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Malign Orta Serebral Arter Enfarktüsü İçin Dekompresif Kraniyotomi: Prospektif Bir Kohort Çalışması

Year 2024, Volume: 8 Issue: 2, 234 - 241, 27.08.2024
https://doi.org/10.46332/aemj.1355202

Abstract

Amaç: Malign orta serebral arter (Middle Cerebral Artery- MCA) infarktları için ölüm oranı çok yüksektir. Dekompresif kraniyotomi (DK) mortaliteyi azaltıyor gibi görünse de yaşam kalitesi halen güncel bir tartışma konusudur. Yüksek hacimli üçüncü basamak hastanemizde medikal veya cerrahi olarak tedavi edilen malign MCA enfarktüslü hastaların sonuçlarını sunmayı amaçladık.

Araçlar ve Yöntem: Çalışma prospektif kohort olarak tasarlanmıştır. Kriterleri karşılayan her hastaya DK önerildi, kabul etmeyenler kontrol medikal tedavi grubu olarak takibe alındı. Hastalar ameliyat öncesi, ameliyat sonrası erken dönem ve 1./3./6./12. aylarda değerlendirilmiştir.

Bulgular: Kırk iki hasta çalışmaya dahil edildi (17/ameliyat, 25/medikal). Her takip döneminde DK hastalarının hayatta kalma oranları, sadece tıbbi tedavi alanlardan daha yüksekti. Bu fark postoperatif 1., 3. ve 6. aylarda da anlamlıydı. Ek olarak, modifiye Rankin Ölçeği incelemesi, DK'nin her kontrol periyodunda üstün olduğunu göstermiştir.

Sonuç: Çalışmamızda DK uygulanan hastaların mortalitesinin (sadece medical tedavi uygulananlara göre daha düşük olsa da) diğer serilere göre daha yüksek olması, ameliyat sırasındaki nörolojik durumun kötü olması ile açıklanabilir. Ameliyat endikasyonu için hastanın durumunun çok kötüleşmesi beklenmemelidir. Bu amaçla hastaların nörolojik durumundaki kötüleşmenin erken dönemde sık muayene ile beyin cerrahına bildirilmesi gerekmektedir. Nörolojik durumunda kötüleşme olasılığı olan hastaların beyin cerrahisi kliniğine sevk edilmesi alternatif bir çözüm olabilir.

References

  • 1. Collaborators GBDS. Global, regional, and national burden of stroke, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019;18(5):439-458.
  • 2. Saini V, Guada L, Yavagal DR. Global Epidemiology of Stroke and Access to Acute Ischemic Stroke Interventions. Neurology. 2021;97(20):6-16.
  • 3. Collaborators GBDS. Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2021;20(10):795-820.
  • 4. Kjellberg RN, Prieto A, Jr. Bifrontal decompressive craniotomy for massive cerebral edema. J Neurosurg. 1971;34(4):488-493.
  • 5. Rengachary SS, Batnitzky S, Morantz RA, Arjunan K, Jeffries B. Hemicraniectomy for acute massive cerebral infarction. Neurosurgery. 1981;8(3):321-328.
  • 6. Mori K, Aoki A, Yamamoto T, Horinaka N, Maeda M. Aggressive decompressive surgery in patients with massive hemispheric embolic cerebral infarction associated with severe brain swelling. Acta Neurochir (Wien). 2001;143(5):483-491.
  • 7. Rieke K, Schwab S, Krieger D, et al. Decompressive surgery in space-occupying hemispheric infarction: results of an open, prospective trial. Crit Care Med. 1995;23(9):1576-1587.
  • 8. Schwab S, Steiner T, Aschoff A, et al. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke. 1998;29(9):1888-1893.
  • 9. Bansal H, Chaudhary A, Singh A, Paul B, Garg R. Decompressive craniectomy in malignant middle cerebral artery infarct: An institutional experience. Asian J Neurosurg. 2015;10(3):203-206.
  • 10. Jüttler E, Schwab S, Schmiedek P, et al. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke. 2007;38(9):2518 -2525.
  • 11. Hofmeijer J, Amelink GJ, Algra A, et al. Hemicraniectomy after middle cerebral artery infarction with life-threatening Edema trial (HAMLET). Protocol for a randomised controlled trial of decompressive surgery in space-occupying hemispheric infarction. Trials. 2006;7:1-7.
  • 12. Aberg E, Adielsson G, Britton M, et al. Multicenter trial of hemodilution in ischemic stroke--background and study protocol. Scandinavian Stroke Study Group. Stroke. 1985;16(5):885-890.
  • 13. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974; 2(7872):81-84.
  • 14. Bamford JM, Sandercock PA, Warlow CP, Slattery J. Interobserver agreement for the assessment of handicap in stroke patients. Strok. 1989;20(6):828.
  • 15. Mahoney FI, Barthel DW. Functional Evaluation: The Barthel Index. Md State Med J. 1965;14:61-65.
  • 16. Kilincer C, Asil T, Utku U, et al. Factors affecting the outcome of decompressive craniectomy for large hemispheric infarctions: a prospective cohort study. Acta Neurochir (Wien). 2005;147(6):587-594.
  • 17. Fiorot JA, Jr., Silva GS, Cavalheiro S, Massaro AR. Use of decompressive craniectomy in the treatment of hemispheric infarction. Arq Neuropsiquiatr. 2008;66(2A):204-208.
  • 18. Gupta R, Connolly ES, Mayer S, Elkind MS. Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review. Stroke. 2004;35(2):539-543.
  • 19. Sedney CL, Julien T, Manon J, Wilson A. The effect of craniectomy size on mortality, outcome, and complications after decompressive craniectomy at a rural trauma center. J Neurosci Rural Pract. 2014;5(3):212-217.
  • 20. Schur S, Martel P, Marcoux J. Optimal Bone Flap Size for Decompressive Craniectomy for Refractory Increased Intracranial Pressure in Traumatic Brain Injury: Taking the Patient's Head Size into Account. World Neurosurg. 2020;137:430-436.
  • 21. Macha K, Schwab S. It is all about timing: decompressive hemicraniectomy for malignant middle-cerebral-artery infarction. Arq Neuropsiquiatr. 2023;81(4):327-328.
  • 22. Montalbetti M, Lörcher S, Nowacki A, et al. How much space is needed for decompressive surgery in malignant middle cerebral artery infarction: Enabling single-stage surgery. Brain Spine. 2023;3:101730.
  • 23. Tanrikulu L, Oez-Tanrikulu A, Weiss C, et al. The bigger, the better? About the size of decompressive hemicraniectomies. Clin Neurol Neurosurg. 2015;135:15-21.

Decompressive Craniotomy for Malignant Middle Cerebral Artery Infarction: A Prospective Cohort Study

Year 2024, Volume: 8 Issue: 2, 234 - 241, 27.08.2024
https://doi.org/10.46332/aemj.1355202

Abstract

Purpose: For malignant middle cerebral artery (MCA) infarctions, the mortality rate is very high. Although decompressive craniotomy (DC) appears to reduce mortality, the quality of life remains a current topic of debate. We aimed to present the outcomes of patients with malignant MCA infarctions treated medically or surgically at our high-volume tertiary care hospital.

Materials and Methods: The study was designed as a prospective cohort. Decompressive craniotomy (DC) was offered to all patients meeting the criteria, while those who declined were included in the control group receiving medical treatment. Patients were evaluated preoperatively and early postoperatively and also in the follow-ups at 1, 3, 6, and 12 months.

Result: Forty-two patients were included in the study (17/surgery, 25/medical). Survival rates of those who received DC in each follow-up period were higher than those who received only medical treatment. This difference was also significant at the postoperative 1st, 3rd, and 6th months. In addition, the modified Rankin-Scale examination showed that DC was superior in each control period.
Conclusion: In our study, the higher mortality among patients who underwent DC, albeit lower than those treated with medical therapy alone, could be attributed to poorer neurological status at the time of surgery compared to other series. The indication for surgery should not wait until the patient's condition deteriorates significantly. Therefore, it is crucial to promptly report any neurological deterioration observed during early period to the neurosurgeon. Referring patients who are at risk of neurological decline to a neurosurgery clinic could serve as an alternative solution.

Ethical Statement

Izmir Ataturk Training and Research Hospital's local ethics committee approved it with the decision number 2003/7.

References

  • 1. Collaborators GBDS. Global, regional, and national burden of stroke, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019;18(5):439-458.
  • 2. Saini V, Guada L, Yavagal DR. Global Epidemiology of Stroke and Access to Acute Ischemic Stroke Interventions. Neurology. 2021;97(20):6-16.
  • 3. Collaborators GBDS. Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2021;20(10):795-820.
  • 4. Kjellberg RN, Prieto A, Jr. Bifrontal decompressive craniotomy for massive cerebral edema. J Neurosurg. 1971;34(4):488-493.
  • 5. Rengachary SS, Batnitzky S, Morantz RA, Arjunan K, Jeffries B. Hemicraniectomy for acute massive cerebral infarction. Neurosurgery. 1981;8(3):321-328.
  • 6. Mori K, Aoki A, Yamamoto T, Horinaka N, Maeda M. Aggressive decompressive surgery in patients with massive hemispheric embolic cerebral infarction associated with severe brain swelling. Acta Neurochir (Wien). 2001;143(5):483-491.
  • 7. Rieke K, Schwab S, Krieger D, et al. Decompressive surgery in space-occupying hemispheric infarction: results of an open, prospective trial. Crit Care Med. 1995;23(9):1576-1587.
  • 8. Schwab S, Steiner T, Aschoff A, et al. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke. 1998;29(9):1888-1893.
  • 9. Bansal H, Chaudhary A, Singh A, Paul B, Garg R. Decompressive craniectomy in malignant middle cerebral artery infarct: An institutional experience. Asian J Neurosurg. 2015;10(3):203-206.
  • 10. Jüttler E, Schwab S, Schmiedek P, et al. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke. 2007;38(9):2518 -2525.
  • 11. Hofmeijer J, Amelink GJ, Algra A, et al. Hemicraniectomy after middle cerebral artery infarction with life-threatening Edema trial (HAMLET). Protocol for a randomised controlled trial of decompressive surgery in space-occupying hemispheric infarction. Trials. 2006;7:1-7.
  • 12. Aberg E, Adielsson G, Britton M, et al. Multicenter trial of hemodilution in ischemic stroke--background and study protocol. Scandinavian Stroke Study Group. Stroke. 1985;16(5):885-890.
  • 13. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974; 2(7872):81-84.
  • 14. Bamford JM, Sandercock PA, Warlow CP, Slattery J. Interobserver agreement for the assessment of handicap in stroke patients. Strok. 1989;20(6):828.
  • 15. Mahoney FI, Barthel DW. Functional Evaluation: The Barthel Index. Md State Med J. 1965;14:61-65.
  • 16. Kilincer C, Asil T, Utku U, et al. Factors affecting the outcome of decompressive craniectomy for large hemispheric infarctions: a prospective cohort study. Acta Neurochir (Wien). 2005;147(6):587-594.
  • 17. Fiorot JA, Jr., Silva GS, Cavalheiro S, Massaro AR. Use of decompressive craniectomy in the treatment of hemispheric infarction. Arq Neuropsiquiatr. 2008;66(2A):204-208.
  • 18. Gupta R, Connolly ES, Mayer S, Elkind MS. Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review. Stroke. 2004;35(2):539-543.
  • 19. Sedney CL, Julien T, Manon J, Wilson A. The effect of craniectomy size on mortality, outcome, and complications after decompressive craniectomy at a rural trauma center. J Neurosci Rural Pract. 2014;5(3):212-217.
  • 20. Schur S, Martel P, Marcoux J. Optimal Bone Flap Size for Decompressive Craniectomy for Refractory Increased Intracranial Pressure in Traumatic Brain Injury: Taking the Patient's Head Size into Account. World Neurosurg. 2020;137:430-436.
  • 21. Macha K, Schwab S. It is all about timing: decompressive hemicraniectomy for malignant middle-cerebral-artery infarction. Arq Neuropsiquiatr. 2023;81(4):327-328.
  • 22. Montalbetti M, Lörcher S, Nowacki A, et al. How much space is needed for decompressive surgery in malignant middle cerebral artery infarction: Enabling single-stage surgery. Brain Spine. 2023;3:101730.
  • 23. Tanrikulu L, Oez-Tanrikulu A, Weiss C, et al. The bigger, the better? About the size of decompressive hemicraniectomies. Clin Neurol Neurosurg. 2015;135:15-21.
There are 23 citations in total.

Details

Primary Language English
Subjects Clinical Sciences (Other)
Journal Section Original Articles
Authors

Hasan Kamil Sucu 0000-0002-2795-9049

Mustafa Kemal Arı 0000-0001-6947-8924

Selin Bozdağ 0000-0002-3355-8954

Early Pub Date August 20, 2024
Publication Date August 27, 2024
Published in Issue Year 2024 Volume: 8 Issue: 2

Cite

APA Sucu, H. K., Arı, M. K., & Bozdağ, S. (2024). Decompressive Craniotomy for Malignant Middle Cerebral Artery Infarction: A Prospective Cohort Study. Ahi Evran Medical Journal, 8(2), 234-241. https://doi.org/10.46332/aemj.1355202
AMA Sucu HK, Arı MK, Bozdağ S. Decompressive Craniotomy for Malignant Middle Cerebral Artery Infarction: A Prospective Cohort Study. Ahi Evran Med J. August 2024;8(2):234-241. doi:10.46332/aemj.1355202
Chicago Sucu, Hasan Kamil, Mustafa Kemal Arı, and Selin Bozdağ. “Decompressive Craniotomy for Malignant Middle Cerebral Artery Infarction: A Prospective Cohort Study”. Ahi Evran Medical Journal 8, no. 2 (August 2024): 234-41. https://doi.org/10.46332/aemj.1355202.
EndNote Sucu HK, Arı MK, Bozdağ S (August 1, 2024) Decompressive Craniotomy for Malignant Middle Cerebral Artery Infarction: A Prospective Cohort Study. Ahi Evran Medical Journal 8 2 234–241.
IEEE H. K. Sucu, M. K. Arı, and S. Bozdağ, “Decompressive Craniotomy for Malignant Middle Cerebral Artery Infarction: A Prospective Cohort Study”, Ahi Evran Med J, vol. 8, no. 2, pp. 234–241, 2024, doi: 10.46332/aemj.1355202.
ISNAD Sucu, Hasan Kamil et al. “Decompressive Craniotomy for Malignant Middle Cerebral Artery Infarction: A Prospective Cohort Study”. Ahi Evran Medical Journal 8/2 (August 2024), 234-241. https://doi.org/10.46332/aemj.1355202.
JAMA Sucu HK, Arı MK, Bozdağ S. Decompressive Craniotomy for Malignant Middle Cerebral Artery Infarction: A Prospective Cohort Study. Ahi Evran Med J. 2024;8:234–241.
MLA Sucu, Hasan Kamil et al. “Decompressive Craniotomy for Malignant Middle Cerebral Artery Infarction: A Prospective Cohort Study”. Ahi Evran Medical Journal, vol. 8, no. 2, 2024, pp. 234-41, doi:10.46332/aemj.1355202.
Vancouver Sucu HK, Arı MK, Bozdağ S. Decompressive Craniotomy for Malignant Middle Cerebral Artery Infarction: A Prospective Cohort Study. Ahi Evran Med J. 2024;8(2):234-41.

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