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Health & Medicine for Senior Citizens

Senior Stroke Patients Double Survival with Surgery to Relieve Brain Pressure

Proven successful with patients under 60, it has now been proven that hemicraniectomy surgery can save elderly lives, too

March 20, 2014 – Seniors over the age of 60 double their chance of surviving a major stroke due to blockage of the middle cerebral artery if they undergo surgery in the first 48 hours to remove part of the skull above the affected brain tissue to relieve pressure on the brain. But, the news is not all good – they often survive with severe disabilities. On the other hand, those without this surgery generally die quickly, according to a new study.

These findings on this surgery (hemicraniectomy) came from a study conducted by 13 German stroke centers led by Heidelberg University Hospital’s Departments of Neurology and Neurosurgery. The report is published in the current New England Journal of Medicine.

 

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“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 in Lancet Neurology showed that in patients below the age of 60, the results of the procedure are more favorable.

“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%.

About Stroke (MedlinePlus)

A stroke is a medical emergency. Strokes happen when blood flow to your brain stops. Within minutes, brain cells begin to die. There are two kinds of stroke. The more common kind, called ischemic stroke, is caused by a blood clot that blocks or plugs a blood vessel in the brain. The other kind, called hemorrhagic stroke, is caused by a blood vessel that breaks and bleeds into the brain. "Mini-strokes" or transient ischemic attacks (TIAs), occur when the blood supply to the brain is briefly interrupted.

Symptoms of stroke are

   • Sudden numbness or weakness of the face, arm or leg (especially on one side of the body)
   • Sudden confusion, trouble speaking or understanding speech
   • Sudden trouble seeing in one or both eyes
   • Sudden trouble walking, dizziness, loss of balance or coordination
   • Sudden severe headache with no known cause

If you have any of these symptoms, you must get to a hospital quickly to begin treatment. Acute stroke therapies try to stop a stroke while it is happening by quickly dissolving the blood clot or by stopping the bleeding. Post-stroke rehabilitation helps individuals overcome disabilities that result from stroke damage. Drug therapy with blood thinners is the most common treatment for stroke.

NIH: National Institute of Neurological Disorders and Stroke

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 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.”

Links:

>> American Heart Association/Stroke Guidelines for Ischemic Stroke

>> Heidelberg University Hospital Department of Neurology

>> Heidelberg University Hospital Department of Neurosurgery

 

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