Weighing the Options after Life-Altering Stroke

Choosing to have aggressive brain surgery after suffering a severe stroke generally improves the patients’ lives and allows them to live longer, according to research by neurologists at the University of Rochester Medical Center.

The findings should help patients and families put into perspective a decision that is nearly always painful and difficult to make – whether putting a patient through aggressive surgery after a catastrophic stroke is worth it.

“For families facing this difficult choice, the more information we can provide, the better for their decision-making,” said neurologist Adam G. Kelly, M.D., who has helped hundreds of families chart a course after severe stroke. Kelly presented the findings last month at the International Stroke Conference in San Diego.

Kelly and colleague Robert Holloway, M.D., studied three separate analyses of patients who had had a serious type of stroke known as a malignant middle cerebral artery infarction, in which blood flow to a large part of the brain is cut off. Further damage occurs when the damaged brain swells in the days immediately following the initial stroke, as delicate brain tissue is pushed up against the hard inner skull. Increased swelling and pressure in the brain diminish blood flow even further.

Even under the best circumstances, patients who have suffered such strokes face at least moderate disability, and often their challenges are severe, no matter what type of treatment is chosen. A patient might be paralyzed on one side of the body. They may have lost their ability to speak or even to comprehend what is said to them. They may need a breathing or feeding tube. At the very least, they’ll likely need help each day with tasks like bathing, cooking, and taking care of themselves.

Kelly and Holloway looked at patients who were treated with medical options alone and compared their outcomes to those of patients who had a surgical procedure known as a hemicraniectomy. In that procedure, doctors remove a piece of the skull temporarily, limiting further damage by giving the brain room to swell. The portion of the skull that is removed is put back in place a few months later.

Typically the decision whether or not to go ahead with the surgery is made by families grappling with the catastrophic effects of severe stroke on their loved one. In the face of great uncertainty and under great duress and time pressures, families have to make the decision.

“There is no reliable early predictor of how most people will do after a stroke,” said Kelly, an instructor and fellow in the Department of Neurology.

“Some people have a small stroke, with few effects, and we can predict that outcome fairly well. Others have strokes that are immediately catastrophic. But the vast majority of patients are in the middle, and we have a hard time predicting what the outcome will be. There is a lot we don’t know about how the brain responds to injury, and how it recovers,” Kelly said.