Neurosciences Research Center (NSRC), Department of Neurology, Imam-Reza hospital, Tabriz University of Medical Sciences, Tabriz, Iran.
Department of Neurosurgery, Imam-Reza hospital, Tabriz University of Medical Sciences, Tabriz, Iran.
BMC Neurol. 2023 Mar 28;23(1):125. doi: 10.1186/s12883-022-03014-4.
The optimal timing for decompressive hemicraniectomy (DHC) after intravenous thrombolysis (IVT) remains unclear. This study in patients with acute ischemic stroke treated with IVT aimed to assess the safety of DHC and patient outcome.
Data was extracted from the Tabriz stroke registry from June 2011 up to September 2020. In all, 881 patients were treated with IVT. Among these, 23 patients underwent DH. Six patients were excluded due to symptomatic intracranial hemorrhage (parenchymal hematoma type 2 based on SITS-MOST definition) after IVT, but other types of bleeding after venous thrombolysis, including HI1, HI2, and PH1 were not excluded; so the remaining 17 patients were enrolled in the study. Functional Outcome was defined as the proportion of patients who achieved mRS score of 2-3 (moderate disability), 4-5 (severe disability), or 6 (mortality) at 90 days after stroke. mRSwas assess by trained neurologist at the hospital clinic with direct interview Safety outcome was assessed by comparison of two scans just prior to and after craniectomy. Any new hemorrhage or worsening of previous hemorrhage was reported. Parenchymal hematoma type 2, based on ECASS II definition, was considered as major surgical complication. This study was approved by the local ethics committee of the Tabriz University of Medical Sciences (Ethics Code: IR.TBZMED.REC.1398.420).
At the three-month mRS follow up, six patients (35%) had moderate and five (29%) had severe disability. The outcome of death was observed in six patients (35%).Nine of 15 patients (60%) underwent surgery in the first 48 hours after onset of symptoms. No patient over 60 years of age survived to the three-month follow up; 67% of those who were under60 years and underwent DH in the first 48 hours had favorable outcome. Hemorrhagic complication was seen in 64% of patients but none was major.
Results of this study showed that the rate of major bleeding and outcome of acute ischemic stroke patients who underwent DHC after IVT is comparable with the reported data in the literature and intentionally waiting for the fibrinolytic effects of IVT to disappear may not outweigh the benefits of DHC. Although the findings of the study should be interpreted with caution and larger studies are needed to confirm the results.
经静脉溶栓（IVT）后行去骨瓣减压术（DHC）的最佳时机仍不清楚。本项针对接受 IVT 治疗的急性缺血性脑卒中患者的研究旨在评估 DHC 的安全性和患者预后。
本研究从 2011 年 6 月至 2020 年 9 月期间从大不里士脑卒中登记处提取数据。共有 881 例患者接受 IVT 治疗。其中，23 例行 DH。6 例患者因 IVT 后出现症状性颅内出血（SITS-MOST 定义的实质血肿 2 型）而被排除，但排除了其他类型的静脉溶栓后出血，包括 HI1、HI2 和 PH1；因此，其余 17 例患者被纳入研究。功能结局定义为在脑卒中后 90 天达到 mRS 评分 2-3（中度残疾）、4-5（重度残疾）或 6（死亡）的患者比例。mRS 评分由经过培训的神经科医生在医院门诊进行评估，通过直接访谈进行。安全性结局通过比较颅骨切开术前和术后的两次扫描进行评估。报告任何新的出血或先前出血的恶化。根据 ECASS II 定义，实质血肿 2 型被认为是主要手术并发症。本研究得到了大不里士塔比里斯医学科学大学地方伦理委员会的批准（伦理代码：IR.TBZMED.REC.1398.420）。
在三个月的 mRS 随访中，6 名患者（35%）有中度残疾，5 名患者（29%）有重度残疾。6 名患者（35%）死亡。15 名患者中有 9 名（60%）在症状出现后 48 小时内接受了手术。没有一名 60 岁以上的患者存活到三个月的随访期；67%的 60 岁以下患者在 48 小时内行 DH 后有良好的结局。64%的患者发生了出血性并发症，但没有严重并发症。
本研究结果表明，在 IVT 后行 DHC 的急性缺血性脑卒中患者的大出血发生率和结局与文献报道的数据相当，因此，等待 IVT 的纤维蛋白溶解作用消失可能并不优于 DHC 的益处。尽管研究结果应谨慎解释，且需要更大规模的研究来证实这些结果。
