Tartara Fulvio, Colombo Elena Virginia, Bongetta Daniele, Pilloni Giulia, Bortolotti Carlo, Boeris Davide, Zenga Francesco, Giossi Alessia, Ciccone Alfonso, Sessa Maria, Cenzato Marco
UO Neurochirurgia, Azienda Ospedaliero-Universitaria, Parma, Italy.
UO Neurochirurgia, Ospedale Fatebenefratelli, Milan, Italy.
Front Neurol. 2019 Sep 26;10:1017. doi: 10.3389/fneur.2019.01017. eCollection 2019.
Ischemic stroke is a major cause of death and disability worldwide. Large MCA stroke may evolve as malignant space occupying lesion and mortality rate reaches 80% despite maximal medical therapy. Early decompressive craniectomy is effective in reducing mortality and improving the functional outcome but is an extended and invasive surgical approach burdened with a significant complication rate. We report a surgical treatment based on partial strokectomy and basal cisterns opening with massive CSF drain. We retrospectively collected 15 cases of massive middle cerebral artery stroke treated with strokectomy between 2010 and 2017: nine males and six females, mean age 61.73 ± 9.5 years. The right side was affected in 66.7%. All patients show clinical deterioration despite standard medical therapy and indication for surgery was placed after collegiate evaluation by neurologists and neurosurgeons based on clinical and radiological data. Surgical procedure was performed 24-96 h after the stroke onset. All the 15 patients survived the intervention, one patient died 20 days after the admission for massive lung embolism. Mean GCS and NIHSS at admission were 12.6 ± 1.18 (range 9-15) and 19.7 ± 2.3 (range 18-23), respectively. Mean mRS at 12 months was 3.6 ± 1.1 (range 2-6). Mean follow-up was 18.1 months (range 12-34). The outcome was evaluated as satisfactory (mRs ≤ 3) in 8 patients (53.3%). Mortality at 1 year was 6.7%. No patients developed hydrocephalus and 1 presented seizures. According to mRs outcome evaluation (mRs ≤ 3 vs. mRs ≥ 4) no quantitative variable resulted significantly different between the two groups, whereas the concomitant use of iv rTPA significantly differed ( < 0.05). Supratentorial strokectomy seems to be safe and could be a potential alternative to decompressive craniectomy for the acute management of malignant MCA stroke. Advantages of this approach could be low complication rate, avoidance of bone reconstruction procedure, and reduced occurrence of hydrocephalus or seizures. A co-operative multicentric, prospective pilot study will be necessary to validate this technical approach.
缺血性中风是全球范围内死亡和残疾的主要原因。大脑中动脉大面积中风可能会发展为恶性占位性病变，尽管采取了最大程度的药物治疗，死亡率仍高达80%。早期减压性颅骨切除术在降低死亡率和改善功能预后方面是有效的，但这是一种范围较大且具有侵袭性的手术方法，并发症发生率较高。我们报告了一种基于部分脑梗死切除术和打开基底池并大量引流脑脊液的手术治疗方法。我们回顾性收集了2010年至2017年间接受脑梗死切除术治疗的15例大脑中动脉大面积中风患者：男性9例，女性6例，平均年龄61.73±9.5岁。右侧受累占66.7%。尽管进行了标准的药物治疗，但所有患者的病情仍出现恶化，经神经科医生和神经外科医生根据临床和影像学资料进行联合评估后确定手术指征。手术在中风发作后24 - 96小时进行。15例患者均在干预后存活，1例患者在入院20天后因大面积肺栓塞死亡。入院时平均格拉斯哥昏迷量表（GCS）评分和美国国立卫生研究院卒中量表（NIHSS）评分分别为12.6±1.18（范围9 - 15）和19.7±2.3（范围18 - 23）。12个月时改良Rankin量表（mRS）平均评分为3.6±1.1（范围2 - 6）。平均随访时间为18.1个月（范围12 - 34）。8例患者（53.3%）的预后评估为满意（mRs≤3）。1年时死亡率为6.7%。没有患者发生脑积水，1例出现癫痫发作。根据mRs预后评估（mRs≤3与mRs≥4），两组之间没有定量变量存在显著差异，而静脉注射重组组织型纤溶酶原激活剂（iv rTPA）的联合使用情况存在显著差异（<0.05）。幕上脑梗死切除术似乎是安全的，对于恶性大脑中动脉中风的急性治疗可能是减压性颅骨切除术的一种潜在替代方法。这种方法的优点可能是并发症发生率低、避免了颅骨重建手术以及减少了脑积水或癫痫发作的发生。需要进行一项多中心合作的前瞻性试点研究来验证这种技术方法。
