 months in the late surgery group were significantly improved to 17.2 % and 27.6 %, respectively, (p *lt; 0.01) and in the early surgery group were further improved to 4.8 % and 19.1 %, respectively. The functional recovery of the patients was estimated by the Glasgow Outcome Scale (GOS) and Barthel Index (BI) at 6 months after the ictus. The GOS scores of the early surgery group were significantly better than that of the late surgery group (p *lt; 0.05). The mean BI score of the survivors in the late surgery group (26.9 +/-30.4) was not significantly different from that of the conservative group (28.3 +/-42.2), but was significantly improved in the early surgery group (52.9 +/-34.2) compared with the late surgery group (p *lt; 0.05). CONCLUSIONS: Early decompressive craniectomy with duroplasty before the onset of brain herniation should be performed to achieve satisfactory functional recovery if the infarct volume of the hemispheric cerebral infarction is more than 200 cm (3) and computed tomography on the second day after the ictus shows mass effect.



Or here the German experience (http: // www.ncbi.nlm.nih.gov/entrez/query.fcgi? cmd=Retrieve*amp; db=pubmed*amp; dopt=Abstract*amp; list_uids=14742603). Impresses - 188 patients! Among patients till 50 years quantity or amount survived with a decent functional outcome through 6 mes almost 35 %. Or here the last year's regular review (http: // www.ncbi.nlm.nih.gov/entrez/query.fcgi? cmd=Retrieve*amp; db=pubmed*amp; dopt=Abstract*amp; list_uids=14707232): a mortality + serious physical inability among "young" - 32 % (As otsenivalili disability - on abstraktu it is not clear).

All this, certainly, only experience and at all randomizirovannyj, but Some questions of rest do not give. Whether after such data ethically to include patients till 50 years in RKI? Even, if the functional outcome does not improve (that, IMHO, it is poorly probable - an another matter what there is no correlation with survival rate) at depression of a mortality in 2 - 3 times (and in absolute digits almost on 45 %) whether is had we is right to refuse now this intervention? Compare about the PULMONARY ventilation at patients to a serious insult - on survival rate and a functional outcome of influence is not present, what - these patients not intubirovat and to not ventilate or fan?



By experience of results up to these on spent RKI in surgery and neurosurgery in particular - it seems to me that in difference from therapy (a cardiology, a neurology, etc., etc.) - RKI in surgery while look or appear *quot; a deadlock branch Yo????*quot;, so-called *quot; ON?O?yOaOU*quot; usually: first do not give the final answer; secondly variability of surgeons (we shall recollect hotjaby CEA trials where among conclusions separation of surgeons dominated over complications, etc.) very or very much influences; in the third - surgery all the same it *quot; Y?????o*quot; and *quot; ??n??o*quot; in high comprehension of this word:) do not judge strictly, I not the surgeon, but am how much complex or difficult technically gemikraniektomija what to not be reproduced more or less equally for carrying out RKI? Really coronary shunting less complex or difficult intervention?

Yours faithfully.

[Irina Tishchenko]

That's just the point, that *quot; at one Oa?ONO*quot; and others are not present and... As a result of the majority of researches it is received:

Results of surgical treatment in patients *lt; 50 years of age undergoing decompressive craniectomy are encouraging. The effectiveness of decompressive craniectomy for patients *gt; 50 years remains questionable and should be analysed in the framework of a prospective randomised study.



And after carrying out of these or it PRS - the conclusion usually sounds as conclusions from ISUIA (1998) Data on treatment-related morbidity and mortality rates according to aneurysmal size and location and specific symptoms are required

to determine whether surgical or endovascular intervention may be warranted in various subgroups of patients with unruptured intracranial aneurysms,

including those with acutely symptomatic unruptured aneurysms.



In general - while it in surgery *quot; not so ?O?aNO?n*quot;.



In occasion of yours of questions:

1) the PULMONARY ventilation and surgery all the same different methods (while at least historically it so has developed:)) Except for that is in fact we shall reanimate all over again, and then we understand *quot; from what ONa????Ooa??*quot;, and if to understand from the beginning (before performance by all known ABC) at us the lethality from poperhivanija an ossicle or a bonelet becomes 100 %;



2) it is ethic/is unethical or is ethic/unethically - I do not know (not the expert or auditeur). Mine t.z. - it is better to ask *quot; that want On?OoN????*quot; - if want *quot; survival*quot; at any cost - there are no problems, it is possible and gemikraniektomiju if want *quot; functional outcome - i.e. GOS 4/5*quot; is absolutely other conversation. And by the way, just on these questions RKI will not give the unequivocal answer for this patient...



3) In occasion of operation - she primitive with t.z. Neurosurgery, but rather travmatichnaja (the big cut or section and dissektsija the big area of tissues) for critically sick patient (therefore, I think that in all nerandomizirovannyh researches is available huge selection bias on *quot; to the general or common state of health a?N?Oa*quot;. AKSH with this t.z. Unequivocally more complex or difficult and hi-tech operation. About indposhiv I wrote not for this situation, and in general about surgery:)



- break in insults it is necessary to search for my opinion in prophylaxis, corrections of original causes, fast diagnostics and effective methods emergency reperfuzii ishimizirovannyh territories. Strongly I doubt that at a massive insult on MCA it is possible to talk in general about *quot; functional oU??oaN??O?*quot; if to approach or suit to concept function with narrow-minded t.z.. Interesting the conclusion from German job looks or appears, the link on which you have given (it where 188 patients):

The side of the infarct did not have prognostic relevance

They then measured what function;)???

[The loony]

PULMONARY ventilation and surgery all the same different methods (while at least historically it so has developed:)) Except for that is in fact we shall reanimate all over again, and then we understand *quot; from what ONa????Ooa??*quot;, and if to understand from the beginning (before performance by all known ABC) at us the lethality from poperhivanija an ossicle or a bonelet becomes 100 %

The example about the PULMONARY ventilation, certainly, not direct analogy, but intubirovat these patients is necessary to the extremity or end of the first day...

Mine t.z. - it is better to ask *quot; that want On?OoN????*quot; - if want *quot; survival*quot; at any cost - there are no problems, it is possible and gemikraniektomiju if want *quot; functional outcome - i.e. GOS 4/5*quot; is absolutely other conversation. That wanted by relatives of the patient of 45 years? And what will be a functional outcome through 3 - 5 years - who knows? In occasion of operation - she primitive with t.z. Neurosurgery, but rather travmatichnaja (the big cut or section and dissektsija the big area of tissues Means, there is a chance, what results RKI will really primenimy?

- break in insults it is necessary to search for my opinion in prophylaxis, corrections of original causes, fast diagnostics and effective methods emergency reperfuzii ishimizirovannyh territories. Certainly, it is good to be rich and healthy, but By the way, a thrombolysis at these patients, spend reluctantly.

Interesting the conclusion from German job looks or appears, the link on which you have given (it where 188 patients):

The citation: The side of the infarct did not have prognostic relevance

They then measured what function??? Can, simply sick with an infarct of not dominant or prepotent hemisphere operated is more often, and with dominant or prepotent selected *quot; most ?a?UO*quot;?. How much or As far as in general the outcome at an insult depends from *quot; the right - ?No*quot; localizations?

Yours faithfully.