When You Are Old
See related article, p 2833.
W.B. Yeat’s exquisite poem, “When You Are Old,” has been variously interpreted, but to the literary rube, it could reflect a fundamental value that it is better to be alive than dead. A recent study on craniectomy for stroke investigates this.1
Prehistoric skulls have holes or trepanations/trephinations in them that are believed to have been made antemortem.2 Why these procedures were performed is unknown, but most are thought to have been for head injuries. As early as 1956, Scarcella operated on 6 patients with presumed cerebral infarctions, 2 of them in the acute stage, and recommended removing the infarcted tissue because the patients who did not have this done were more likely to die.3 Surgery to reduce mortality in patients with large cerebral infarctions was controversial until publication of randomized clinical trials in 2007.4,5
Some patients with ischemic stroke develop brain swelling and will die from this, particularly those with large hemispheric and cerebellar infarctions. The pathophysiology begins with edema formation that leads to brain swelling, increased local pressure in adjacent tissue, expansion of ischemia, hemorrhagic conversion, and a vicious cycle of further edema and swelling.6 Brain shifts develop that are associated with altered consciousness even before increased intracranial pressure develops.7,8
Edema and brain swelling, with or without hemorrhagic conversion, eventually leads to herniation, increased intracranial pressure, and death in ≤80% of patients with large cerebral infarctions.9 A review of published case series of craniectomy suggested it improved survival, with mortality being 24%, but that the effect on functional outcome was uncertain.10 These data in part stimulated the conduct of randomized clinical trials (Table I in the online-only Data Supplement). There are at least 6 randomized clinical trials …