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Malignant Middle Cerebral Artery Infarction Decompressive Craniectomy Score: A Prognostic Model for Malignant Middle
Modar Alhamdan1, Alba Corell2, Klas Holmgren3
1Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden.
Background:
Malignant middle cerebral artery infarction (MMI) is a severe condition caused by space-occupying brain edema due to ischemia. While decompressive hemicraniectomy (DC) improves outcome, many survivors experience lasting disabilities, and tools to predict outcome are lacking. We aimed to identify independent predictors of outcome following DC in MMI and to create a pragmatic, bedside tool for patient prognostication.
Methods:
This retrospective, multicenter study analyzed 318 MMI patients treated with DC at 4 Swedish university hospitals (2008-2022). Demographic, preoperative, and postoperative variables were collected from medical records. Six-month modified Rankin Scale (mRS) was the primary endpoint, with favorable outcome defined as mRS 0-3. Univariable and multivariable ordinal logistic regressions were employed to identify independent predictors of mRS. Significant independent preoperative variables were included in the malignant middle cerebral artery infarction DC (MAD) score.
Results:
Median age was 56 (interquartile range: 48-61) years; 75% were male. At 6 months, median mRS was 4 (4-5), 24% achieved favorable outcome, and 17% were deceased. MAD score assigned 1 point to each independent preoperative predictor of worse outcome: higher age (≥ 60 years), female sex, lower Glasgow Coma Scale Motor score (< 4), and impaired pupillary reactivity (all P ≤ 0.03). MAD-stratified outcome, ordered from 0 to 4 points, was 32%, 25%, 15%, 0%, and 0% (favorable outcome) and 9%, 16%, 23%, 40%, and 100% (mortality).
Conclusions:
A large proportion of MMI patients recover unfavorably following DC. The presented MAD score was an internally reliable prognostic tool for MMI patients treated with DC. External validity of MAD and predictive value of female sex should be further explored.
Insights
A new score helps predict outcomes for malignant middle cerebral artery infarction patients after decompressive hemicraniectomy. The MMI-DC (MAD) score identifies key predictors to guide patient prognostication and care.
Area of Science:
- Neurology
- Neurosurgery
- Critical Care Medicine
Background:
- Malignant middle cerebral artery infarction (MMI) presents a high risk of mortality and disability.
- Decompressive hemicraniectomy (DC) is a life-saving procedure but patient outcomes vary significantly.
- Predictive tools for prognostication after DC in MMI patients are currently lacking.
Purpose of the Study:
- To identify independent predictors of outcome in MMI patients undergoing DC.
- To develop a pragmatic, bedside prognostic tool for MMI patients treated with DC.
Main Methods:
- Retrospective analysis of 318 MMI patients treated with DC across four Swedish university hospitals (2008-2022).
- Data collection included demographic, preoperative, and postoperative variables.
- Ordinal logistic regression analysis was used to identify predictors of 6-month modified Rankin Scale (mRS), forming the MMI-DC (MAD) score.
Main Results:
- A significant proportion of patients (76%) had unfavorable outcomes (mRS 4-6) at 6 months post-DC.
- The MAD score incorporates age (≥60), female sex, low Glasgow Coma Scale (GCS M <4), and impaired pupillary reactivity.
- Higher MAD scores correlated with significantly worse functional outcomes and increased mortality rates.
Conclusions:
- Decompressive hemicraniectomy for MMI is associated with a high rate of unfavorable outcomes.
- The MMI-DC (MAD) score demonstrates internal reliability as a prognostic tool for MMI patients undergoing DC.
- Further external validation of the MAD score and investigation into the predictive value of female sex are warranted.
