Mohan Rajwani Kapil, Crocker Matthew, Moynihan Barry
a Department of Neurosurgery , St George's Hospital , London , UK.
b Department of Neurology , St George's Hospital , London , UK.
Br J Neurosurg. 2017 Aug;31(4):401-409. doi: 10.1080/02688697.2017.1329518. Epub 2017 Jun 12.
Malignant middle cerebral artery (MCA) infarction is associated with up to 80% mortality in the first week, despite maximal medical therapy. Decompressive craniectomy (DC) has been shown to improve survival rates in these patients. However, there are concerns that DC prolongs poor quality of life by increasing the number of survivors with major disability. This review will assess if DC in patients with malignant MCA infarction improves functional outcomes compared to maximal medical therapy. It will estimate the optimal time for surgery following stroke onset and ask if DC is effective in older patients (>60 years).
A literature search was conducted using Medline, Embase, PubMed and the Cochrane Library. Randomised controlled trials and meta-analysis that fulfilled the inclusion criteria and answered the clinical question were evaluated.
Twelve papers were identified and considered appropriate to answer the clinical question. These included 8 prospective randomised controlled trials and 4 meta-analysis. A critical review of these papers was conducted.
In patients 60 years of age or younger, DC within 48 hours of stroke onset significantly reduced risk of death and major disability (mRS >3) compared to maximal medical therapy only. In older patients (>60 years) DC also significantly improved survival but the majority of survivors were left with major disability (mRS 4-5). DC performed more than 48 hours after symptom onset does not appear to be superior to best medical management. The decision to perform decompressive surgery needs to be made on a case-by-case basis, taking into account the degree of disability patients and their carers are willing to accept.
尽管采取了最大程度的药物治疗，恶性大脑中动脉（MCA）梗死在发病第一周的死亡率仍高达80%。减压颅骨切除术（DC）已被证明可提高这些患者的生存率。然而，有人担心DC会因增加重度残疾幸存者的数量而延长患者的低质量生活期。本综述将评估与最大程度的药物治疗相比，DC对恶性MCA梗死患者的功能结局是否有改善。将估计卒中发作后手术的最佳时机，并探讨DC对老年患者（>60岁）是否有效。
使用Medline、Embase、PubMed和Cochrane图书馆进行文献检索。对符合纳入标准并能回答临床问题的随机对照试验和荟萃分析进行评估。
共识别出12篇论文，认为适合回答该临床问题。其中包括8项前瞻性随机对照试验和4项荟萃分析。对这些论文进行了严格审查。
与单纯最大程度的药物治疗相比，60岁及以下患者在卒中发作后48小时内进行DC可显著降低死亡风险和重度残疾（改良Rankin量表评分>3）的风险。对于老年患者（>60岁），DC也显著提高了生存率，但大多数幸存者仍有重度残疾（改良Rankin量表评分4 - 5）。症状发作后超过48小时进行DC似乎并不优于最佳药物治疗。是否进行减压手术需要根据具体情况决定，要考虑患者及其照顾者愿意接受的残疾程度。
