Ayling Oliver G S, Alotaibi Naif M, Wang Justin Z, Fatehi Mostafa, Ibrahim George M, Benavente Oscar, Field Thalia S, Gooderham Peter A, Macdonald R Loch
Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada.
Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia.
World Neurosurg. 2018 Feb;110:450-459.e5. doi: 10.1016/j.wneu.2017.10.144. Epub 2017 Dec 2.
Suboccipital decompressive craniectomy (SDC) for cerebellar infarction has been traditionally performed with minimal high-quality evidence. The aim of this systematic review and meta-analysis is to investigate the impact of SDC on functional outcomes, mortality, and adverse events in patients with cerebellar infarcts.
A systematic review and meta-analysis in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Our primary outcome was the proportion of patients with moderate-severe disability after SDC. Secondary outcomes included mortality and adverse events. A sensitivity analysis was conducted to examine the roles of age, preoperative neurologic status, external ventricular drain insertion, and debridement of infarcted tissue on SDC outcomes.
Eleven studies (with 283 patients) met our inclusion criteria. The pooled event rate for moderate-severe disability was 28% (95% confidence interval [CI], 20%-37%) and for mortality, it was 20% (95% CI, 12%-31%). The estimated overall rate of adverse events for SDC was 23% (95% CI, 14%-35%). Sensitivity analysis found less mortality with mean age <60 years, higher rates of concomitant external ventricular drain insertion, and debridement of infarcted tissue. Several factors were identified for heterogeneity between studies, including follow-up time, outcomes scale, extent of infarction, and other neuroimaging features.
The best available evidence for SDC is based on retrospective observational studies. SDC for cerebellar infarction is associated with better outcomes compared with decompressive surgery for hemispheric infarctions. Lack of standardized reporting methods for SDC is a considerable drawback to the development of a better understanding of the impact of this surgery on patient outcomes.
传统上，枕下减压颅骨切除术（SDC）治疗小脑梗死的高质量证据极少。本系统评价和荟萃分析的目的是研究SDC对小脑梗死患者功能结局、死亡率和不良事件的影响。
按照PRISMA（系统评价和荟萃分析优先报告项目）指南进行系统评价和荟萃分析。我们的主要结局是SDC后中重度残疾患者的比例。次要结局包括死亡率和不良事件。进行敏感性分析以检验年龄、术前神经状态、外置脑室引流管置入和梗死组织清创对SDC结局的作用。
11项研究（共283例患者）符合我们的纳入标准。中重度残疾的合并事件发生率为28%（95%置信区间[CI]，20%-37%），死亡率为20%（95%CI，12%-31%）。SDC不良事件的估计总体发生率为23%（95%CI，14%-35%）。敏感性分析发现，平均年龄<60岁、外置脑室引流管置入率较高以及梗死组织清创时死亡率较低。确定了研究间异质性的几个因素，包括随访时间、结局量表、梗死范围和其他神经影像学特征。
SDC的最佳现有证据基于回顾性观察性研究。与半球梗死减压手术相比，小脑梗死的SDC与更好的结局相关。缺乏SDC的标准化报告方法是阻碍更好地理解该手术对患者结局影响的一个相当大的缺点。
