gms | German Medical Science

Objective: Although decompressive hemicraniectomy (DHC) significantly reduces the mortality of malignant cerebral infarction (MCI), still a high rate of moderate to severe disability is observed among the survivors. Particularly the right point in time performing DHC has not been defined yet. In this study, we aimed to identify independent parameters predicting the outcome after DHC.

Methods: A retrospective analysis of patients with MCI, who underwent DHC from 2011 to 2016 was performed. The initial and preoperative clinical statuses were documented using the Glasgow Coma Scale (GCS). Volumetry of the infarction area was performed based on CT scans. The time from symptom onset to DHC was registered. The midline-shift and the presence of anisocoria were documented. The clinical outcome was determined using the modified Rankin scale (mRS) at discharge and categorized in favorable (0-3) and unfavorable (4-6) outcome. Multivariable logistic regression was performed using SPSS.

Results: A total of 90 patients (49 male, 41 female) were analyzed. The mean age was 58 years (25-86). The mean initial GCS score was 9.5 and directly before surgery 5.5.Midline-shift (mean 6.9; 1-35mm) was observed in 93% (84/90) and anisocoria in 14% (13/90) of the patients. DHC was performed in 64% (58/90) within 24, in 15% (13/90) within 48 and in 21% (16/90) within 72 hours after symptom onset. The mean initial infarction volume was 188ml and 305ml at discharge. Favorable outcome (mRS 0-3) had 14% (12/90) of the patients. A smaller infarction volume was associated with a better outcome (linear regression, p=0.0004). A better preoperative clinical status (GCS > 8) was significantly correlated with a smaller infarction volume (linear regression, p<0.0001) and with a favorable clinical outcome (linear regression, p=0.0003). A trend to smaller infarction volume in case of earlier DHC was found (linear regression, p=0.05). Multivariate analysis identified preoperative GCS as an independent predictor of infarction endvolume (OR 1.39 95%CI 1.12-1.73; p?=?0.003). Midline-shift and anisocoria were no predictors of outcome.

Conclusion: The preoperative clinical status according to GCS is an independent predictor of infarction endvolume after DHC in patients with MCI, which correlates with clinical outcome. Preoperative GCS > 8 and early DHC within 24 hours are associated with smaller infarction volume. A prospective study is needed to evaluate the right point in time for performing DHC for reducing disability among the survivors.