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Published on: June 10, 2020
Predictors of clinical failure of decompressive hemicraniectomy for malignant hemispheric infarction
Amedeo Merenda1, Jon Perez-Barcena1, Guiem Frontera2
1Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA.
Insights
A nonreactive pupil before decompressive hemicraniectomy (DH) for malignant hemispheric infarction predicts clinical failure. This finding may guide decisions on adjunctive strokectomy during the initial DH procedure.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Malignant hemispheric infarction (MHI) can lead to severe brain swelling and herniation.
- Decompressive hemicraniectomy (DH) is a life-saving procedure for MHI, but clinical failure can occur.
- Identifying predictors of DH failure is crucial for optimizing patient outcomes.
Purpose of the Study:
- To identify pre-operative clinical and radiological predictors of clinical failure following DH in MHI patients.
- To guide the decision-making process for adjunctive internal brain decompression, such as strokectomy, during initial DH.
Main Methods:
- Retrospective chart review of MHI patients who underwent DH between November 2008 and January 2013.
- Analysis of pre- and post-operative clinical characteristics and neuroimaging data.
- Definition of clinical failure included lack of cistern effacement, insufficient midline shift reduction, or neurological deterioration due to persistent mass effect.
Main Results:
- Seven out of 26 patients (26.9%) experienced clinical failure after DH.
- A pre-operative nonreactive pupil was significantly associated with clinical failure (p=0.0015).
- Patients with clinical failure had lower post-operative Glasgow Coma Scale (GCS) motor scores and a trend towards poorer functional outcomes.
Conclusions:
- The presence of a nonreactive pupil prior to DH is a significant predictor of clinical failure.
- This finding should be considered when determining the need for strokectomy at the time of DH.
- Early identification of patients at high risk for DH failure can inform surgical strategy and improve patient management.
Object:
The aim of this study is to identify pre-operative clinical and/or radiological predictors of clinical failure of decompressive hemicraniectomy (DH) in the setting of malignant hemispheric infarction. These predictors could guide the decision for adjunctive internal brain decompression (e.g. strokectomy) at the time of the initial DH.
Methods:
Retrospective chart review of all patients with malignant hemispheric infarction who underwent DH at our institution, from November 2008 to January 2013. Demographics, pre- and post-operative clinical characteristics and neuroimaging data were reviewed. The surgical outcome after DH was evaluated and clinical failure was defined as follows: lack of post-operative resolution of basal cistern effacement, and/or failure to achieve a post-operative decrease in midline shift by at least 50%, and/or post-operative neurological deterioration felt to be due to persistent mass effect, with or without a second, salvage operation (strokectomy).
Results:
Out of 26 patients included in the study, 7 were considered to have clinical failure of their DH. Preoperative clinical and imaging variables were similar in the two groups, except that the presence of a nonreactive pupil immediately before surgery was associated clinical failure of the DH (p=0.0015). Patients in the clinical failure group had a lower postoperative GCS motor score and a strong but not statistically significant trend towards less favorable functional outcome (GOS 1-3).
Conclusions:
The presence of a nonreactive pupil before surgery is associated with clinical failure of DH, and should be taken into account when deciding whether to perform strokectomy at the time of DH.
