CORRESPONDENCE
Santhanam Rengarajan1, Manjesh Rathi2, Suresh Kumar2, Preetham Chennareddy2, Karthikeyan Napa1 From the Departments of 1Neurosurgery and 2Neurology, Sree Balaji Medical College & Hospital, Bharath University, Chennai, India To whom correspondence should be addressed: Santhanam Rengarajan, M.Ch. [E-mail: [email protected]] Published online 6 September 2014; http://dx.doi.org/10.1016/j.wneu.2014.09.020.
REFERENCES 1. Dubey A, Sung WS, Shaya M, Patwardhan R, Willis B, Smith D, Nanda A: Complications of posterior cranial fossa surgery—an institutional experience of 500 patients. Surg Neurol 72:369-375, 2009. 2. Gensicke H, Datta AN, Dill P, Schindler C, Fischer D: Increased incidence of Guillain-Barre syndrome after surgery. Eur J Neurol 19:1239-1244, 2012. 3. Hogan JC, Briggs TP, Oldershaw PJ: Guillain-Barre syndrome following cardiopulmonary bypass. Int J Cardiol 35:427-428, 1992. 4. Renlund DG, Hanley DF, Traill TA: Guillain-Barre syndrome following coronary artery bypass surgery. Am Heart J 113:844-845, 1987. 5. Vucic S, Kiernan MC, Cornblath DR: Gullain Barre syndrome: an update. J Clin Neurosci 16:733-741, 2009.
Hemicraniectomy for Older Patients in Low-Income Countries? alignant middle cerebral artery infarction represents a devastating type of ischemic stroke associated with fatal outcome or long-term disability. Only early decompressive hemicraniectomy (DHC) has been shown to be effective in lowering the rate of mortality and improving outcomes, especially in younger patients. Recently, Jüttler et al. (4) reported the results of DHC in older patients with extensive middle-cerebral artery stroke in a randomized trial. They demonstrated a survival and functional benefit of this procedure in patients older than 61 years of age. As the authors note, there has been significant controversy surrounding this procedure, some of it directed at the prospect of increasing survival in patients who will ultimately suffer from severe disability and possibly reduced quality of life. Although this study answered some important questions, at the same time it raises questions about whether survival is necessarily the best outcome for older patients who have suffered a large stroke and who will suffer from severe disability for the rest of their lives. A year after stroke, a significant proportion of patients in the hemicraniectomy group and patients treated with standard care were unable to walk or attend to own bodily needs without assistance. Although
M
Key words Advanced age - Cost - Hemicraniectomy - Low-income countries - Outcome - Stroke -
Abbreviations and Acronyms DHC: Decompressive hemicraniectomy mRs: Modified Rankin scale
e840
www.SCIENCEDIRECT.com
hemicraniectomy is a life-saving procedure, we believe its international applicability could still be questioned, particularly in low-income countries. In this issue of WORLD NEUROSURGERY, Suyama et al. (6) analyzed the clinical characteristics of patients undergoing DHC for malignant middle cerebral artery stroke in Japanese neurosurgical departments. The majority of their patients (a little more than 80%) were older than 60 years of age, and age was not found to be an important prognostic factor. In their 3month follow-up, only 5.2% had modified Rankin scale (mRs) scores less than 3, 49.8% had mRs 4 5, and 45.1% patients had died. These data are somewhat different from Jüttler et al’s. They reported a mortality of 33% in patients undergoing DHC, and 3% of those patients had a mRs of 3, whereas 27% had mRs 4 5. Although Suyama et al. reported retrospective data, their outcome assessment was performed at 3 months, whereas Jüttler et al performed it at 6 months in. Interestingly, the point where these 2 studies seem to agree is in the low proportion of patients resulting with good functional outcome (mRs 60 years of age) (8). Little attention has been paid to the implications of this procedure in third-world and low-income countries. Both Germany (Jüttler et al.) and Japan (Suyama et al.) are countries that share high economic and health-related indices, and even then their results of DCH outcomes appear to vary. It is true that costeffectiveness analyses should not independently decide the value of a therapeutic intervention. Nonetheless, Hofmeijer et al. for the HAMLET (Hemicraniectomy After Middle Cerebral Artery Infarction with Life-threatening Edema Trial) investigators recently reported an incremental costs of V127,000 per qualityadjusted life year gained after hemicraniectomy in young patients with malignant stroke (3), representing a cost 11 times the gross domestic product per capita for a middle-income country like Mexico, well above what would normally be considered as costeffective. The follow-up for up to 12 months also implies that severely disabled patients (60% with a mRs score 4 or 5) received long-term institutionalized care and rehabilitation (but this information is lacking), which in the context of a clinical trial and in a high-income country would be expected to be offered without cost, but in most middle- and low-income countries would represent additional out-of pocket expenditures for the patients, if it could be afforded at all. Out-of-pocket expenditures and days without income increase substantially in the families of hospitalized patients older than 60 years of age in Mexico (5), even in patients with social security (statedependent health insurance). In addition, severe disability is associated with almost a 2-fold increase in health-related costs in the poor (7). How these hardships would influence quality of care and outcome can only be hypothesized but could significantly affect the decision to perform a craniectomy in low- or middle-income countries.
82 [6]: e831ee844, DECEMBER 2014 WORLD NEUROSURGERY
CORRESPONDENCE
An analysis of global surveillance data found that change in stroke incidence in different populations is partially related to socioeconomic status, and low-income countries appear to be most affected. After age adjustment, there was a 10-fold difference in rate of stroke mortality and disability-adjusted life-years between the most and least affected countries, with national per-capita income being the strongest predictor of mortality and loss of disability-adjusted life-years, even after adjustment for vascular risk factors (2). These data suggest that DHC could turn out not to be an effective treatment strategy in all countries. Other therapeutic interventions, such as corticosteroid use in bacterial meningitis, have shown benefit in high-income countries while failing to show any effect in the developing world, and although epidemiologic and socioeconomic factors are suspect, the precise cause for this discrepancy has not been fully established (1). Although a clear mortality benefit is evident for hemicraniectomy in older patients with malignant stroke, functional outcomes and specially the impact over quality of life could differ in the context of most of the developing world. Only prospective studies could answer this question. With the current evidence, surgery appears appropriate, but in our opinion the individual decision to operate is not clear-cut in middle and low-income countries.
Carlos R. Camara-Lemarroy1, Fernando Gongora-Rivera1, Antonio Arauz2 From the 1Departamento de Neurología. Hospital Universitario “Dr. José E. González,” Universidad Autónoma de Nuevo León, Madero y Gonzalitos S/N, Monterrey NL, México; and 2 Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología MVS, Insurgentes sur 3877, Colonia la Fama, 14269, México D.F. To whom correspondence should be addressed: Fernando Gongora-Rivera, M.D. [E-mail: [email protected]] Published online 25 August 2014; http://dx.doi.org/10.1016/j.wneu.2014.08.050.
8. van Middelaar T, Nederkoorn PJ, van der Worp HB, Stam J, Richard E: Quality of life after surgical decompression for space-occupying middle cerebral artery infarction: systematic review. Int J Stroke 2014 Jul 15 [Epub ahead of print].
Screening for Brain Cancer: Why (Not) Letter:
In an era of emphasis on disease prevention and its early detection, some have raised the possibility of systematic screening programs concerning brain/cranial disease, namely in search of asymptomatic brain tumors. In this work, the authors enumerate major arguments in favor and against this approach by analyzing the existing literature and conclude there is an absence of evidence sustaining this procedure in terms of clinical and economical advantages, with no clear benefit both to the patient and health systems.
INTRODUCTION rate for primary nervous system tumors in adults T he(agedincidence 20 years or older) is estimated to be 27.4 per 100,000 persons (data from 50 cancer registries, 2006 2010, in the United States) (2). Approximately one third are malignant, with the remainder being benign or borderline malignant. Despite continuous research, little is known regarding risk factors for brain cancer (environmental and genetic) and the real utility of systematically screening large populations with the aim of early detection and improved medical care. DISCUSSION
REFERENCES 1. Brouwer MC, McIntyre P, Prasad K, van de Beek D: Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev 6:CD004405, 2013. 2. Feigin VL, Lawes CM, Bennet DA, Barker-Collo SL, Parag V: Worldwide stroke incidence and early case fatality in 56-population-based studies; a systematic review. Lancet Neurol 8:355-369, 2009. 3. Hofmeijer J, van der Worp HB, Kappelle LJ, Eshuis S, Algra A, Greving JP; ; HAMLET Steering Committee: Cost-effectiveness of surgical decompression for space-occupying hemispheric infarction. Stroke 44:2923-2925, 2013. 4. Jüttler E, Unterberg A, Woitzik J, Bösel J, Amiri H, Sakowitz OW, Gondan M, Schiller P, Limprecht R, Luntz S, Schneider H, Pinzer T, Hobohm C, Meixensberger J, Hacke W; ; DESTINY II Investigators: Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 370:1091-1100, 2014. 5. López-Ortega M, García-Peña C, Granados-García V, García-González JJ, Pérez-Zepeda MU: Economic burden to primary informal caregivers of hospitalized older adults in Mexico: a cohort study. BMC Health Serv Res 13:51, 2013. 6. Suyama K, Horie N, Hayashi K, Nagata I: Nationwide survey of decompressive hemicraniectomy for malignant middle cerebral artery infarction in Japan. World Neurosurg 82:1158-1163, 2014. 7. Urquieta-Salomón JE, Figueroa JL, Hernández-Prado B: Health expenditure related to disability. A study with poor population in Mexico. Salud Publica Mex 50:136-146, 2008.
WORLD NEUROSURGERY 82 [6]: e831ee844, DECEMBER 2014
In 2008, brain scanning with magnetic resonance imaging (MRI) was performed on asymptomatic volunteers in the New York metropolitan area (3). This mobile program was run by a nonprofit organization, The Brain Tumor Foundation, and, because it was largely publicized, raised again the question: is it clinically and economically advantageous to scan asymptomatic individuals in search for brain/cranial disease (aneurysms, tumors, or other)? Its defenders argue that performing a $200 $300 innocuous examination, one that is presumably able to detect tumors on an earlier stage, would result in less costly and aggressive procedures and therapies, shorter hospital stays, and prolonged overall survival. This would apparently ease the significant financial burden on treating a late-stage brain malignant tumor (up to $500.000, concerning thes multimodal treatment of glioblastoma). In the previously mentioned screening program, 1700 brain scans led to the discovery of more than 50 abnormalities, including aneurysms, multiple sclerosis, and neoplastic lesions.
Key words Brain tumors - Prevention - Screening -
Abbreviations and Acronyms MRI: Magnetic resonance imaging
www.WORLDNEUROSURGERY.org
e841
Santhanam Rengarajan1, Manjesh Rathi2, Suresh Kumar2, Preetham Chennareddy2, Karthikeyan Napa1 From the Departments of 1Neurosurgery and 2Neurology, Sree Balaji Medical College & Hospital, Bharath University, Chennai, India To whom correspondence should be addressed: Santhanam Rengarajan, M.Ch. [E-mail: [email protected]] Published online 6 September 2014; http://dx.doi.org/10.1016/j.wneu.2014.09.020.
REFERENCES 1. Dubey A, Sung WS, Shaya M, Patwardhan R, Willis B, Smith D, Nanda A: Complications of posterior cranial fossa surgery—an institutional experience of 500 patients. Surg Neurol 72:369-375, 2009. 2. Gensicke H, Datta AN, Dill P, Schindler C, Fischer D: Increased incidence of Guillain-Barre syndrome after surgery. Eur J Neurol 19:1239-1244, 2012. 3. Hogan JC, Briggs TP, Oldershaw PJ: Guillain-Barre syndrome following cardiopulmonary bypass. Int J Cardiol 35:427-428, 1992. 4. Renlund DG, Hanley DF, Traill TA: Guillain-Barre syndrome following coronary artery bypass surgery. Am Heart J 113:844-845, 1987. 5. Vucic S, Kiernan MC, Cornblath DR: Gullain Barre syndrome: an update. J Clin Neurosci 16:733-741, 2009.
Hemicraniectomy for Older Patients in Low-Income Countries? alignant middle cerebral artery infarction represents a devastating type of ischemic stroke associated with fatal outcome or long-term disability. Only early decompressive hemicraniectomy (DHC) has been shown to be effective in lowering the rate of mortality and improving outcomes, especially in younger patients. Recently, Jüttler et al. (4) reported the results of DHC in older patients with extensive middle-cerebral artery stroke in a randomized trial. They demonstrated a survival and functional benefit of this procedure in patients older than 61 years of age. As the authors note, there has been significant controversy surrounding this procedure, some of it directed at the prospect of increasing survival in patients who will ultimately suffer from severe disability and possibly reduced quality of life. Although this study answered some important questions, at the same time it raises questions about whether survival is necessarily the best outcome for older patients who have suffered a large stroke and who will suffer from severe disability for the rest of their lives. A year after stroke, a significant proportion of patients in the hemicraniectomy group and patients treated with standard care were unable to walk or attend to own bodily needs without assistance. Although
M
Key words Advanced age - Cost - Hemicraniectomy - Low-income countries - Outcome - Stroke -
Abbreviations and Acronyms DHC: Decompressive hemicraniectomy mRs: Modified Rankin scale
e840
www.SCIENCEDIRECT.com
hemicraniectomy is a life-saving procedure, we believe its international applicability could still be questioned, particularly in low-income countries. In this issue of WORLD NEUROSURGERY, Suyama et al. (6) analyzed the clinical characteristics of patients undergoing DHC for malignant middle cerebral artery stroke in Japanese neurosurgical departments. The majority of their patients (a little more than 80%) were older than 60 years of age, and age was not found to be an important prognostic factor. In their 3month follow-up, only 5.2% had modified Rankin scale (mRs) scores less than 3, 49.8% had mRs 4 5, and 45.1% patients had died. These data are somewhat different from Jüttler et al’s. They reported a mortality of 33% in patients undergoing DHC, and 3% of those patients had a mRs of 3, whereas 27% had mRs 4 5. Although Suyama et al. reported retrospective data, their outcome assessment was performed at 3 months, whereas Jüttler et al performed it at 6 months in. Interestingly, the point where these 2 studies seem to agree is in the low proportion of patients resulting with good functional outcome (mRs 60 years of age) (8). Little attention has been paid to the implications of this procedure in third-world and low-income countries. Both Germany (Jüttler et al.) and Japan (Suyama et al.) are countries that share high economic and health-related indices, and even then their results of DCH outcomes appear to vary. It is true that costeffectiveness analyses should not independently decide the value of a therapeutic intervention. Nonetheless, Hofmeijer et al. for the HAMLET (Hemicraniectomy After Middle Cerebral Artery Infarction with Life-threatening Edema Trial) investigators recently reported an incremental costs of V127,000 per qualityadjusted life year gained after hemicraniectomy in young patients with malignant stroke (3), representing a cost 11 times the gross domestic product per capita for a middle-income country like Mexico, well above what would normally be considered as costeffective. The follow-up for up to 12 months also implies that severely disabled patients (60% with a mRs score 4 or 5) received long-term institutionalized care and rehabilitation (but this information is lacking), which in the context of a clinical trial and in a high-income country would be expected to be offered without cost, but in most middle- and low-income countries would represent additional out-of pocket expenditures for the patients, if it could be afforded at all. Out-of-pocket expenditures and days without income increase substantially in the families of hospitalized patients older than 60 years of age in Mexico (5), even in patients with social security (statedependent health insurance). In addition, severe disability is associated with almost a 2-fold increase in health-related costs in the poor (7). How these hardships would influence quality of care and outcome can only be hypothesized but could significantly affect the decision to perform a craniectomy in low- or middle-income countries.
82 [6]: e831ee844, DECEMBER 2014 WORLD NEUROSURGERY
CORRESPONDENCE
An analysis of global surveillance data found that change in stroke incidence in different populations is partially related to socioeconomic status, and low-income countries appear to be most affected. After age adjustment, there was a 10-fold difference in rate of stroke mortality and disability-adjusted life-years between the most and least affected countries, with national per-capita income being the strongest predictor of mortality and loss of disability-adjusted life-years, even after adjustment for vascular risk factors (2). These data suggest that DHC could turn out not to be an effective treatment strategy in all countries. Other therapeutic interventions, such as corticosteroid use in bacterial meningitis, have shown benefit in high-income countries while failing to show any effect in the developing world, and although epidemiologic and socioeconomic factors are suspect, the precise cause for this discrepancy has not been fully established (1). Although a clear mortality benefit is evident for hemicraniectomy in older patients with malignant stroke, functional outcomes and specially the impact over quality of life could differ in the context of most of the developing world. Only prospective studies could answer this question. With the current evidence, surgery appears appropriate, but in our opinion the individual decision to operate is not clear-cut in middle and low-income countries.
Carlos R. Camara-Lemarroy1, Fernando Gongora-Rivera1, Antonio Arauz2 From the 1Departamento de Neurología. Hospital Universitario “Dr. José E. González,” Universidad Autónoma de Nuevo León, Madero y Gonzalitos S/N, Monterrey NL, México; and 2 Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología MVS, Insurgentes sur 3877, Colonia la Fama, 14269, México D.F. To whom correspondence should be addressed: Fernando Gongora-Rivera, M.D. [E-mail: [email protected]] Published online 25 August 2014; http://dx.doi.org/10.1016/j.wneu.2014.08.050.
8. van Middelaar T, Nederkoorn PJ, van der Worp HB, Stam J, Richard E: Quality of life after surgical decompression for space-occupying middle cerebral artery infarction: systematic review. Int J Stroke 2014 Jul 15 [Epub ahead of print].
Screening for Brain Cancer: Why (Not) Letter:
In an era of emphasis on disease prevention and its early detection, some have raised the possibility of systematic screening programs concerning brain/cranial disease, namely in search of asymptomatic brain tumors. In this work, the authors enumerate major arguments in favor and against this approach by analyzing the existing literature and conclude there is an absence of evidence sustaining this procedure in terms of clinical and economical advantages, with no clear benefit both to the patient and health systems.
INTRODUCTION rate for primary nervous system tumors in adults T he(agedincidence 20 years or older) is estimated to be 27.4 per 100,000 persons (data from 50 cancer registries, 2006 2010, in the United States) (2). Approximately one third are malignant, with the remainder being benign or borderline malignant. Despite continuous research, little is known regarding risk factors for brain cancer (environmental and genetic) and the real utility of systematically screening large populations with the aim of early detection and improved medical care. DISCUSSION
REFERENCES 1. Brouwer MC, McIntyre P, Prasad K, van de Beek D: Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev 6:CD004405, 2013. 2. Feigin VL, Lawes CM, Bennet DA, Barker-Collo SL, Parag V: Worldwide stroke incidence and early case fatality in 56-population-based studies; a systematic review. Lancet Neurol 8:355-369, 2009. 3. Hofmeijer J, van der Worp HB, Kappelle LJ, Eshuis S, Algra A, Greving JP; ; HAMLET Steering Committee: Cost-effectiveness of surgical decompression for space-occupying hemispheric infarction. Stroke 44:2923-2925, 2013. 4. Jüttler E, Unterberg A, Woitzik J, Bösel J, Amiri H, Sakowitz OW, Gondan M, Schiller P, Limprecht R, Luntz S, Schneider H, Pinzer T, Hobohm C, Meixensberger J, Hacke W; ; DESTINY II Investigators: Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 370:1091-1100, 2014. 5. López-Ortega M, García-Peña C, Granados-García V, García-González JJ, Pérez-Zepeda MU: Economic burden to primary informal caregivers of hospitalized older adults in Mexico: a cohort study. BMC Health Serv Res 13:51, 2013. 6. Suyama K, Horie N, Hayashi K, Nagata I: Nationwide survey of decompressive hemicraniectomy for malignant middle cerebral artery infarction in Japan. World Neurosurg 82:1158-1163, 2014. 7. Urquieta-Salomón JE, Figueroa JL, Hernández-Prado B: Health expenditure related to disability. A study with poor population in Mexico. Salud Publica Mex 50:136-146, 2008.
WORLD NEUROSURGERY 82 [6]: e831ee844, DECEMBER 2014
In 2008, brain scanning with magnetic resonance imaging (MRI) was performed on asymptomatic volunteers in the New York metropolitan area (3). This mobile program was run by a nonprofit organization, The Brain Tumor Foundation, and, because it was largely publicized, raised again the question: is it clinically and economically advantageous to scan asymptomatic individuals in search for brain/cranial disease (aneurysms, tumors, or other)? Its defenders argue that performing a $200 $300 innocuous examination, one that is presumably able to detect tumors on an earlier stage, would result in less costly and aggressive procedures and therapies, shorter hospital stays, and prolonged overall survival. This would apparently ease the significant financial burden on treating a late-stage brain malignant tumor (up to $500.000, concerning thes multimodal treatment of glioblastoma). In the previously mentioned screening program, 1700 brain scans led to the discovery of more than 50 abnormalities, including aneurysms, multiple sclerosis, and neoplastic lesions.
Key words Brain tumors - Prevention - Screening -
Abbreviations and Acronyms MRI: Magnetic resonance imaging
www.WORLDNEUROSURGERY.org
e841
