Predictors of decompressive hemicraniectomy in malignant middle cerebral artery stroke

Abstract

Identification of factors in malignant middle cerebral artery (MMCA) stroke patients that may be useful in selecting patients for DHC. This study was a retrospective multicenter study of patients referred for DHC based on the criteria of the randomized control trials of DHC in MMCA stroke. Demographic, clinical, and radiology data were analyzed. Patients who underwent DHC were compared to those who survived without surgery. Two hundred three patients with MMCA strokes were identified: 137 underwent DHC, 47 survived without DHC, and 19 refused surgery and died. Multivariate analysis identified the following factors determining DHC in MMCA stroke: age < 55 years (OR 8.5, 95% CI 3.3-22.1, P < 0.001), MCA with involvement of additional vascular territories (anterior cerebral artery, posterior cerebral artery (OR 4.8, 95% CI 1.5-14.9, P = 0.007), septum pellucidum displacement ≥ 7.5 mm (OR 4.8, 95% CI 1.9-11.7, P = 0.001), diabetes (OR 3.7, 95% CI 1.3-10.6, P = 0.012), infarct growth rate (IGR) ml/h (OR 1.11, 95% CI 1.02-1.2, P = 0.015), and temporal lobe involvement (OR 2.5, 95% CI 1.01-6.1, P = 0.048). The internal validation of the multivariate logistic regression model using bootstrapping analysis showed marginal bias. Among patients with MMCA infarctions, an increased possibility of DHC is associated with younger age, MCA with additional infarction, septum pellucidum deviation of > 7.5 mm, diabetes, IGR, and temporal lobe involvement. The presence of these risk factors identifies those MMCA stroke patients who may require DHC. Bootstrapping analysis indicated the model is good enough to predict the outcome in general population.

Cerebral Venous Drainage in Patients With Space-Occupying Middle Cerebral Artery Infarction: Effects on Functional Outcome After Hemicraniectomy

“…About one-third of patients of the cohort had an additional infarction of the ACA/PCA territory, reflecting clinical practice to select patients for hemicraniectomy at our center during the study period. In previous studies, higher MCA infarction volume and occurrence of additional ACA/PCA infarction were shown to be independent predictors for poor outcome in patients with MCA infarction and hemicraniectomy ( 24 , 25 ). Additional ACA/PCA infarction was more frequently observed in patients with poor outcome in our cohort, although not independently predictive for outcome, which is attributable in part to the number of patients included in our cohort.…”

Radiologic and Blood Markers Predicting Long-Term Neurologic Outcome Following Decompressive Craniectomy for Malignant Ischemic Stroke: A Preliminary Single-Center Study

“…Basal cistern effacement before DC, in particular, is a well-known marker of increased ICP, and one of the most accredited factors affecting prognosis. 5,6,[18][19][20] Fatima et al 18 reported postoperative radiologic markers of decreased ICP (absence of effacement of cortical sulci, absence of compression of the lateral ventricle) and absence of hemorrhagic transformation to be predictors of good neurologic outcomes following MIS. In contrast to this report, we were not able to identify specific patterns of postoperative CT findings to be associated with good neurologic outcomes.…”

“…extent (p=0.001), compression of basal (p=0.02), Sylvian (p=0.02), ambiens (p=0.04), and quadrigeminal cisterns (p=0.01), and the evidence of cerebral herniation (p=0.001). Basal cistern effacement before DC, in particular, is a well-known marker of increased ICP, and one of the most accredited factors affecting prognosis [5,6,[18][19][20]. Fatima et al [18], reported post-operative radiological markers of decreased ICP (absence of effacement of cortical sulci, absence of compression of the lateral ventricle) and absence of hemorrhagic transformation to be predictors of good neurological outcomes following MIS.…”