Artikel
Management and outcome after decompressive hemicraniectomy for malignant hemispheric stroke after cardiac surgery
Management und Outcome nach dekompressiver Hemikraniektomie bei malignem Schlaganfall in Folge eines herzchirurgischen Eingriffs
Suche in Medline nach
Autoren
Veröffentlicht: | 25. Mai 2022 |
---|
Gliederung
Text
Objective: Neurosurgical management of malignant hemispheric stroke (MHS) after cardiac surgery remains difficult because decision-making needs to consider severe cardiovascular comorbidities and anticoagulation requirements. Here, we analyzed anticoagulation management and outcome in patients undergoing decompressive hemicraniectomy (DHC) for treatment of MHS following cardiothoracic surgery.
Methods: All consecutive patients that underwent DHC for MHS in our department as a complication of cardiothoracic surgery between June 2012 and November 2021 were included. Clinical and demographic data, anticoagulation management and postoperative hemorrhagic complications were assessed. Outcome was determined according to the modified Rankin Scale (mRS) score at 30 days and 3-6 months.
Results: Thirty patients with a female-to-male ratio of 1:1.7 and a mean age of 55±11 years (range 27-71) were identified. Depending on laboratory analysis and the type of preoperative anticoagulation and/or platelet inhibition, perioperative coagulation was corrected by platelet concentrates, fresh frozen plasma, prothrombin complex concentrate, tranexamic acid, or a combination of the above. Out of 30 patients, 15 (50%) experienced new postoperative hemorrhagic lesions with 4 out of 15 lesions (27%) being fatal. Notably, all but one hemorrhagic lesions occurred before the discontinued anticoagulation and/or platelet inhibition were re-initiated and despite perioperative discontinuation of anticoagulation and/or platelet inhibition, no coagulation-associated cardiovascular complications were noted. Overall mortality and neurological outcome at 30 days were 30% with a median mRS of 5 (IQR 4-6), which remained similar at 3-6 months [Mortality: 30%, median mRS: 5 (IQR 5-6)]. Multivariate linear regression suggested a trend towards worse outcome in patients with new postoperative hemorrhagic lesions.
Conclusion: In this series, discontinuation and correction of anticoagulation and/or platelet inhibition did not result in cardiovascular complications and DHC reduced mortality compared to the reported natural course of MHS (80%). However, decompressive surgery for MHS after cardiothoracic surgery also resulted in a high proportion of severely disabled patients, which needs to be considered during counselling and surgical decision-making.