From the Department of Neurology (D.L., H.N.), University Hospital of Würzburg; Department of Neurology (K.L., H.-P.M., J.K.), University Hospital of Ulm, Institute of Clinical Epidemiology and Biometry (V.R.), University of Würzburg; and Department of Neurology (E.J.), Ostalb-Klinikum Aalen, Germany.
Neurology. 2021 Jun 1;96(22):e2704-e2713. doi: 10.1212/WNL.0000000000011987. Epub 2021 Apr 19.
To determine the impact of infarct volume before hemicraniectomy in malignant middle cerebral artery infarction (MMI) as an independent predictor for patient selection and outcome prediction, we retrospectively analyzed data of 140 patients from a prospective multicenter study.
Patients from the Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY) Registry who underwent hemicraniectomy after ischemic infarction of >50% of the middle cerebral artery territory were included. Functional outcome according to the modified Rankin Scale (mRS) was assessed at 12 months. Unfavorable outcome was defined as mRS score of 4 to 6. Infarct size was quantified semiautomatically from CT or MRI before hemicraniectomy. Subgroup analyses in patients fulfilling inclusion criteria of randomized trials in younger patients (age ≤60 years) were predefined.
Among 140 patients with complete datasets (34% female, mean [SD] age 54 [11] years), 105 (75%) had an unfavorable outcome (mRS score >3). Mean (SD) infarct volume was 238 (63) mL. Multivariable logistic regression identified age (odds ratio [OR] 1.08 per 1-year increase, 95% confidence interval [CI] 1.02-1.13, = 0.004), infarct size (OR 1.27 per 10-mL increase, 95% CI 1.12-1.44, < 0.001), and NIH Stroke Scale score (OR 1.10, 95% CI 1.01-1.20, = 0.030) before hemicraniectomy as independent predictors of unfavorable outcome. Findings were reproduced in patients fulfilling inclusion criteria of randomized trials in younger patients. Infarct volume thresholds for prediction of unfavorable outcome with high specificity (94% in overall cohort and 92% in younger patients) were >258 mL before hemicraniectomy.
Outcome in MMI depends strongly on age and infarct size before hemicraniectomy. Standardized volumetry may be helpful in the process of decision-making concerning hemicraniectomy.
通过回顾性分析一项前瞻性多中心研究中的 140 例患者的数据，明确在接受大脑中动脉梗死（MMI）半切开减压术的患者中，术前梗死体积是否为独立预测因素，以此来预测患者的选择和结局。
该研究纳入了 DESTINY 登记研究中接受大脑中动脉梗死>50%的大脑中动脉区域半切开减压术的患者。术后 12 个月采用改良 Rankin 量表（mRS）评估功能结局，定义 mRS 评分 4 至 6 分为预后不良。术前通过 CT 或 MRI 半自动定量梗死体积。根据年龄≤60 岁的随机试验纳入标准，对患者进行了亚组分析。
在 140 例有完整数据集的患者中（34%为女性，平均年龄 54[11]岁），105 例（75%）预后不良（mRS 评分>3）。平均梗死体积为 238（63）mL。多变量逻辑回归分析确定年龄（每增加 1 岁，优势比[OR]为 1.08，95%置信区间[CI]为 1.02-1.13， = 0.004）、梗死体积（每增加 10 mL，OR 为 1.27，95% CI 为 1.12-1.44， < 0.001）和术前 NIH 卒中量表评分（OR 为 1.10，95% CI 为 1.01-1.20， = 0.030）为预后不良的独立预测因素。这些发现也在符合年轻患者随机试验纳入标准的患者中得到了复制。术前梗死体积阈值>258 mL 可高度预测预后不良（总体队列中特异性为 94%，年轻患者中特异性为 92%）。
MMI 的预后与术前大脑中动脉梗死的年龄和梗死体积密切相关。标准化容积测量可能有助于半切开减压术决策过程。
