A Study of the Opinions of Swedish Healthcare Personnel Regarding Acceptable Outcome Following Decompressive Hemicraniectomy for Ischaemic Stroke

Overview

Journal Acta Neurochir (Wien)

Specialty Neurosurgery

Date 2017 Nov 6

PMID 29103136

Citations 1

Authors

Magnus Olivecrona

Stephen Honeybul

Affiliations

Soon will be listed here.

Abstract

Background: Decompressive hemicraniectomy (DC) is an established lifesaving treatment for malignant infarction of the middle cerebral artery (mMCAI). However, surgical decompression will not reverse the effects of the stroke and many survivors will be left severely disabled. The objective of this study was to assess what neurological outcome would be considered acceptable in these circumstances amongst Swedish healthcare workers.

Method: Healthcare workers were invited to participate in a presentation that outlined the pathophysiology of mMCAI, the rationale behind DC and outcome data from randomised controlled trials that have investigated efficacy of the procedure. They were then asked which neurological outcome would they feel to be acceptable based on the modified Rankin Score (mRS) and the Aphasia Handicap Scale (AHS). Information regarding sex, age, marital status, relatives, religion, earlier experience of stroke and occupation was also collected.

Results: Six hundred and nine persons participated. The median accepted mRS was 3. An mRS of 4 or 5 was perceived to be acceptable by only 30.5% of participants. Therefore the most likely outcome, based on the results of the randomised controlled trials, would be unacceptable to most of the participants [OR 0.39 (CI, 0.22-0.69)]. The median accepted AHS was 3. A worst language outcome of restricted autonomy of verbal communication (AHS 3) or better would be accepted by 44.6%.

Conclusions: This study has highlighted the ethical problems when obtaining consent for DC following mMCAI, because for many of the participants the most likely neurological outcome would be deemed unacceptable. These issues need to be considered prior to surgical intervention and the time may have come for a broader societal discussion regarding the value of a procedure that converts death into survival with severe disability given the attendant financial and healthcare resource implications.

Citing Articles

Fluid Balance Variations During the Early Phase of Large Hemispheric Stroke Are Associated With Patients' Functional Outcome.

Pelz J, Fischer M, Bungert-Kahl P, Lindner D, Fricke C, Michalski D Front Neurol. 2019; 10:720.

PMID: 31333571 PMC: 6616133. DOI: 10.3389/fneur.2019.00720.

References

Neugebauer H, Schnabl M, Lule D, Heuschmann P, Juttler E . Attitudes of Patients and Relatives Toward Disability and Treatment in Malignant MCA Infarction. Neurocrit Care. 2016; 26(2):311-318. DOI: 10.1007/s12028-016-0362-7. View

Juttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J . Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke. 2007; 38(9):2518-25. DOI: 10.1161/STROKEAHA.107.485649. View

Leonhardt G, Wilhelm H, Doerfler A, Ehrenfeld C, Schoch B, Rauhut F . Clinical outcome and neuropsychological deficits after right decompressive hemicraniectomy in MCA infarction. J Neurol. 2002; 249(10):1433-40. DOI: 10.1007/s00415-002-0875-1. View

Honeybul S, Ho K, Gillett G . Outcome Following Decompressive Hemicraniectomy for Malignant Cerebral Infarction: Ethical Considerations. Stroke. 2015; 46(9):2695-8. DOI: 10.1161/STROKEAHA.115.010078. View

Larach D, Larach D, Larach M . A life worth living: seven years after craniectomy. Neurocrit Care. 2009; 11(1):106-11. DOI: 10.1007/s12028-008-9180-x. View

Druml C . Informed consent of incapable (ICU) patients in Europe: existing laws and the EU Directive. Curr Opin Crit Care. 2004; 10(6):570-3. DOI: 10.1097/01.ccx.0000144765.73540.89. View

Honeybul S, Janzen C, Kruger K, Ho K . Decompressive craniectomy for severe traumatic brain injury: is life worth living?. J Neurosurg. 2013; 119(6):1566-75. DOI: 10.3171/2013.8.JNS13857. View

Puetz V, Campos C, Eliasziw M, Hill M, Demchuk A . Assessing the benefits of hemicraniectomy: what is a favourable outcome?. Lancet Neurol. 2007; 6(7):580. DOI: 10.1016/S1474-4422(07)70160-6. View

Hofmeijer J, Kappelle L, Algra A, Amelink G, van Gijn J, van der Worp H . 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. 2009; 8(4):326-33. DOI: 10.1016/S1474-4422(09)70047-X. View

10.

Azuar C, Leger A, Arbizu C, Henry-Amar F, Chomel-Guillaume S, Samson Y . The Aphasia Rapid Test: an NIHSS-like aphasia test. J Neurol. 2013; 260(8):2110-7. PMC: 3734736. DOI: 10.1007/s00415-013-6943-x. View

11.

Berkhemer O, Fransen P, Beumer D, van den Berg L, Lingsma H, Yoo A . A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2014; 372(1):11-20. DOI: 10.1056/NEJMoa1411587. View

12.

Neugebauer H, Creutzfeldt C, Hemphill 3rd J, Heuschmann P, Juttler E . DESTINY-S: attitudes of physicians toward disability and treatment in malignant MCA infarction. Neurocrit Care. 2014; 21(1):27-34. DOI: 10.1007/s12028-014-9956-0. View

13.

Goyal M, Demchuk A, Menon B, Eesa M, Rempel J, Thornton J . Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015; 372(11):1019-30. DOI: 10.1056/NEJMoa1414905. View

14.

Holtkamp M, Buchheim K, Unterberg A, Hoffmann O, Schielke E, Weber J . Hemicraniectomy in elderly patients with space occupying media infarction: improved survival but poor functional outcome. J Neurol Neurosurg Psychiatry. 2001; 70(2):226-8. PMC: 1737204. DOI: 10.1136/jnnp.70.2.226. View

15.

Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard J . Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke. 2007; 38(9):2506-17. DOI: 10.1161/STROKEAHA.107.485235. View

16.

Dunn L, Nowrangi M, Palmer B, Jeste D, Saks E . Assessing decisional capacity for clinical research or treatment: a review of instruments. Am J Psychiatry. 2006; 163(8):1323-34. DOI: 10.1176/ajp.2006.163.8.1323. View

17.

Al-Ajlan F, Goyal M, Demchuk A, Minhas P, Sabiq F, Assis Z . Intra-Arterial Therapy and Post-Treatment Infarct Volumes: Insights From the ESCAPE Randomized Controlled Trial. Stroke. 2016; 47(3):777-81. DOI: 10.1161/STROKEAHA.115.012424. View

18.

Juttler E, Unterberg A, Woitzik J, Bosel J, Amiri H, Sakowitz O . Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med. 2014; 370(12):1091-100. DOI: 10.1056/NEJMoa1311367. View

19.

Honeybul S, Gillett G, Ho K . Futility in neurosurgery: a patient-centered approach. Neurosurgery. 2013; 73(6):917-22. DOI: 10.1227/NEU.0000000000000014. View

20.

Farrell B, Godwin J, Richards S, Warlow C . The United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: final results. J Neurol Neurosurg Psychiatry. 1991; 54(12):1044-54. PMC: 1014676. DOI: 10.1136/jnnp.54.12.1044. View