CT pattern of Infarct location and not infarct volume determines outcome after decompressive hemicraniectomy for Malignant Middle Cerebral Artery Stroke

Abstract

Malignant middle cerebral artery [MMCA] infarction has a different topographic distribution that might confound the relationship between lesion volume and outcome. Retrospective study to determine the multivariable relationship between computerized tomographic [CT] infarct location, volume and outcomes in decompressive hemicraniectomy [DHC] for MMCA infarction. The MCA infarctions were classified into four subgroups by CT, subtotal, complete MCA [co-MCA], Subtotal MCA with additional infarction [Subtotal MCAAI] and co-MCA with additional infarction [Co-MCAAI]. Maximum infarct volume [MIV] was measured on the pre-operative CT. Functional outcome was measured by the modified Rankin Scale [mRS] dichotomized as favourable 0–3 and unfavourable ≥4, at three months. In 137 patients, from least favourable to favourable outcome were co-MCAAI, subtotal MCAAI, co-MCA and subtotal MCA infarction. Co-MCAAI had the worst outcome, 56/57 patients with additional infarction had mRS ≥ 4. Multiple comparisons Scheffe test showed no significant difference in MIV of subtotal infarction, co-MCA, Subtotal MCAAI but the outcome was significantly different. Multivariate analysis confirmed MCAAI [7.027 (2.56–19.28), p = 0.000] as the most significant predictor of poor outcomes whereas MIV was not significant [OR, 0.99 (0.99–01.00), p = 0.594]. Other significant independent predictors were age ≥ 55 years 12.14 (2.60–56.02), p = 0.001 and uncal herniation 4.98(1.53–16.19), p = 0.007]. Our data shows the contribution of CT infarction location in determining the functional outcome after DHC. Subgroups of patients undergoing DHC had different outcomes despite comparable infarction volumes.

Association of Infarct Volume Before Hemicraniectomy and Outcome After Malignant Infarction

“…13 Last, a retrospective study of 134 patients after hemicraniectomy did not find infarct volume to be as predictive of outcome as the location of the infarction. 12 In our opinion, these opposite results are driven mainly by late CT examinations and hemicraniectomy procedures after 48 hours of symptom onset with signs of impending transtentorial herniation in most of the patients.…”

“…[8][9][10][11] In contrast, others have suggested that infarct volume may not be a useful predictor of outcome after hemicraniectomy. 12,13 More data from larger cohorts are necessary to resolve this issue. The aim of the current study was to evaluate the predictive value of volumetrically assessed infarct size in patients who receive hemicraniectomy on the functional long-term outcome in a large prospective multicenter study.…”

Decompressive Craniectomy in Extensive Ischemic Stroke. An Experience in a Single Institution

“…Considering that nonsurgical treatment to reduce ICP has been shown to be mostly ineffective, the release of the cranial vault and of the dura mater allows the edematous brain tissue to expand outwards, thus offering a clear survival advantage, decreasing the mortality rate from 80% to ∼ 20%, which appears to be related to changes in the pressure gradients that develop within the skull, provided by surgical decompression. 7 8 9 10…”

“…Considering that nonsurgical treatment to reduce ICP has been shown to be mostly ineffective, the release of the cranial vault and of the dura mater allows the edematous brain tissue to expand outwards, thus offering a clear survival advantage, decreasing the mortality rate from 80% to $ 20%, which appears to be related to changes in the pressure gradients that develop within the skull, provided by surgical decompression. 7,8,9,10 There are currently no well-defined levels for the treatment of elevated ICP caused by clinical conditions other than traumatic brain injury. However, in different medical centers, therapy is started when ICP is > 20 to 25 mmHg.…”