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Decompressive craniectomy combined with mild hypothermia in patients with large hemispheric infarction: a randomized
Linlin Fan1, Yingying Su2, Yan Zhang1
1Department of Neurology, Xuanwu Hospital Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China.
Insights
Hypothermia combined with decompressive craniectomy (DC) for large hemispheric infarction (LHI) did not significantly reduce long-term mortality or improve outcomes. Local cooling showed a trend toward better results in survivors with fewer complications.
Area of Science:
- Neurology
- Neurosurgery
- Critical Care Medicine
Background:
- Large hemispheric infarction (LHI) poses significant mortality risks.
- The efficacy of hypothermia in conjunction with decompressive craniectomy (DC) for LHI remains debated.
- This study investigates therapeutic outcomes of combining DC with different hypothermia methods.
Purpose of the Study:
- To evaluate the impact of decompressive craniectomy (DC) combined with hypothermia on mortality and neurological outcomes in patients with large hemispheric infarction (LHI).
- To compare the effectiveness of head surface cooling (DCSC) versus endovascular hypothermia (DCEH) alongside DC.
Main Methods:
- Patients with LHI were randomized into three groups: DC alone (normothermia), DC with head surface cooling (DCSC), and DC with endovascular hypothermia (DCEH).
- Outcomes including mortality and modified Rankin Scale (mRS) scores were assessed at 6 months post-intervention.
- Complication rates were also recorded for each treatment group.
Main Results:
- While initial discharge mortality varied, 6-month mortality showed no significant difference between groups (44.4% DC, 21.4% DCSC, 45.5% DCEH).
- Good neurological outcomes (mRS 0-3) were achieved by 35.3% of patients, with a trend favoring the DCSC group (42.9%) over DC (22.2%) and DCEH (36.4%), though not statistically significant.
- The endovascular hypothermia group experienced a higher incidence of complications (18.9%) compared to DCSC (12.0%) and DC (12.1%).
Conclusions:
- Current evidence does not confirm that hypothermia significantly improves long-term survival or neurological outcomes in LHI patients undergoing DC.
- A trend suggests potential benefits for survivors with hypothermia, particularly with local cooling methods.
- Local cooling (DCSC) may be a preferable strategy for DC patients due to a lower risk of systemic complications.
Background:
The effect of hypothermia on large hemispheric infarction (LHI) remains controversial. Our study aimed to explore the therapeutic outcomes of decompressive craniectomy (DC) combined with hypothermia on LHI.
Methods:
Patients were randomly divided into three groups: the DC group, the DC plus head surface cooling (DCSC) group and the DC plus endovascular hypothermia (DCEH) group. The DC group was maintained normothermia. The DCSC group received 24-h ice cap on the head for 7 days. While the DCEH group were given endovascular hypothermia (34 °C). Mortality and modified Rankin Scale (mRS) score at 6 months were evaluated.
Results:
Thirty-four patients were included in the study. Mortality of the DC, DCSC and DCEH groups at discharge were 22.2% (2/9), 0% (0/14) and 9.1% (1/11), respectively. However, it increased to 44.4% (4/9), 21.4% (3/14) and 45.5% (5/11) at 6 months, respectively (p = 0.367). Pneumonia (8 cases) was the leading cause of death after discharge. Twelve cases (35.3%) achieved good neurological outcome (mRS 0-3) at 6 months. The proportions of good neurological outcome in the DC, DCSC and DCEH groups were 22.2% (2/9 cases), 42.9% (6/14 cases) and 36.4% (4/11), respectively. The DCSC group seemed to have higher proportion of good outcomes, but there was no significant difference between groups (p = 0.598). Among survivors, endovascular hypothermia had a higher proportion of good outcome (DC group, 2/5 cases, 40.0%; DCSC group, 6/11 cases, 54.5%; DCEH group, 4/6 cases, 66.7%; p = 0.696). The incidence of complications in the DCEH group was higher than those of the DC and DCSC groups (18.9%, 12.0%, and 12.1%, respectively; p = 0.025).
Conclusions:
There is still no evidence to confirm that hypothermia further reduces long-term mortality and improves neurological outcomes in LHI patients with DC. However, there is a trend to benefit survivors from hypothermia. A local cooling method may be a better option for DC patients, which has little impact on systematic complications.
Trial Registration:
Decompressive Hemicraniectomy Combined Hypothermia in Malignant Middle Cerebral Artery Infarct, ChiCTR-TRC-12002698. Registered 11 Oct 2012- Retrospectively registered, URL: http://www.chictr.org.cn/showproj.aspx?proj=6854 .
