In patients over 60, hemicraniectomies save lives but do not prevent severe disability / Clinical study led by Heidelberg University Hospital’s Neurology and Neurosurgery pub-lished in New England Journal of Medicine
Patients who are over the age of 60 and have suffered a major stroke due to blockage of the middle cerebral artery benefit from hemicraniectomy – removal of part of the skull located above the affected brain tissue.
Professor Werner Hacke, Medical Director of Heidelberg University Hospital’s Department of Neurology.
Photo: Heidelberg University Hospital
Professor Andreas Unterberg, Medical Director of Heidelberg University Hospital’s Department of Neurosurgery.
Photo: Heidelberg University Hospital
The procedure relieves increased pressure on the brain in the first 48 hours after the stroke. These patients’ chances of survival increase two-fold if they undergo surgery. However, patients who have been operated on often survive with severe disabilities, while patients who do not undergo the surgery generally die quickly.
These findings were obtained in a study conducted by 13 German stroke centers led by Heidelberg University Hospital’s Departments of Neurology and Neurosurgery and have been published in the current issue of the renowned New England Journal of Medicine.
“For the first time, it has now been proven that for a cohort of elderly patients too, hemicraniectomy can save lives,” explained Professor Werner Hacke, Medical Director of Heidelberg University Hospital’s Department of Neurology.
A study published 5 years ago showed that in patients below the age of 60, the results of the procedure are more favorable (see Lancet Neurology, 2007 under Literature). “In younger patients, the surgery tripled the chances of survival.
In addition, they rarely sustained severe disabilities,” said Professor Andreas Unterberg, Medical Director at Heidelberg University Hospital’s Department of Neurosurgery. “We were not surprised by the lower treatment effect in the current study, since we know that the older a stroke patient, the poorer his or her prognosis.”
Elderly patients: Overall poorer prognosis after severe stroke
The prognosis in patients with a blockage of the middle cerebral artery is very poor. In nearly 80% of the patients, without surgery, it causes death in a matter of days, even if they receive the maximum possible conservative intensive care. The necrotic brain tissue and its surroundings expand due to brain swelling (edema) and intracranial pressure severely increases, destroying vitally important brain tissue.
The decompression surgery provides space for the swollen brain tissue in the critical phase. The exposed brain is covered with a protective membrane. Once brain swelling has decreased, the removed bone flap is replaced. The procedure has low risks, can be performed quickly and has few complications. Since its efficacy was proven in younger patients (below 60), it has become the standard treatment at many stroke centers. The surgery reduced mortality in younger patients from a rate of over 70% to around 20%.
Strict indications and additional studies warranted
The results of the current study are highly significant for the treatment of elderly stroke patients. The analysis includes 112 patients between the ages of 61 and 82 who had experienced a severe stroke and were treated with intensive care only or who underwent a hemicraniectomy within 48 hours of the stroke.
The study was already stopped after the inclusion of 83 patients due to the clear superiority of the surgical procedure. The use of hemicraniectomies reduced the mortality rate from 70% to 33%. However, the proportion of very severely disabled patients in the group undergoing the procedure was nearly 30%.
“Many patients do not accept the notion of survival with severe disability, especially in very old age,” Professor Unterberg reported. “For this reason, in older patients in particular, the pros and cons of the procedure must be discussed with the patients and their families,” Professor Hacke added. Neurosurgeons and neurologists therefore need to discuss this type of treatment with patients and their families. Further studies may succeed in finding out which older patients especially will benefit from a hemicraniectomy.
Hemicraniectomy in Older Patients with Extensive Middle-Cerebral-Artery Stroke; Jüttler, E., Unterberg, A., Woitzik, J. , Bösel, J., Amiri, H., Sakowitz, O., Gondan, M., Schiller, P., Lamprecht, R., Luntz, S., Schneider, H., Pinzer, Th., Hobohm, C., Meixensberger, J., and Hacke W., for the DESTINY II Investigators , N Engl J Med. 2014 March 20;370(12):1-9. DOI: 10.1056/NEJMoa1311367
Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A, Amelink GJ, Schmiedeck P, Schwab S, Rothwell PM, Bousser MG, van der Worp HB, Hacke W; DECIMAL, DESTINY, and HAMLET investigators: Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol. 2007 Mar;6(3):215-22. doi:10.1016/S1474-4422(07)70036-4
Heidelberg University Hospital Department of Neurology:
Heidelberg University Hospital Department of Neurosurgery:
Professor Werner Hacke
Heidelberg University Hospital Department of Neurology
Tel: +49 (0) 6221 56-8210
Professor Andreas Unterberg
Heidelberg University Hospital Department of Neurosurgery
Tel: +49 (0) 6221 56-6301
Heidelberg University Hospital and Medical Faculty:
Internationally recognized patient care, research, and teaching
Heidelberg University Hospital is one of the largest and most prestigious medical centers in Germany. The Medical Faculty of Heidelberg University belongs to the internationally most renowned biomedical research institutions in Europe. Both institutions have the common goal of developing new therapies and implementing them rapidly for patients. With about 11,000 employees, training and qualification is an important issue. Every year, around 118,000 patients are treated on an inpatient basis and around 1.000.000 cases on an outpatient basis in more than 50 clinics and departments with 2,200 beds. Currently, about 3,500 future physicians are studying in Heidelberg; the reform Heidelberg Curriculum Medicinale (HeiCuMed) is one of the top medical training programs in Germany.
Requests by journalists:
Dr. Annette Tuffs
Director, Corporate Communication/Public Relations
University Hospital and
Medical Faculty of Heidelberg
Im Neuenheimer Feld 672
phone: +49 (0) 6221 56-4536
fax: +49 (0) 6221 56-4544
Selected english press releases online:
Dr. Annette Tuffs | idw - Informationsdienst Wissenschaft
Loyola study reveals how HIV enters cell nucleus
23.06.2016 | Loyola University Health System
Updated DIfE – GERMAN DIABETES RISK TEST Optimized for Mobile Devices
22.06.2016 | Deutsches Institut für Ernährungsforschung Potsdam-Rehbrücke
Physicists in Innsbruck have realized the first quantum simulation of lattice gauge theories, building a bridge between high-energy theory and atomic physics. In the journal Nature, Rainer Blatt‘s and Peter Zoller’s research teams describe how they simulated the creation of elementary particle pairs out of the vacuum by using a quantum computer.
Elementary particles are the fundamental buildings blocks of matter, and their properties are described by the Standard Model of particle physics. The...
A year and a half on the outer wall of the International Space Station ISS in altitude of 400 kilometers is a real challenge. Whether a primordial bacterium...
Researchers at Case Western Reserve University have developed a way to swiftly and precisely control electron spins at room temperature.
A physics experiment performed at the National Institute of Standards and Technology (NIST) has enhanced scientists' understanding of how free neutrons decay...
Chemically the same, graphite and diamonds are as physically distinct as two minerals can be, one opaque and soft, the other translucent and hard. What makes...
09.06.2016 | Event News
24.05.2016 | Event News
20.05.2016 | Event News
24.06.2016 | Materials Sciences
24.06.2016 | Physics and Astronomy
24.06.2016 | Physics and Astronomy