Olivecrona Magnus, Honeybul Stephen
Department of Anaesthesia and Intensive Care, Section for Neurosurgery, Faculty of Health and Medicine, Department for Medical Sciences, Örebro University, Örebro, Sweden.
Departement of Neurosurgery, Sir Charles Gairdner Hospital, Perth, WA, Australia.
Acta Neurochir (Wien). 2018 Jan;160(1):95-101. doi: 10.1007/s00701-017-3358-y. Epub 2017 Nov 4.
Decompressive hemicraniectomy (DC) is an established lifesaving treatment for malignant infarction of the middle cerebral artery (mMCAI). However, surgical decompression will not reverse the effects of the stroke and many survivors will be left severely disabled. The objective of this study was to assess what neurological outcome would be considered acceptable in these circumstances amongst Swedish healthcare workers.
Healthcare workers were invited to participate in a presentation that outlined the pathophysiology of mMCAI, the rationale behind DC and outcome data from randomised controlled trials that have investigated efficacy of the procedure. They were then asked which neurological outcome would they feel to be acceptable based on the modified Rankin Score (mRS) and the Aphasia Handicap Scale (AHS). Information regarding sex, age, marital status, relatives, religion, earlier experience of stroke and occupation was also collected.
Six hundred and nine persons participated. The median accepted mRS was 3. An mRS of 4 or 5 was perceived to be acceptable by only 30.5% of participants. Therefore the most likely outcome, based on the results of the randomised controlled trials, would be unacceptable to most of the participants [OR 0.39 (CI, 0.22-0.69)]. The median accepted AHS was 3. A worst language outcome of restricted autonomy of verbal communication (AHS 3) or better would be accepted by 44.6%.
This study has highlighted the ethical problems when obtaining consent for DC following mMCAI, because for many of the participants the most likely neurological outcome would be deemed unacceptable. These issues need to be considered prior to surgical intervention and the time may have come for a broader societal discussion regarding the value of a procedure that converts death into survival with severe disability given the attendant financial and healthcare resource implications.
减压性颅骨切除术（DC）是治疗大脑中动脉恶性梗死（mMCAI）的一种既定的挽救生命的治疗方法。然而，手术减压并不能逆转中风的影响，许多幸存者将严重致残。本研究的目的是评估在这些情况下，瑞典医护人员认为何种神经功能结果是可以接受的。
邀请医护人员参加一场介绍会，该介绍会概述了mMCAI的病理生理学、DC背后的原理以及研究该手术疗效的随机对照试验的结果数据。然后询问他们基于改良Rankin量表（mRS）和失语障碍量表（AHS），认为何种神经功能结果是可以接受的。还收集了有关性别、年龄、婚姻状况、亲属、宗教、既往中风经历和职业的信息。
609人参与。可接受的mRS中位数为3。只有30.5%的参与者认为mRS为4或5是可以接受的。因此，根据随机对照试验的结果，最可能出现的结果对大多数参与者来说是不可接受的[比值比0.39（可信区间，0.22 - 0.69）]。可接受的AHS中位数为3。44.6%的人会接受言语交流自主性受限（AHS 3）或更好的最差语言结果。
本研究突出了在mMCAI后获得DC同意时的伦理问题，因为对许多参与者来说，最可能的神经功能结果将被认为是不可接受的。在手术干预之前需要考虑这些问题，鉴于随之而来的经济和医疗资源影响，也许是时候就一种将死亡转化为严重残疾生存的手术的价值进行更广泛的社会讨论了。
