J Korean Neurosurg Soc.  2018 Mar;61(2):267-276. 10.3340/jkns.2016.1111.002.

Safety and Efficacy of Hypothermia (34°C) after Hemicraniectomy for Malignant MCA Infarction

• Park HS
• Choi JH

• KMID: 2408029
• DOI: http://doi.org/10.3340/jkns.2016.1111.002

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°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±2 days (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.

Keyword

Hypothermia; Decompressive craniecotmy; Cerebral infarction; Middle cerebral artery; Brain edema; Mortality

MeSH Terms

Arrhythmias, Cardiac
Brain Edema
Cerebral Infarction
Glasgow Coma Scale
Hemorrhage
Humans
Hypotension
Hypothermia*
Infarction
Infarction, Middle Cerebral Artery*
Logistic Models
Middle Cerebral Artery
Mortality
National Institutes of Health (U.S.)
Pneumonia
Postoperative Care
Prognosis
Retrospective Studies
Sepsis
Stroke
Treatment Outcome

Figure

• 

  Fig. 1 A : Apparent diffusion coefficient map of magnetic resonance (MR) image demonstrating an acute cerebral infarction in the right MCA territory. B : MR angiography showing occlusions of right internal carotid artery and MCA. C : One day after admission, the patient underwent decompressive hemicraniectomy because his neurological symptoms worsened. D : Four days after hemicraniectomy, his mentality worsened to stupor showing a marked midline shift on the follow-up CT. E : Four days after hypothermia treatment, follow-up CT revealing an improved state of cerebral oedema. F : The patient underwent cranioplasty 3 months after hemicraniectomy, follow-up CT. MCA : middle cerebral artery, CT : computed tomography.

• 

  Fig. 2 A : Magnetic resonance (MR) image showing a large acute infarction in the right MCA territory at admission. B : MR angiography demonstrating an occlusion of right internal carotid artery terminus portion. C : One day after admission, the patient underwent decompressive hemicraniectomy due to an increase of cerebral oedema with haemorrhagic transformation. D : One day after hemicraniectomy, his mentality worsened from drowsy to stupor with an increase in cerebral oedema and haemorrhagic transformation on the follow-up CT. E : Seven days after hypothermia treatment, the follow-up CT showed an improved state of cerebral oedema. F : Ten months later, the patient could walk alone without assistance, although the follow-up MR image revealed a large porencephaly and cerebromalacia in the right MCA territory. MCA : middle cerebral artery, CT : computed tomography.

Reference

References

1. Bernard SA, Buist M. Induced hypothermia in critical care medicine: a review. Crit Care Med. 31:2041–2051. 2003.

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.

3. Berrouschot J, Sterker M, Bettin S, Köster J, Schneider D. Mortality of space-occupying (‘malignant’) middle cerebral artery infarction under conservative intensive care. Intensive Care Med. 24:620–623. 1998.

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.

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.

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.

8. Frank JI. Large hemispheric infarction, deterioration, and intracranial pressure. Neurology. 45:1286–1290. 1995.

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.

10. Heiss WD. Malignant MCA Infarction: pathophysiology and imaging for early diagnosis and management decisions. Cerebrovasc Dis. 41:1–7. 2016.

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.

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.

13. Jüttler 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.

14. Jüttler E, Unterberg A, Woitzik J, Bösel 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.

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.

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.

17. Kollmar R, Schäbitz 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.

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.

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.

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.

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.

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.

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.

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.

26. Shaw CM, Alvord EC Jr, Berry RG. Swelling of the brain following ischemic infarction with arterial occlusion. Arch Neurol. 1:161–177. 1959.

27. Silver FL, Norris JW, Lewis AJ, Hachinski VC. Early mortality following stroke: a prospective review. Stroke. 15:492–496. 1984.

28. Tahir RA, Pabaney AH. Therapeutic hypothermia and ischemic stroke: a literature review. Surg Neurol Int. 7(Suppl 14):S381–S386. 2016.

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.

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.

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.

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.

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.

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.