von Olnhausen Oliver, Thorén Magnus, von Vogelsang Ann-Christin, Svensson Mikael, Schechtmann Gastón
Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.
Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.
Acta Neurochir (Wien). 2016 May;158(5):865-72; discussion 873. doi: 10.1007/s00701-016-2749-9. Epub 2016 Feb 29.
The mortality rate of patients with brain oedema after malignant middle cerebral artery (MCA) infarction approaches 80 % without surgical intervention. Surgical treatment with ipsilateral decompressive hemicraniectomy (DHC) has been shown to dramatically improve survival rates. DHC currently lacks established inclusion criteria and additional research is needed to assess the impact of prognostic factors on functional outcome. The aim of this study was to assess the impact of prognostic factors on functional outcome.
A retrospective cohort study was carried out including 46 patients who underwent DHC at the Karolinska University Hospital between 2004 and 2014. The maximum time to surgery was 5 days after symptom debut. The primary endpoint was a dichotomised score on the modified Rankin Scale (mRS) 3 months after surgery, with favourable outcome defined as mRS ≤ 4.
When the study population was dichotomised according to the primary endpoint, a significant difference between the groups was seen in preoperative Glasgow Coma Score (GCS), blood glucose levels and the infarction's involvement of the basal ganglia (p < 0.05). In a logistic regression model, preoperative GCS contributed significantly with a 59.6 % increase in the probability of favourable outcome for each point gained in preoperative GCS (p = 0.035).
The results indicate that preoperative GCS, blood glucose and the infarction's involvement of the basal ganglia are strong predictors of clinical outcome. These factors should be considered when assessing the probable outcome of DHC, and additional research based on these factors may contribute to improved inclusion criteria for DHC.
恶性大脑中动脉（MCA）梗死患者若不进行手术干预，脑水肿患者的死亡率接近80%。同侧减压性颅骨切除术（DHC）已被证明可显著提高生存率。目前DHC缺乏既定的纳入标准，需要进一步研究以评估预后因素对功能结局的影响。本研究的目的是评估预后因素对功能结局的影响。
进行了一项回顾性队列研究，纳入2004年至2014年在卡罗林斯卡大学医院接受DHC的46例患者。手术的最长时间为症状出现后5天。主要终点是术后3个月改良Rankin量表（mRS）的二分法评分，良好结局定义为mRS≤4。
根据主要终点将研究人群二分后，两组在术前格拉斯哥昏迷量表（GCS）、血糖水平以及梗死累及基底节方面存在显著差异（p<0.05）。在逻辑回归模型中，术前GCS对良好结局概率有显著贡献，术前GCS每增加1分，良好结局概率增加59.6%（p=0.035）。
结果表明，术前GCS、血糖和梗死累及基底节是临床结局的有力预测因素。在评估DHC的可能结局时应考虑这些因素，基于这些因素的进一步研究可能有助于改进DHC的纳入标准。
