CUT OFF VALUE OF GOOD PRONOSTIC FACTOR OUTCOMES IN LARGE TERRITORY ISCHEMIC STROKE UNDERGOING EARLY DECOMPRESSIVE CRANIECTOMY

  • Panu Boontoterm Neurosurgery Unit, Department of Surgery and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand https://orcid.org/0000-0002-3989-1301
  • Siraruj Sakoolnamarka Department of Surgery, Phramongkutklao Hospital, Phayathai, Bangkok, Thailand
  • Pusit Feungfoo Department of Surgery, Phramongkutklao Hospital, Phayathai, Bangkok, Thailand
  • Chesda Udommongkol Neurology Unit, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand
Keywords: Intractable cerebral edema, Large-territory ischemic strokes, Decompressive craniectomy, Modified Rankin Scale, Outcome predictor

Abstract

Background: Decompressive craniectomy (DC) significantly reduces mortality in large territory ischemic strokes that develop intractable cerebral edema. However, evidence for functional benefit remains sparse and contradictory.

Objective: This study aimed to assess cut-off value for predictor outcomes of early DC.

Methods: We conducted a prospective, observational cohort study from December 2016 to June 2021. Patients were screened for ischemic stroke involving the middle cerebral, internal carotid artery or both using the National Institutes of Health Stroke Scale score. All patients underwent DC. Multivariate analysis was performed for an array of clinical variables in relation to functional outcomes according to the modified Rankin Scale (mRS) and Pearson’s correlation coefficient analysis. Clinical outcome was assessed after 3- and 6-month follow-up.

Results: In total, 243 patients were included in this study. Age ≤71 years (AUC=0.955, p <0.001 accuracy 89.7%), onset to DC ≤9 hours (AUC=0.824, p <0.001 accuracy 78.8%), volume of infarction ≤155 cm3 (AUC=0.939, p <0.001 accuracy 93.6%) and the Alberta Stroke Program Early CT Score or ASPECT score ≥6 (AUC = 1, p <0.001 accuracy 100%) were significantly associated with good clinical outcomes in early DC (mRS 0 to 3).

Conclusion: Among patients with large territory ischemic strokes undergoing early DC, age ≤71 years, onset to DC ≤9 hours, volume of infarction ≤155 cm3 and ASPECT score ≥6 was significantly associated with good clinical outcomes. All prognostic factors in early DC correlated well with functional outcomes at 6 months which could be used to predict outcome, and consider clinical indications and informed postoperative complications among patients with large territory ischemic stroke.

Downloads

Download data is not yet available.

References

Berrouschot J, Sterker M, Bettin S, Köster J, Schneider D. Mortality of space-occupying (‘malignant’) middle cerebral artery infarction under conservative intensive care. Intensive Care Med 1998; 24: 620-3. DOI: https://doi.org/10.1007/s001340050625

Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R. ‘Malignant’ middle cerebral artery territory infarction: Clinical course and prognostic signs. Arch Neurol 1996; 53: 309-15.

Hofmeijer J, van der Worp HB, Kappelle LJ. Treatment of space-occupying cerebral infarction. Crit Care Med 2003; 31: 617-25. DOI: https://doi.org/10.1097/01.CCM.0000050446.16158.80

Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A, et al.Early decompressive surgery in malignant infarction of the middle cerebral artery: A pooled analysis of three randomised controlled trials. Lancet Neurol 2007; 6: 215-22.

Puetz V, Campos CR, Eliasziw M, Hill MD, Demchuk AM, Calgary Stroke Program. Assessing the benefits of hemicraniectomy: What is a favourable outcome? Lancet Neurol 2007; 6: 580. DOI: https://doi.org/10.1016/S1474-4422(07)70160-6

Kerrtesz A. Western Aphasia Battery. New York: Grune and Stratton;1982.

Heinsius T, Bogousslavsky J, Van Melle G. Large infarcts in the middle cerebral artery territory. Etiology and outcome patterns. Neurology1998; 50: 341-50. DOI: https://doi.org/10.1212/WNL.50.2.341

Krieger DW, Demchuk AM, Kasner SE, Jauss M, Hantson L. Early clinical and radiological predictors of fatal brain swelling in ischemic stroke. Stroke 1999; 30: 287-92. DOI: https://doi.org/10.1161/01.STR.30.2.287

Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R.’Malignant’ middle cerebral artery territory infarction: Clinical course and prognostic signs. Arch Neurol 1996; 53: 309-15. DOI: https://doi.org/10.1001/archneur.1996.00550040037012

Koh MS, Goh KY, Tung MY, Chan C. Is decompressive craniectomy for acute cerebral infarction of any benefit? Surg Neurol 2000; 53: 225-30.

Mori K, Nakao Y, Yamamoto T, Maeda M. Early external decompressive craniectomy with duroplasty improves functional recovery in patients with massive hemispheric embolic infarction: Timing and indication of decompressive surgery for malignant cerebral infarction. Surg Neurol 2004; 62: 420-29. DOI: https://doi.org/10.1016/S0090-3019(04)00151-X

Juttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, et al. Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (destiny): A randomized, controlled trial. Stroke 2007; 38: 2518-25. DOI: https://doi.org/10.1161/STROKEAHA.107.485649

Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: A pooled analysis of three randomised controlled trials. Lancet Neurol 2007; 6: 215-22. DOI: https://doi.org/10.1016/S1474-4422(07)70036-4

Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, et al. Sequentialdesign, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (decimal trial).Stroke 2007; 38: 2506-17.

Rahmanian A, Seifzadeh B, Razmkon A, Petramfar P, Kivelev J, Alibai EA, et al. Outcome of decompressive craniectomy in comparison to nonsurgical treatment in patients with malignant mca infarction. Springerplus 2014; 3: 115. DOI: https://doi.org/10.1186/2193-1801-3-115

van Middelaar T, Nederkoorn P, van der Worp HB, Stam J, Richard E. Quality of life after surgical decompression for space-occupying middle cerebral artery infarction: Systematic review. Int J Stroke 2015; 10: 170-76. DOI: https://doi.org/10.1111/ijs.12329

Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, vander Worp HB, et al. Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): A multicentre, open, randomised trial. Lancet Neurol 2009; 8: 326-33. DOI: https://doi.org/10.1016/S1474-4422(09)70047-X

Cruz-Flores S, Berge E, Whittle IR. Surgical decompression for cerebral oedema in acute ischaemic stroke. Cochrane Database Syst Rev 2012; 1: CD003435. DOI: https://doi.org/10.1002/14651858.CD003435.pub2

Gupta R, Connolly ES, Mayer S, Elkind MS. Hemicraniectomy for massive middle cerebral artery territory infarction: A systematic review. Stroke 2004; 35: 539-43. DOI: https://doi.org/10.1161/01.STR.0000109772.64650.18

Arac A, Blanchard V, Lee M, Steinberg GK. Assessment of outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 60 years of age. Neurosurg Focus 2009; 26: E3. DOI: https://doi.org/10.3171/2009.3.FOCUS0958

Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, et al. Sequentialdesign, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (decimal trial). Stroke 2007; 38: 2506-17. DOI: https://doi.org/10.1161/STROKEAHA.107.485235

Carter BS, Ogilvy CS, Candia GJ, Rosas HD, Buonanno F. One-year outcome after decompressive surgery for massive nondominant hemispheric infarction. Neurosurgery 1997; 40: 1168-76. DOI: https://doi.org/10.1097/00006123-199706000-00010

Holtkamp M, Buchheim K, Unterberg A, Hoffmann O, Schielke E, Weber JR, et al. Hemicraniectomy in elderly patients with space occupying media infarction: improved survival but poor functional outcome. J Neurol Neurosurg Psychiatry 2001; 70: 226-8. DOI: https://doi.org/10.1136/jnnp.70.2.226

Walz B, Zimmemann C, Bottger S, Haberl RL. Prognosis of patients after hemicraniectomy in malignant middle cerebral artery infarction. J Neurol 2002; 249: 1183-90. DOI: https://doi.org/10.1007/s00415-002-0798-x

Koh M, Goh K, Tung MYY, Chan C. Is decompressive craniectomy for acute cerebral infarction of any benefit? Surg Neurol 2000; 53: 225-30. DOI: https://doi.org/10.1016/S0090-3019(00)00163-4

Nakayama H, Jorgensen HS, Raaschou HO, Olsen TS. The influence of age on stroke outcome. The Copenhagen Stroke Study. Stroke 1994; 25: 808-13. DOI: https://doi.org/10.1161/01.STR.25.4.808

Foerch C, Lang JM, Jochen K, Raabe A, Sitzer M, Seifert V, et al. Functional impairment, disability, and quality of life outcome after decompressive hemicraniectomy in malignant middle cerebral artery infarction. J Neurosurg 2004; 101: 248-54. DOI: https://doi.org/10.3171/jns.2004.101.2.0248

Uhl E, Kreth FW, Elias B, Goldammer A, Hempelmann RG, Liefner M, et al. Outcome and prognostic factors of hemicraniectomy for space occupying cerebral infarction. J Neurol Neurosurg Psychiatry 2004; 75: 270-4.

Forsting M, Reith W, Schabitz WR, Heiland S, Kummer R, Hacke W, et al. Decompressive craniectomy for cerebral infarction: an experimental study in rats. Stroke 1995; 26: 259-64. DOI: https://doi.org/10.1161/01.STR.26.2.259

Schwab S, Steiner T, Aschoff A, Schwarz S, Steiner HH, Jansen O, et al. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 1998; 29: 1888–93. DOI: https://doi.org/10.1161/01.STR.29.9.1888

Cho DY, Chen TC, Lee HC. Ultra-early decompressive craniectomy for malignant middle cerebral artery infarction. Surg Neurol 2003; 60: 227-32. DOI: https://doi.org/10.1016/S0090-3019(03)00266-0

Barber PA, Davis SM, Darby DG, Desmond PM, Gerraty RP, Yang Q, et al. Absent middle cerebral artery flow predicts the presence and evolution of the ischemic penumbra. Neurology 1999; 52: 1125-32. DOI: https://doi.org/10.1212/WNL.52.6.1125

Oppenheim C, Samson Y, Manai R, Lalam T, Vandamme X, Crozier S, et al. Prediction of malignant middle cerebral artery infarction by diffusion weighted imaging. Stroke 2000; 31: 2175-81. DOI: https://doi.org/10.1161/01.STR.31.9.2175

Published
2022-03-17
How to Cite
1.
Boontoterm P, Sakoolnamarka S, Feungfoo P, Udommongkol C. CUT OFF VALUE OF GOOD PRONOSTIC FACTOR OUTCOMES IN LARGE TERRITORY ISCHEMIC STROKE UNDERGOING EARLY DECOMPRESSIVE CRANIECTOMY. J Southeast Asian Med Res [Internet]. 2022Mar.17 [cited 2022May26];60:e0102. Available from: https://www.jseamed.org/index.php/jseamed/article/view/102
Section
Original Articles