Department of Neurology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany.
Department of Neurology, University Hospital Ulm, Ulm, Germany.
J Neurol. 2023 Aug;270(8):4080-4089. doi: 10.1007/s00415-023-11766-3. Epub 2023 May 10.
In malignant cerebral infarction decompressive hemicraniectomy has demonstrated beneficial effects, but the optimum size of hemicraniectomy is still a matter of debate. Some surgeons prefer a large-sized hemicraniectomy with a diameter of more than 14 cm (HC > 14). We investigated whether this approach is associated with reduced mortality and an improved long-term functional outcome compared to a standard hemicraniectomy with a diameter of less than 14 cm (HC ≤ 14).
Patients from the DESTINY (DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY) registry who received hemicraniectomy were dichotomized according to the hemicraniectomy diameter (HC ≤ 14 cm vs. HC > 14 cm). The primary outcome was modified Rankin scale (mRS) score ≤ 4 after 12 months. Secondary outcomes were in-hospital mortality, mRS ≤ 3 and mortality after 12 months, and the rate of hemicraniectomy-related complications. The diameter of the hemicraniectomy was examined as an independent predictor of functional outcome in multivariable analyses.
Among 130 patients (32.3% female, mean (SD) age 55 (11) years), the mean hemicraniectomy diameter was 13.6 cm. 42 patients (32.3%) had HC > 14. There were no significant differences in the primary outcome and mortality by size of hemicraniectomy. Rate of complications did not differ (HC ≤ 14 27.6% vs. HC > 14 36.6%, p = 0.302). Age and infarct volume but not hemicraniectomy diameter were associated with outcome in multivariable analyses.
In this post-hoc analysis, large hemicraniectomy was not associated with an improved outcome or lower mortality in unselected patients with malignant middle cerebral artery infarction. Randomized trials should further examine whether individual patients could benefit from a large-sized hemicraniectomy.
German Clinical Trials Register (URL: https://www.drks.de ; Unique Identifier: DRKS00000624).
在恶性大脑梗死中，去骨瓣减压术已被证明具有有益的效果，但最佳的去骨瓣大小仍存在争议。一些外科医生更喜欢直径大于 14cm 的大骨瓣去骨瓣切除术（HC>14）。我们研究了与标准直径小于 14cm 的去骨瓣切除术（HC≤14）相比，这种方法是否与降低死亡率和改善长期功能预后相关。
来自 DESTINY（去减压手术治疗大脑中动脉恶性梗死）登记处的接受去骨瓣减压术的患者根据去骨瓣直径（HC≤14cm 与 HC>14cm）分为两组。主要结局是 12 个月后改良 Rankin 量表（mRS）评分≤4。次要结局是住院死亡率、mRS≤3 和 12 个月后死亡率，以及去骨瓣相关并发症的发生率。在多变量分析中，检查去骨瓣直径作为功能结局的独立预测因子。
在 130 名患者（32.3%为女性，平均年龄 55（11）岁）中，平均去骨瓣直径为 13.6cm。42 名患者（32.3%）的 HC>14。两组主要结局和死亡率无显著差异。并发症发生率无差异（HC≤14 为 27.6%，HC>14 为 36.6%，p=0.302）。年龄和梗死体积，但不是去骨瓣直径与多变量分析中的结局相关。
在这项回顾性分析中，在未选择的恶性大脑中动脉梗死患者中，大骨瓣去骨瓣减压术与改善结局或降低死亡率无关。随机试验应进一步研究是否个体患者可以从大骨瓣去骨瓣减压术中受益。
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