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Published on: August 11, 2015
Primary decompressive craniectomy for poor-grade middle cerebral artery aneurysms with associated intracerebral
Bing Zhao1, Yuanli Zhao2, Xianxi Tan3
1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (Center of Stroke, Beijing Institute for Brain Disorders; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease), Beijing, China; Department of Neurosurgery, First affiliated Hospital of Wenzhou Medical University, Wenzhou, China; Department of Neurosurgery, Mayo Clinic, Rochester, USA.
Insights
Primary decompressive craniectomy (DC) for poor-grade middle cerebral artery aneurysms with hemorrhage may not improve outcomes but doesn't increase risks. Over half of patients benefit, warranting further study.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Poor-grade middle cerebral artery (MCA) aneurysms with intracerebral hemorrhage (ICH) often require aggressive surgical intervention.
- The role of primary decompressive craniectomy (DC) in managing these complex cases remains controversial.
Purpose of the Study:
- To investigate the efficacy and safety of primary decompressive craniectomy (DC) in patients with poor-grade middle cerebral artery (MCA) aneurysms and associated intracerebral hemorrhage (ICH).
Main Methods:
- A case-control study comparing patients who underwent primary DC with a control group.
- Data analyzed from multicenter prospective registry (AMPAS) and a national database (NCRC-ND).
- Outcomes assessed using modified Rankin Scale (mRS), dichotomized into favorable (0-3) and unfavorable (4-6) outcomes, comparing complication rates, mortality, and outcomes.
Main Results:
- Twenty-four patients underwent primary DC; 14 served as controls. Younger patients and those with lower Glasgow Coma Scale (GCS) scores were more likely to receive primary DC.
- No significant difference in major complications between groups.
- Favorable outcome (mRS 0-3) was observed in 58% of patients; overall mortality was 29%. Primary DC showed trends towards lower in-hospital mortality and better outcomes, but these were not statistically significant after adjusting for age and admission GCS.
Conclusions:
- Primary DC in poor-grade MCA aneurysm with ICH does not elevate postoperative complication or mortality risks.
- Current findings suggest primary DC is not significantly associated with improved mortality or outcomes, though over half of patients may benefit.
- Further prospective controlled studies are necessary to definitively clarify the role of primary DC in this patient population.
Objective:
Aggressive surgery seems mandatory for poor-grade middle cerebral artery (MCA) aneurysm with associated intracerebral hemorrhage (ICH). However, primary decompressive craniectomy (DC) is controversial. We performed a case control study to define the role of primary DC.
Materials And Methods:
We analyzed data from the two cohorts: a multicenter prospective poor-grade aSAH registry study (AMPAS); and the National Clinical Research Center for Neurological Diseases (NCRC-ND) database of poor-grade patients. Outcome was assessed by modified Rankin Scale (mRS) and was dichotomized into favorable (mRS 0-3) and unfavorable outcome (mRS 4-6). We compared major complication rates, mortality and outcomes between primary DC and control groups.
Results:
Twenty-four patients with primary DC were included in the study group. Fourteen patients without DC were included in the control group. Patients with younger age and lower Glasgow coma score (GCS) more often underwent primary DC. Major complications did not differ between the two groups. Fourteen (58%) patients had a favorable outcome, and the mortality was 29%. Primary DC appeared to have lower in-hospital mortality and have better outcome. Adjusting for age and admission GCS, primary DC was not significantly associated with decreased mortality and improved outcomes.
Conclusions:
Although primary DC does not increase postoperative complication and mortality risk, current results showed primary DC does not seem to be significantly associated with improved outcomes. However, more than one half of patients most benefit from primary DC. Further prospective controlled studies are warranted to clarify the issue.
