Decompressive craniectomy index: Does the size of decompressive craniectomy matter in malignant middle cerebral
Thiago Pereira Rodrigues1, Mariana Athaniel Silva Rodrigues2, Leonardo Favi Bocca1
1Department of Neurology and Neurosurgery, Federal University of Sao Paulo, São Paulo, Brazil.
Background:
Malignant middle cerebral artery (MCA) infarction is associated with high mortality, mainly due to intracranial hypertension. This malignant course develops when two-thirds or more of MCA territory is infarcted. Randomized clinical trials demonstrated that in patients with malignant MCA infarction, decompressive craniectomy (DC) is associated with better prognosis. In these patients, some prognostic predictors are already known, including age and time between stroke and DC. The size of bone flap was not associated with long-term prognosis in the previous studies. Therefore, this paper aims to further expand the analysis of the bone removal toward a more precise quantification and verify the prognosis implication of the bone flap area/whole supratentorial hemicranium relation in patients treated with DC for malignant middle cerebral infarcts.
Methods:
This study included 45 patients operated between 2015 and 2020. All patients had been diagnosed with a malignant MCA infarction and were submitted to DC to treat the ischemic event. The primary endpoint was dichotomized modified Rankin scale (mRS) 1 year after surgery (mRS≤4 or mRS>4).
Results:
Patients with bad prognosis (mRS 5-6) were on average: older and with a smaller decompressive craniectomy index (DCI). In multivariate analysis, with adjustments for "age" and "time" from symptoms onset to DC, the association between DCI and prognosis remained.
Conclusion:
In our series, the relation between bone flap size and theoretical maximum supratentorial hemicranium area (DCI) in patients with malignant MCA infarction was associated with prognosis. Further studies are necessary to confirm these findings.
Insights
A smaller bone flap area relative to the skull (Decompressive Craniectomy Index) is linked to worse outcomes after decompressive craniectomy for malignant middle cerebral artery infarction.
Area of Science:
- Neurosurgery
- Neurology
- Stroke Medicine
Background:
- Malignant middle cerebral artery (MCA) infarction leads to high mortality, often due to intracranial hypertension.
- Decompressive craniectomy (DC) improves prognosis in selected patients with malignant MCA infarction.
- Previous studies identified age and time to DC as prognostic factors, but bone flap size's role was unclear.
Purpose of the Study:
- To investigate the prognostic implication of the bone flap area relative to the supratentorial hemicranium in patients undergoing DC for malignant MCA infarction.
- To precisely quantify the relationship between bone flap size and patient outcomes.
Main Methods:
- Retrospective analysis of 45 patients with malignant MCA infarction treated with DC between 2015 and 2020.
- Primary endpoint: dichotomized modified Rankin Scale (mRS) at 1 year post-surgery (mRS ≤ 4 vs. mRS > 4).
- Calculation of the Decompressive Craniectomy Index (DCI) as the ratio of bone flap area to the theoretical hemicranium area.
Main Results:
- Patients with unfavorable outcomes (mRS 5-6) were older and had a smaller DCI on average.
- Multivariate analysis, adjusting for age and time from symptom onset to DC, confirmed the independent association between DCI and prognosis.
Conclusions:
- The ratio of bone flap size to hemicranium area (DCI) is associated with prognosis in malignant MCA infarction patients treated with DC.
- Further research is needed to validate these findings and their clinical implications.
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