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Association of Infarct Volume Before Hemicraniectomy and Outcome After Malignant Infarction
Dominik Lehrieder1, Katharina Layer2, Hans-Peter Müller2
1From the Department of Neurology (D.L., H.N.), University Hospital of Würzburg; Department of Neurology (K.L., H.-P.M., J.K.), University Hospital of Ulm, Institute of Clinical Epidemiology and Biometry (V.R.), University of Würzburg; and Department of Neurology (E.J.), Ostalb-Klinikum Aalen, Germany. lehrieder_d@ukw.de.
Objective:
To determine the impact of infarct volume before hemicraniectomy in malignant middle cerebral artery infarction (MMI) as an independent predictor for patient selection and outcome prediction, we retrospectively analyzed data of 140 patients from a prospective multicenter study.
Methods:
Patients from the Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY) Registry who underwent hemicraniectomy after ischemic infarction of >50% of the middle cerebral artery territory were included. Functional outcome according to the modified Rankin Scale (mRS) was assessed at 12 months. Unfavorable outcome was defined as mRS score of 4 to 6. Infarct size was quantified semiautomatically from CT or MRI before hemicraniectomy. Subgroup analyses in patients fulfilling inclusion criteria of randomized trials in younger patients (age ≤60 years) were predefined.
Results:
Among 140 patients with complete datasets (34% female, mean [SD] age 54 [11] years), 105 (75%) had an unfavorable outcome (mRS score >3). Mean (SD) infarct volume was 238 (63) mL. Multivariable logistic regression identified age (odds ratio [OR] 1.08 per 1-year increase, 95% confidence interval [CI] 1.02-1.13, p = 0.004), infarct size (OR 1.27 per 10-mL increase, 95% CI 1.12-1.44, p < 0.001), and NIH Stroke Scale score (OR 1.10, 95% CI 1.01-1.20, p = 0.030) before hemicraniectomy as independent predictors of unfavorable outcome. Findings were reproduced in patients fulfilling inclusion criteria of randomized trials in younger patients. Infarct volume thresholds for prediction of unfavorable outcome with high specificity (94% in overall cohort and 92% in younger patients) were >258 mL before hemicraniectomy.
Conclusion:
Outcome in MMI depends strongly on age and infarct size before hemicraniectomy. Standardized volumetry may be helpful in the process of decision-making concerning hemicraniectomy.
Insights
Infarct size before hemicraniectomy is a key predictor of outcomes in malignant middle cerebral artery infarction (MMI). Larger infarct volumes (>258 mL) indicate a higher likelihood of unfavorable outcomes, aiding surgical decision-making.
Area of Science:
- Neurology
- Neurosurgery
- Radiology
Background:
- Malignant middle cerebral artery infarction (MMI) is a severe condition requiring prompt intervention.
- Hemicraniectomy is a crucial treatment, but patient selection and outcome prediction remain challenging.
Purpose of the Study:
- To evaluate infarct volume before hemicraniectomy as an independent predictor of patient outcomes in MMI.
- To identify infarct size thresholds for predicting unfavorable outcomes.
Main Methods:
- Retrospective analysis of 140 patients from the DESTINY Registry undergoing hemicraniectomy for MMI.
- Infarct size quantified via CT/MRI before surgery; functional outcome assessed using modified Rankin Scale (mRS) at 12 months.
- Multivariable logistic regression and subgroup analyses in younger patients (age ≤60 years).
Main Results:
- 75% of patients experienced unfavorable outcomes (mRS 4-6).
- Infarct volume (OR 1.27 per 10-mL increase), age, and NIH Stroke Scale score were independent predictors of unfavorable outcomes.
- An infarct volume threshold of >258 mL predicted unfavorable outcomes with high specificity (94% overall, 92% in younger patients).
Conclusions:
- Patient age and infarct size prior to hemicraniectomy significantly influence outcomes in MMI.
- Standardized infarct volumetry is a valuable tool for guiding hemicraniectomy decisions.
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