Casey Albin, MD Profile picture
Feb 8 25 tweets 11 min read
In early residency, I was in a family meeting.

“Unfortunately, your 55yo loved one has suffered a very large stroke affecting a large portion of the brain. Surgery would reduce the change of death, but not the disability from the stroke.”

True or False? Vote below
A #tweetorial, #EmoryNCCTweetorial, @medtweetorials about the role of decompressive hemicraniectomy in ischemic stroke.

First, I cringe now thinking about this statement, because I was the one that said it 😳😱.


Fortunately, I was corrected. But, unfortunately, I have heard a version of this said on *numerous* occasions since then.

Why all the confusion?
A tweetorial covering (goals for the scroll, if you will @sigman_md)

✅What is malignant edema & what's the natural history
✅The evidence for DHC in MCA stroke
✅ Why the hesitation and confusion about poppin' the top?
“Malignant” MCA infarcts are complete, or near complete MCA territory infarctions which develop space-occupying mass effect which often results in herniation.

Much of what we know of the natural history was studied by Hacke et al (1996)
They prospectively eval'ed 55 pts w/ full territory MCA infarctions. Pt were 34-74 yo (avg 56). They were treated w/ intubation, hyperosmolar therapy, & barbiturates as needed (aggressive medical therapy).

💥78%💥 died despite maximal medical treatment with first 7 days.
Let’s contextualize this: ARDS sucks.

But our best estimates of death from ARDS is ~40% ( This is significant.

But, malignant middle cerebral ischemic edema?
~2x as deadly as ARDS 💀
When exactly do these patients herniate & die?

The median day of herniation was day 4⃣. But just making it to day 4⃣ did not mean you were out of the woods. Half of the worsening happened after that point. This is important for later.

The pts who survived were the older pt
So, we’re now all on the same page.
Full territory MCA stroke = bad. Particularly bad for young patients who have more robust edema responses and less atrophy to tolerate the swelling.

Medical therapy… *very* often fails.

Surgical therapy?
3 trials were published in the late 2000s to address this question: DESTINY I, DECIMAL, and HAMLET
All had some unique features.

👉Pts <60, w/ excellent functional baselines
👉All DHCs were completed b/f 96hrs;
👉Most were <48 hr (DESTINY<36hrs, DECIMAL<30hrs)
Importantly, the patients did not have to have “full” territory infarctions. Most trials required ~2/3 of the territory with some basal ganglia involvement.

Big strokes, but not necessarily every. single. thing in the MCA territory.
A pooled analysis of these trials was published in the Lancet in 2007 which looked at DHC which had been completed within *48 hours* of ictus of stroke.

The Result?
Survival more than doubled, but contrary what seems to be a pervasive misunderstanding, the patients that survived were not often left totally dependent (mRS = 5). In fact, the rate of mRS 5 was very low.

43% of patients achieved an mRS of 2 or 3.
This of course is not a “perfect” outcome. Most of the patients enrolled had no prior disability.

So, yes, you can make case that surgery doesn’t “cure” the disability of stroke.

But is this a worthwhile outcome?

For many patients, absolutely.

A reminder about mRS:
Of course, is mRS even the right score to determine the worthiness of a pt’s life?

In DECIMAL 2/3 patients were living at home @ 1 yr

In HAMLET, pts & caregivers had low rates of being dissatisfied with tx.
Potentially biased? yes.
Demonstrative of human resiliency? yes.
On the flip side, does decompressive hemicraniectomy guarantee a “good” outcome?


Even with the most aggressive care, about 1 in 4.5 patients will go on to die of their stroke. That is not an insignificant number.

An example of progression despite surgery (Day 2-7)
That said, the disability curve clearly shifts with DHC.

So why is there confusion?

I think there are 3 reasons:
1⃣ Surgery doesn’t reverse injury
2⃣ DHC has a different effect for older pts and in TBI
3⃣ Surgery is preventive not reactive
Even the best surgery can’t take back the stroke.

Like many things in #NCC, our job is preventing 2⃣nd injury.

By reducing compression and herniation we prevent secondary injury ➡️ decreases disability + mortality.

This keeps being proven. Meta-analysis from 2021.
What is more likely to be muddling the picture is that all of the data above applies to *young patients* (<60 yo).

Things are more complicated >60yo. DESTINY II looked at DHC in the >60 group:
👉Only 6% attained an mRS=3.
👉19% of pt were left severely disabled. mRS 5.
Similarly, DHC for TBI is a different beast.
Charts from
DECRA (Left): poor outcomes on the left of bar
(⬆️in the DHC group).

And RESCUEicp (Right). Not a major change in the number of “good” outcomes w/ DHC; higher “bad” outcomes fill the mortality difference.
Finally, I don’t think this is the reason there is confusion, but I think there is sometimes hesitancy to take the bone off. Why?

B/c we this is often a preventive action. The patients may be doing ok at the time of the surgery.

Remember swelling peaks at day ~4
The hope is to intervene b/f the midline shift, b/f the patient has transtentorial herniation that is making them sleepy (and aspirating)

But, I get it. This exposes a patient who seems to be “doing ok” to a surgical risk before they have demonstrated the need.
I like this example of a patient that was doing ok at hour 36 (CT scan on the left). Protecting airway, easily arousable. Kinda borderline size but had deep territory and the anterior temporal lobe infarcted.

By day 4 they would not have been doing well.
So, the take-away here?
⭐️ DHC for malignant MCA edema improves BOTH a mortality & disability .
⭐️Data support early (w/I 48 hrs) action for young pts (<60yo) w/ large MCA stroke
⭐️Pls reach out & transfer these pts early if u don't have NSGY! 23% isn't going to fix this!
And finally, family/pts values matter so much here, this has to be a personalized convo! Thoughts? Additions? @aartisarwal @drdangayach @theABofPharmaC @emcrit @rkchoi @namorrismd @nsanar @ghoshal_shivani @PulmCrit @AaronLBerkowitz @karenccrx @EricLawson90 @Capt_Ammonia

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More from @caseyalbin

Dec 15, 2021
A pt w/ ESRD on HD, a fib on coumadin is transferred after a 2 wk hosp for SDH/contusions + ESBL PNA w/ status epilepticus

Scan ⬇️

AEDs: fPHT 100mg Q8H, LEV 1g BID, LAC 100mg BID, VPA 750mg BID + propofol 30, midaz 5.

Admission VPA level 13 (tx range 50-~100)
Whats going on… That’s a 15mg/kg/day dose… why is the VPA level so low?
VPA is a great AED.

But a @medtweetorial #tweetorial, on how in the critically ill, this drug often becomes problematic and complicated.

Read 18 tweets
Nov 29, 2021
It was a delight to work with @gabifpucci of @neudrawlogy to explore the incredibly diverse CNS complications of infective endocarditis!

An #infographic & #tweetorial investigating the radiographic & clinical findings in IE + some management pearls!
#MedEd #Neurotwitter
The most common cause of neurologic injury in IE is ischemic stroke.
But! Management is somewhat different.

Notably, due to the high risk of hemorrhagic transformation, tPA is relatively contraindicated or should be used with extreme caution.

You don’t want to end up with ⬇️!
As evidence: in this series, 1 in 5 patients experienced post-tPA ICH and only 10% achieved a good outcome.

Thrombolysis for Ischemic Stroke Associated With Infective Endocarditis…
Read 13 tweets
Nov 5, 2021
It’s no secret what’s growing in blood.
But, the cultures won’t clear,
On valves it adheres!

Patient aphasic,
What’s with the agitation?

ESR & CRP rising!
An #Tweetorial advising:
Never overlook the spinal epidural abscess!!

All poetry aside (pretty good tho, right?!)

Goals for the scroll (⬅️credit @sigman_md 😂):
1⃣ How difficult it can be to diagnose spiral epidural abscesses (SEA)
2⃣ What exactly is the spinal epidural space
3⃣ How these should be treated
4⃣ And why decompress?
Diagnosing SEA = super tricky. The symptoms & labs are so non-specific!
✅Back pain ⏫(but back pain--who doesn't?)
✅Fever is often present, but not always.
✅WBC may be elevated, but sometimes just mildly. ✅Blood cultures are only positive about 60% of the time.
Read 21 tweets
Oct 30, 2021
A #tweetorial about simulation in NCC
Today @namorris opened his remarks on Sim in NCC @ #NCS2021 w/ a simple question about the correct first line treatment for SE? Everyone got it.

Then he posed a tougher question.

How often does that happen?

No one voted "always"
Even the most groundbreaking research won’t benefit our patients if we aren’t delivering it correctly.

I so highly encourage you to check out Nick’s talk on-demand if you have access to #NCS2021.

It is 🚨critical🚨 that we teach more effectively!

Some practical, take-aways from this talk about finding right Simulation Solution. Image
Read 19 tweets
Jul 14, 2021
In the early days of fellowship, I remember checking our SAH patients’ transcranial dopplers (TCD), scanning the Vmeans & if they were ~<70 cm/sec throughout thinking:

“Great. Perfect. TCDs globally low. Nothing to worry about here!”


A #tweetorial on TCDs
Right? Sort of.

🚨Note. This is not a #tweetorial about if large vessel vasospasm is the cause of DCI or just an epiphenomenon OR if treating vasospasm is the way to improve functional outcomes …That is important!... but that is not this tweetorial.
Given #TCDs is a pretty large topic, this @medtweetorial will be told in 3 parts:
Part 1⃣:
⭐️Basic principles of TCDs
⭐️Use of TCDs to detect Vasospasm

Part 2⃣: The Pulsatility Index - why it matters
Part 3⃣: The Utility of TCDs as an ancillary test in BDT
Read 25 tweets
May 28, 2021
1st week of NeuroICU fellowship. A #tweetorial summary:

1⃣ Pt in DI. Give anti-diuretic hormone (ADH), call it “pit drip”
2⃣Pt in distributive shock. Give ADH, call it “vaso”
3⃣Pt on ASA needs EVD. Give ADH (sort of), call it “DDAVP”
4⃣ Fellow postcall & confused, give….
Just kidding… everyone knows the drug for that is
All the names and purposes of ADH had me feeling ⬇️

So – a review of all things ADH including:
✅It’s various aliases
✅Receptors and function
✅Clinical utility in NeuroICU (+general ICUs)
Read 25 tweets

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