Decompressive craniotomy for the treatment of malignant infarction of the middle cerebral artery: mortality and outcome

Bongiorni, Gianise Toboliski; Hockmuller, Marjeane Cristina Jaques; Klein, Cristini; Antunes, Ápio Cláudio Martins

doi:10.1590/0004-282X20170053

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ARTICLES • Arq. Neuro-Psiquiatr. 75 (7) • July 2017 • https://doi.org/10.1590/0004-282X20170053 copy

Decompressive craniotomy for the treatment of malignant infarction of the middle cerebral artery: mortality and outcome

Craniotomia descompressiva para tratamento do infarto maligno da artéria cerebral media: mortalidade e desfecho

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective

To assess, by Rankin scale, the functional disability of patients who had a malignant middle cerebral artery (MCA) ischemic stroke, who underwent decompressive craniotomy (DC) within the first 30 days.

Methods

A cross-sectional study in a University hospital. Between June 2007 and December 2014, we retrospectively analyzed the records of all patients submitted to DC due to a malignant MCA infarction. The mortality rate was defined during the hospitalization period. The modified outcome Rankin score (mRS) was measured 30 days after the procedure, for stratification of the quality of life.

Results

The DC mortality rate was 30% (95% CI 14.5 to 51.9) for the 20 patients reported. The mRS 30 days postoperatively was ≥ 4 [3.3 to 6] for all patients thereafter.

Conclusion

DC is to be considered a real alternative for the treatment of patients with a malignant ischemic MCA infarction.

craniotomy; cerebral infarction; intracranial hypertension

Protocol inclusion criteria
National Institutes of Health Stroke Scale (NIHSS) > 15, clinical evidence of MCA extensive infarction (complete hemiparesis contralateral to the lesion, homonymous hemianopsia contralateral to the lesion, tendency for oculocephalic deviation towards the lesion, language alteration, heminegligence);
Age ≤ 60 years (in patients older than 60 years, the decision must be individualized);
Tomographic evidence of early hypodensity involving cortico-subcortical topography > 50% of the MCA territory.

Protocol exclusion criteria

Other previous incapacitating diseases (skeletal muscle, neurologic or clinical);
Signs of severe neurological deterioration at the time of surgical indication (unilateral or bilateral pupil dilatation, with mydriasis or absence of photo-reaction, and/or signs of pathological extension or flexion);
Severe clinical complications;
Terminal illness;
mRS ≥ 3;
Clotting disorders;
Unavailability of the intensive care unit (ICU) beds;
Hemodynamic instability at the time of surgical indication.

Patient initial follow-up

Second CT between 6–12 hours after patient arrival, or less, in the case of neurological deterioration – early detection of the malignant evolution;
After the second CT: new CT every six to eight hours.

Indication for decompressive surgery

Any neurological deterioration in relation to the admission or history of neurological deterioration since the beginning of the symptoms;
Any tomographic worsening (extension of the infarction or worsening of the space-occupying effect).

Levels of evidence of the recommendations

Early DC is recommended for the treatment of MCA space occupying cerebral infarction in patients up to 60 years of age, before the manifestation of clinical or radiological signs of cerebral herniation, within the time span of 48 hours (evidence level 1, recommendation grade A - Systematic Review (with homogeneity) of controlled and randomized clinical trials).
The decision of DC for patients older than 60 years of age or after 48 hours must be individualized. (evidence level 4, recommendation grade C - case reports (including cohort or case control of lesser quality).
The independent variables studied were: age, sex, marital status, time elapsed between ictus and surgery, first CT and surgery and the score of the National Institutes of Health Stroke Scale (NIHSS) upon admission.
The mRS evaluates the functionality of the individual after a CVA (either ischemic or hemorrhagic) and it became an important clinical tool capable of estimating the prognosis and the outcome. It comprises seven items, with a score of zero being considered without symptoms, and a score of 6 being death (Addendum 1).
The primary regarded outcomes were death and hospital discharge: surgical deaths were considered up to 30 days after the DC operation. For every patient, the mRS scores were measured: those that died scored 6; patients discharged from hospital within 30 days had their score measured at that time.

Demographic variables	n = 20
Age (years)*	52.7 ± 7.4
Sex (%)**
Male	11 (55)
Female	9 (45)
Skin color (%)**
White	15 (75)
Black	5 (25)

Variables	n = 20
Ictus time x admission (hours)*	13.2 ± 1.4
Hospitalization NIHSS (score)*	17.6 ± 3.2
NCI evaluation x surgery (hours)**	2.9 [1.9–4.4]
Ictus time x surgery (hours)**	28.1 [21.2–50.6]
Clinical worsening after 1st NCI evaluation (%)***	13 (65)
Nº of CTs before surgery**	2 [1.2–3]
Time interval between surgery and last CT (hours)**	7.7 [2.3–14.8]
Rankin (30 days score)**	4 [3.3–6]
Rankin (discharge score)**	4 [3–4]
Discharge rate (%)***	14 (70)
Death rate (%)***	6 (30)
Hospitalization time (days)**	21.5 [9.5–34.5]

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E-mail: revista.arquivos@abneuro.org

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[1] Correspondence: Gianise Toboliski Bongiorni; Hospital de Clínicas de Porto Alegre; Rua Ramiro Barcelos, 2350; 90035-007 Porto Alegre RS, Brasil; E-mail: gianise1@hotmail.com