Pandhi Abhi, Tsivgoulis Georgios, Goyal Nitin, Ishfaq Muhammad F, Male Shailesh, Boviatsis Efstathios, Chang Jason J, Zand Ramin, Voumvourakis Konstantinos, Elijovich Lucas, Alexandrov Anne W, Malkoff Marc D, Hoit Daniel, Arthur Adam S, Alexandrov Andrei V
Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee.
Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee; Second Department of Neurology, "Attikon University Hospital", School of Medicine, University of Athens, Athens, Greece.
J Stroke Cerebrovasc Dis. 2018 Sep;27(9):2405-2410. doi: 10.1016/j.jstrokecerebrovasdis.2018.04.031.
Despite recent landmark randomized controlled trials showing significant benefits for hemicraniectomy (HCT) compared with medical therapy (MT) in patients with malignant middle cerebral artery infarction (MMCAI), HCT rates have not substantially increased in the United States. We sought to evaluate early outcomes in patients with MMCAI who were treated with HCT (cases) in comparison to patients treated with MT due to the perception of procedural futility by families (controls).
We retrospectively evaluated consecutive patients with acute MMCAI treated in 2 tertiary care centers during a 7-year period. Pretreatment National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 3 months were documented. Functional independence (FI) and survival without severe disability (SWSD) were defined as mRS of 0-2 and 0-4, respectively.
A total of 66 patients (37 cases and 29 controls) fulfilled the study inclusion criteria (mean age 59 ± 15 years, 52% men, median admission NIHSS score: 19 points [interquartile range {IQR}: 16-22]). Cases were younger (51 ± 11 versus 68 ± 13 years; P < .001) and tended to have lower median admission NIHSS than controls (18 [IQR:16-20] versus 20 [IQR:18-23]; P = .072). The rates of FI and SWSD at 3 months were higher in cases than controls (16% versus 0% [P = .031] and 62% versus 0% [P < .001]), while 3-month mortality was lower (24% versus 77%; P < .001). Multivariable Cox regression analyses adjusting for potential confounders identified HCT as the most important predictor of lower risk of 3-month mortality (hazard ratio: .02, 95% confidence interval: .01-0.10; P < .001).
HCT is a critical and effective therapy for patients with MMCAI but cannot provide a guarantee of functional recovery.
尽管近期具有里程碑意义的随机对照试验表明，对于恶性大脑中动脉梗死（MMCAI）患者，与药物治疗（MT）相比，去骨瓣减压术（HCT）具有显著益处，但在美国，HCT的应用率并未大幅提高。由于家属认为手术无用，我们试图评估接受HCT治疗的MMCAI患者（病例组）与接受MT治疗的患者（对照组）的早期结局。
我们回顾性评估了7年间在2个三级医疗中心接受治疗的连续性急性MMCAI患者。记录治疗前的美国国立卫生研究院卒中量表（NIHSS）评分以及3个月时的改良Rankin量表（mRS）评分。功能独立（FI）和无严重残疾生存（SWSD）分别定义为mRS评分为0 - 2分和0 - 4分。
共有66例患者（37例病例组和29例对照组）符合研究纳入标准（平均年龄59±15岁，男性占52%，入院时NIHSS评分中位数：19分[四分位间距{IQR}：16 - 22]）。病例组患者较年轻（51±11岁对68±13岁；P <.001），且入院时NIHSS评分中位数往往低于对照组（18分[IQR：16 - 20]对20分[IQR：18 - 23]；P = 0.072）。3个月时病例组的FI和SWSD发生率高于对照组（分别为16%对0%[P = 0.031]和62%对0%[P <.001]），而3个月死亡率较低（24%对77%；P <.001）。对潜在混杂因素进行校正的多变量Cox回归分析确定HCT是3个月死亡率较低风险的最重要预测因素（风险比：0.02，95%置信区间：0.01 - 0.10；P <.001）。
HCT是治疗MMCAI患者的关键且有效疗法，但不能保证功能恢复。
