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Factors affecting the outcome of decompressive craniectomy for large hemispheric infarctions: a prospective cohort
1Department of Neurosurgery, Trakya University Medical Faculty, Edirne, Turkey. ckilincer@medscape.com
Insights
Decompressive craniectomy saves lives from large hemispheric infarction but often results in poor functional outcomes. Identifying predictors like age and preoperative GCS can improve patient selection for better results.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Large hemispheric infarction poses significant mortality and morbidity risks.
- Surgical decompression (decompressive craniectomy) is a life-saving intervention but frequently leads to poor functional outcomes.
- Predictive criteria are needed to optimize patient selection and improve surgical results.
Purpose of the Study:
- To identify specific factors predicting functional outcome after decompressive craniectomy for large hemispheric infarction.
- To establish criteria for patient selection to reduce poor surgical results.
Main Methods:
- A prospective, non-randomized study involving 32 patients undergoing decompressive craniectomy for large hemispheric infarctions.
- Patients were categorized into good (modified Rankin Score 0-3) and poor (RS 4-6) functional outcome groups at 6 months postoperatively.
- Statistical analysis compared characteristics between the functional outcome groups.
Main Results:
- One-month mortality was 31%, reaching 50% by 6 months.
- Predictors of poor outcome included advanced age (≥60 years), preoperative midline shift (>10 mm), low preoperative Glasgow Coma Score (< or = 7), preoperative anisocoria, early clinical deterioration (within 3 days), and internal carotid artery infarct.
- Only 7 out of 32 patients achieved a good functional outcome (RS 0-3).
Conclusions:
- Decompressive craniectomy is a life-sparing procedure for space-occupying large hemispheric infarction, occasionally yielding good functional outcomes.
- Dominant hemispheric infarction should not exclude patients from surgery.
- Early operation and careful patient selection using identified predictive factors can enhance functional outcomes.
Background:
Although surgical decompression of large hemispheric infarction is often a life-saving procedure, many patients remain functionally dependent. The aims of this study were to identify specific factors that can be used to predict functional outcome, thus establish predictive criteria to reduce poor surgical results.
Method:
In this non-randomized prospective study, we performed decompressive craniectomy in 32 patients (age range, 27 to 77 years) with large hemispheric infarctions. Based on their modified Rankin Score (RS), which was calculated 6 months postoperatively, patients were divided into two functional groups: good (RS 0-3, n = 7) and poor (RS 4-6, n = 25). The characteristics of the two groups were compared using statistical analysis.
Findings:
One-month mortality was 31%. However, most of the surviving patients were severely disabled (RS 4 or 5), and 6-month total mortality reached 50%. Increased age (> or = 60 years) (P = 0.010), preoperative midline shift greater than 10 mm (P = 0.008), low preoperative Glasgow Coma Score (GCS < or = 7) (P = 0.002), presence of preoperative anisocoria (P = 0.032), early (within the first three days of the stroke) clinical deterioration (P = 0.032), and an internal carotid artery infarct (P = 0.069) were the positive predictors of a poor outcome.
Interpretation:
We view decompressive craniectomy for space-occupying large hemispheric infarction as a life-sparing procedure that sometimes yields good functional outcomes. A dominant hemispheric infarction should not be an exclusion criterion when deciding to perform this operation. Early operation and careful patient selection based on the above-mentioned factors may improve the functional outcome of surgical management for large hemispheric infarction.
