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Predictors of In-Hospital Mortality after Decompressive Hemicraniectomy for Malignant Ischemic Stroke
Saadat Kamran1, Abdul Salam2, Naveed Akhtar1
1The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Weill Cornell School of Medicine, Qatar.
Insights
Decompressive hemicraniectomy for malignant middle cerebral artery stroke is associated with in-hospital mortality. Factors like additional infarcts, midline shift, and postoperative unconsciousness predict mortality in these patients.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Malignant middle cerebral artery (MMCA) stroke often necessitates decompressive hemicraniectomy (DHC).
- Predicting in-hospital mortality after DHC for MMCA stroke is crucial for patient management.
Purpose of the Study:
- To identify factors associated with in-hospital mortality in patients undergoing DHC for MMCA stroke.
- To validate these factors in patients not undergoing DHC.
Main Methods:
- Retrospective analysis of a pooled DHC database from 3 countries.
- Logistic regression analysis to identify predictors of in-hospital mortality.
- Application of identified factors to a cohort of non-operated MMCA patients.
Main Results:
- Middle cerebral artery (MCA) stroke with additional infarcts, preoperative midline shift (≥1 cm), and postoperative unconsciousness on day 7 were significant predictors of mortality.
- The presence of these factors was significantly more common in patients who died, including those not operated on.
- All three factors were exclusively observed in non-survivors.
Conclusions:
- Physical factors including infarct extent, midline shift, and postoperative consciousness level are significant predictors of in-hospital mortality in MMCA stroke patients undergoing DHC.
- These findings can aid in risk stratification and treatment decisions for MMCA stroke.
Objective:
The purpose of this retrospective multicenter, pooled-data analysis was to determine the factors associated with in-hospital mortality in decompressive hemicraniectomy (DHC) for malignant middle cerebral artery (MMCA) stroke.
Patients And Methods:
The authors reviewed pooled DHC database from 3 countries for patients with MMCA with hospital mortality in spite of DHC to identify factors that predicted in-hospital mortality after DHC. The identified factors were applied to the group of patients who were selected for DHC but either refused surgery and died or stabilized and did not undergo DHC.
Findings:
There were 137 patients who underwent DHC. Multiple logistic regression analysis showed middle cerebral artery (MCA) with additional infarcts (odds ratio [OR], 7.9: 95% confidence interval [CI], 2.4-26; P = .001), preoperative midline shift of septum pellucidum of 1 cm or more (OR, 3.83: 95% CI, 1.13-12.96; P = .031), and patients who remained unconscious on day 7 postoperatively (8.82: 95% CI; OR, 1.08-71.9; P = .042) were significant independent predictors for in-hospital mortality. The identified factors were applied to the group of MMCA patients not operated (n = 19 refused, n = 47 stabilized) single (P < .001), and two predictive factors (P < .001) were significantly more common in patients who died. Whereas two predicative factors were identified in only 9%-18.2% of survivors, the presence of all three predictive factors was seen only in patients who expired (P < .001). The Hosmer-Lemeshow goodness-of-fit statistics (chi-square = 4.65; P value = .589) indicate that the model adequately describes the data.
Conclusion:
Direct physical factors, such as MCA with additional territory infarct, extent of midline shift, and postoperative consciousness level, bore a significant relationship to in-hospital mortality in MMCA patients undergoing DHC.
