The Wessex modified Richmond Sedation Scale as a novel tool for monitoring patients at risk of malignant MCA syndrome
The Wessex Modified Richmond Sedation Scale (WMRSS) has been developed with the aim of improving the early identification of patients requiring decompressive hemicraniectomy for malignant middle cerebral artery syndrome (MMS). The objective of this study was to evaluate the WMRSS against the Glasgow Coma Scale (GCS).
A retrospective study was conducted of patients admitted to our unit for observation of MMS. Data were obtained on WMRSS and GCS recordings from admission up to 120-h post-ictus. Patients’ meeting inclusion criteria were recommended for theatre based on subsequent deteriorations in consciousness on either WMRSS or GCS from a 6-h post-stroke baseline, after ruling out non-neurological causes.
Approximately, 60% of those eligible for monitoring were not recommended for theatre, and none died; however, these patients continued to demonstrate some variability in recorded conscious level. Patients requiring surgical intervention showed earlier drops in WMRSS compared to GCS. Neither the GCS nor the WMRSS on admission predicted the subsequent need for decompressive surgery. There was no increase in mortality with the introduction of WMRSS.
WMRSS adds value to monitoring MMS by indicating need for surgery prior to GCS. Early reduction in consciousness may not be sufficient for proceeding to surgical intervention, but subsequent reduction in consciousness may be a more appropriate criterion for surgery.
KeywordsMalignant MCA syndrome Glasgow coma scale Stroke
Compliance with ethical standards
Approval for the study was obtained from Southampton University Hospitals NHS Trust Clinical Effectiveness Committee (Ref: ZUAD3316) and University of Southampton Ethics and Research Governance Committee (Ref: 14786). For this type of study formal consent is not required.
Conflict of interest
The authors declare that they have no conflict of interest.
- 8.Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp HB, investigators HAMLET (2009) Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol 8(4):326–333CrossRefPubMedGoogle Scholar
- 9.Jüttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, Witte S, Jenetzky E, Hacke W, DESTINY Study Group (2007) Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke 38(9):2518–2525CrossRefPubMedGoogle Scholar
- 10.Kamran S, Akhtar N, Salam A, Alboudi A, Kamran K, Ahmed A, Khan RA, Mirza MK, Inshasi J, Shuaib A (2017) Revisiting hemicraniectomy: late decompressive hemicraniectomy for malignant middle cerebral artery stroke and the role of infarct growth rate. Stroke Res Treat 2017:2507834PubMedPubMedCentralGoogle Scholar
- 15.Ronchetti G, Panciani PP, Stefini R, Spena G, Fontanella MM (2014) Acute supratentorial ischemic stroke: when surgery is mandatory. Biomed Res Int 2014:624126Google Scholar