Prolonged use of therapeutic hypothermia in elderly patients as an alternative to decompressive hemicraniectomy: A single-center study

Abstract

Introduction: Decompressive hemicraniectomy (DH) for treating malignant edema from large hemispheric infarction has been reported to decrease mortality rate, but this benefit has not been demonstrated in elderly patients, and alternatives are being explored. This study aimed to investigate the effects of therapeutic hypothermia (TH) on functional outcome in elderly patients with acute severe hemispheric infarction. Methods: We retrospectively reviewed patients with large hemispheric infarction who presented within 24 hours of symptom onset. Patient data were prospectively collected in hypothermia registry and retrospectively reviewed in hemicraniectomy registry. Patients in the DH group underwent DH. In the TH group, the patients body temperature was lowered to 33°C for 72 to 120 hours and did not undergo surgery. We measured pineal gland displacement to estimate cerebral edema progression and obtained modified Rankin Scale (mRS) 3 months after stroke for functional outcome evaluation. We compared the outcomes between both groups. Results: Eleven patients with a median age of 76 (range

64–82) and a median National Institutes of Health Stroke Scale (NIHSS) score of 18 (range

13–22) were treated with TH. In DH group, 9 patients with a median age of 71 (range

66-78) and a median NIHSS score of 17 (range

10-25) were enrolled. The median time from symptom onset to initiation of TH and DH were 30.3±23.0 and 39.5±30.5 hours, respectively. The median duration of TH was 76.7±57.1 hours. Complications of hypothermia included shivering (100%), asymptomatic sinus bradycardia (45%), pneumonia (55%), ventricular tachycardia (n = 2), atrial fibrillation with rapid ventricular response (n = 3), and hypotension (n = 2). Electrolyte imbalances were frequently observed (82%) during TH. Mortality rates in the TH and DH groups were 18% (n = 2) and 33% (n = 3), respectively, but there was no significant difference (p=0.62). Conclusions: Our study suggests that TH is a useful alternative therapeutic option to DH and achieves a similar mortality benefit, particularly in elderly patients. Further studies are warranted in order to validate this finding.