Article
Predictors of outcome after decompressive hemicraniectomy for malignant cerebral infarction
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Published: | June 9, 2017 |
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Objective: Decompressive hemicraniectomy (DHC) significantly reduces the mortality of malignant cerebral infarction (MCI), but still a high rate of disability is observed among the survivors. Although DHC has been increasingly used in the last years, the right point of time to perform DHC is still not defined. In this study, we aimed to identify parameters associated with outcome after DHC, that would facilitate the treatment decision-making in patients with MCI.
Methods: A retrospective analysis of patients with MCI, who underwent DHC from 2011 to 2015 was performed. The initial and preoperative clinical status were documented using the Glasgow Coma Scale (GCS). Volumetric measurements of the infarction area were performed preoperatively and at discharge based on the CT scans. The time from symptom onset to DHC was noted. The midline-shift and the presence of anisocoria were documented. The clinical outcome was determined according to the modified Rankin scale (mRS) at discharge.
Results: A total of 90 patients (49 male, 41 female) were analyzed. The mean age was 58 years (25–86). The mean initial GCS was 9.5 and direct preoperatively 5.5. In 93% (84/90) a midline-shift (mean 6.9; 1–35mm) and in 14% (13/90) anisocoria was observed direct preoperatively. The DHC was performed in 64% (58/90) within 24 hours, in 15% (13/90) within 48 hours and in 21% (16/90) within 72 hours after symptom onset. The mean initial infarction volume was 188ml and 305ml at discharge. Good outcome (mRS 0-3) had 14% (12/90). A smaller infarction volume was associated with a better outcome (linear regression, p=0.0004). A better preoperative clinical status was correlated with a smaller infarction volume (linear regression, p<0.0001) and with a better outcome (linear regression, p=0.0003). A trend of smaller infarction volume in case of earlier DHC was found (linear regression, p=0.05). Midline-shift and anisocoria were no predictors of outcome.
Conclusion: The preoperative clinical status is a predictor of infarction volume and of clinical outcome after DHC for MCI. A prospective study is needed to evaluate the right point of time for performing DHC in order to reduce disability among the survivors with MCI.