Walz Birgit, Zimmermann Carolin, Böttger Stefanie, Haberl Roman L
Department of Neurology, Krankenhaus München-Harlaching, Academic Teaching Hospital of the Ludwig-Maximilians University München, Sanatoriumsplatz 2, 81545 München, Germany.
J Neurol. 2002 Sep;249(9):1183-90. doi: 10.1007/s00415-002-0798-x.
There are unsatisfactory therapeutic options for treatment of large infarctions of the middle cerebral artery with secondary development of life threatening brain edema. In most cases, post-ischemic brain edema can not be adequately treated by conservative means. However, several studies have shown that operative procedures such as decompressive hemicraniectomy can decrease mortality. Apart from mortality, the morbidity and quality of life are major features with which to estimate therapeutic benefit. The aim of this study was to acquire follow-up data on quality of life and outcome in patients treated with hemicraniectomy after stroke.
Eighteen patients were treated with decompressive hemicraniectomy after life threatening middle cerebral artery infarction between July 1997 and April 2000 in our clinic. Six patients (33 %) died within the first six months after the procedure. All twelve surviving patients were seen in a follow-up examination 7 to 26 months after the stroke and tested using the Rankin-Scale, Barthel Index (BI), Aachener Life Quality Inventory (ALQI) and Zung Self-Rating Depression Scale.
Survivors with a mean age of 40.7 +/- 16.5 years were significantly younger than non-survivors with a mean age of 64.5 +/- 9.2 years (p = 0.006). Mean Barthel-Index of surviving patients was 61.1 +/- 26.1 points, mean Rankin-Scale 3.3 +/- 1.2 points. Two patients were able to return to work. Patients younger than 45 years (n = 7) had a significantly better outcome (BI 75.7 +/- 20.7) than patients over 45 years (n = 5) (BI 42.0 +/- 22.7 points, p = 0.026). Among five patients with an infarction of the left hemisphere, four had a slight to moderate Broca aphasia and one patient a global aphasia. Quality of life assessment by ALQI showed moderate disability (58.0 +/- 22.7 of 107 points) with no significant difference between left- and right-hemispheric infarctions. Using the Zung Self-Rating Depression Scale six patients were ranked as slightly depressive, one patient as moderately depressive and five patients as not depressive. Eleven out of twelve survivors, as well as their relatives, approved of the decision to have the operation.
The study provides evidence that hemicraniectomy as treatment of severe space occupying ischemic brain edema saves lives and results in good quality of life in a high proportion of patients, especially in the young. This conclusion is restricted by the lack of a control group, which was deemed unethical in studying a potentially life saving therapy.
对于大脑中动脉大面积梗死继发危及生命的脑水肿，目前的治疗选择并不理想。在大多数情况下，缺血后脑水肿无法通过保守方法得到充分治疗。然而，多项研究表明，诸如去骨瓣减压术等手术操作可降低死亡率。除死亡率外，发病率和生活质量是评估治疗效果的主要指标。本研究的目的是获取中风后接受去骨瓣减压术患者的生活质量和预后的随访数据。
1997年7月至2000年4月期间，我院对18例因大脑中动脉梗死危及生命而接受去骨瓣减压术的患者进行了治疗。6例患者（33%）在术后前6个月内死亡。所有12例存活患者在中风后7至26个月接受了随访检查，并使用Rankin量表、Barthel指数（BI）、亚琛生活质量量表（ALQI）和Zung自评抑郁量表进行了测试。
存活患者的平均年龄为40.7±16.5岁，显著低于非存活患者的平均年龄64.5±9.2岁（p = 0.006）。存活患者的平均Barthel指数为61.1±26.1分，平均Rankin量表评分为3.3±1.2分。2例患者能够重返工作岗位。年龄小于45岁的患者（n = 7）的预后（BI 75.7±20.7）明显优于年龄大于45岁的患者（n = 5）（BI 42.0±22.7分，p = 0.026）。在5例左侧半球梗死的患者中，4例有轻度至中度的布罗卡失语症，1例为完全性失语症。通过ALQI进行的生活质量评估显示为中度残疾（107分中的58.0±22.7分），左右半球梗死之间无显著差异。使用Zung自评抑郁量表，6例患者被评为轻度抑郁，1例为中度抑郁，5例为非抑郁。12例存活患者中的11例及其亲属认可进行手术的决定。
该研究提供了证据表明，去骨瓣减压术作为治疗严重占位性缺血性脑水肿的方法可挽救生命，并使高比例患者，尤其是年轻患者的生活质量良好。由于在研究一种可能挽救生命的治疗方法时设立对照组被认为不符合伦理道德，该结论受到一定限制。
