Article
Severely diseased patients with craniectomy after brain infarct benefit from early rehabilitation
Schwer betroffene Patienten mit Kraniektomie nach Hirninfarkt profitieren von einer Frührehabilitation
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Authors
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Alexander Erich Hartmann
- Kliniken der Stadt Köln, Neurochirurgie, Köln, Deutschland
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Stefanie Blarr
- Kliniken der Stadt Köln, Rehanova, Köln, Deutschland
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Thomas Rommel
- Kliniken der Stadt Köln, Rehanova, Köln, Deutschland
| Published: | May 8, 2019 |
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Outline
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Objective: Craniectomy (CRAN) in patients (pts.) with supratentorial ischemic brain infarct (SIBI) reduces mortality. However, the clinical benefit in patients with severe disability undergoing early rehabilitation is unknown.
Aim: Evaluation of benefits of early rehabilitation in pts. with SIBI and CRAN.
Patients/Method: 74 pts. (mean age 51.8 y) with SIBI and CRAN were admitted to an early rehabilitation center (ERC) between 1999 and 2010. Evaluation on admission, on discharge and 33–122 months later with Early Rehabilitation Barthel Index (ERBI) and Functional Independence Measure (FIM). ERBI includes scores for “Daily Living Activity” plus the parameters: Intensive Care Unit treatment (ICUT), tracheostoma (TR), artificial ventilation (AV), impaired swallowing (IS), severe confusion/severe aggression (SC/SA) to be treated on a protected ward, severely impaired communication (SIC). FIM includes motor ability, communication, social behavior, memory and problem solution.
Results: 3 pts. died during rehabilitation. 71 pts. were tested on admission and on discharge. Mortality after discharge from ERC was 20%. In the ERBI test ICUT was reduced from admission to discharge from 33.3% to 2.6%; TR from 43.6% to 10.3%; AV from 12.8% to 2.6%; IS from 82.1% to 17.9%; SC from 33.3% to 0%, SA from 17.9% to 2.6%, SIC from 69.2% to 30.8% (all significant at p<0.001). On reevaluation there were no significant changes of the parameters except SC which rose from 0% to 10.3% (p<0.001). FIM showed significant improvement from admission to both discharge and reevaluation for all parameters including social behavior, communication and memory (p< 0.001). Best results had pts. who were treated in ERC for at least 100 days. Pts. with early reimplantation of the bone had a better course than those with delayed reimplantation. Best prognostic factors were age <60y, absence of both hypertension and cardiac arrhythmia.
Conclusion: Pts. with SIBI and CRAN are disabled by severe impairment of motor and cognitive function. A 1/3 of them initially must be treated on an ICU and a 1/3 on a protected ward. They are disabled by artificial ventilation, tracheostoma and impaired swallowing, by both cognitive and emotional changes. However, longterm rehabilitation (best for 3 months) leads to excellent results for medical conditions, living activity, motor and cognitive functions. The patients should not be excluded from rehabilitation. 45% of them were finally living at home.
