Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany.
Sci Rep. 2023 Aug 10;13(1):12994. doi: 10.1038/s41598-023-40202-9.
Management of malignant hemispheric stroke (MHS) after cardiothoracic surgery (CTS) remains difficult as decision-making needs to consider severe cardiovascular comorbidities and complex coagulation management. The results of previous randomized controlled trials on decompressive surgery for MHS cannot be generally translated to this patient population and the expected outcome might be substantially worse. Here, we analyzed mortality and functional outcome in patients undergoing decompressive hemicraniectomy (DC) for MHS following CTS and assessed the impact of perioperative coagulation management on postoperative hemorrhagic and cardiovascular complications. All patients that underwent DC for MHS resulting as a complication of CTS between June 2012 and November 2021 were included in this observational cohort study. Outcome was determined according to the modified Rankin Scale (mRS) score at 1 and 3-6 months. Clinical and demographic data, anticoagulation management and postoperative hemorrhagic and thromboembolic complications were assessed. In order to evaluate a predictive association between clinical and radiological parameters and the outcome, we used a multivariate logistic regression analysis. Twenty-nine patients undergoing DC for MHS after CTS with a female-to-male ratio of 1:1.9 and a median age of 60 (IQR 49-64) years were identified out of 123 patients undergoing DC for MHS. Twenty-four patients (83%) received pre- or intraoperative substitution. At 30 days, the in-hospital mortality rate and neurological outcome corresponded to 31% and a median mRS of 5 (5-6), which remained stable at 3-6 months [Mortality: 42%, median mRS: 5 (4-6)]. Postoperatively, 15/29 patients (52%) experienced new hemorrhagic lesions and Bayesian logistic regression predicting mortality (mRS = 6) after imputing missing data demonstrated a significantly increased risk for mortality with longer aPPT (OR = 13.94, p = .038) and new or progressive hemorrhagic lesions after DC (OR = 3.03, p = .19). Notably, all but one hemorrhagic lesion occurred before discontinued anticoagulation and/or platelet inhibition was re-initiated. Despite perioperative discontinuation of anticoagulation and/or platelet inhibition, no coagulation-associated cardiovascular complications were noted. In conclusion, Cardiothoracic surgery patients suffering MHS will likely experience severe neurological disability after DC, which should remain a central aspect during counselling and decision-making. The complex coagulation situation after CTS, however, should not per se rule out the option of performing life-saving surgical decompression.
心脏手术后恶性大脑中动脉梗死（MHS）的管理仍然具有挑战性，因为决策需要考虑严重的心血管合并症和复杂的凝血管理。以前关于减压手术治疗 MHS 的随机对照试验结果不能普遍适用于这一患者群体，预期结果可能要差得多。在这里，我们分析了心脏手术后 MHS 行减压性半脑切除术（DC）患者的死亡率和功能结局，并评估了围手术期凝血管理对术后出血和心血管并发症的影响。所有因心脏手术后发生 MHS 而行 DC 的患者均纳入本观察性队列研究。根据改良 Rankin 量表（mRS）评分在 1 个月和 3-6 个月时确定结果。评估了临床和人口统计学数据、抗凝管理以及术后出血和血栓栓塞并发症。为了评估临床和影像学参数与结局之间的预测关联，我们使用了多变量逻辑回归分析。在因 MHS 而行 DC 的 123 例患者中，发现 29 例女性与男性比例为 1:1.9，中位年龄为 60 岁（IQR 49-64）。24 例（83%）患者接受了术前或术中替代治疗。30 天时，住院死亡率和神经功能结果分别为 31%和中位数 mRS 为 5（5-6），3-6 个月时保持稳定[死亡率：42%，中位数 mRS：5（4-6）]。术后，29 例患者中有 15 例（52%）出现新的出血性病变，贝叶斯逻辑回归预测死亡率（mRS=6）后，对缺失数据进行插补显示，aPPT 延长（OR=13.94，p=0.038）和 DC 后出现新的或进展性出血性病变（OR=3.03，p=0.19）与死亡率显著相关。值得注意的是，所有出血性病变均发生在停止抗凝和/或血小板抑制后。尽管围手术期停止抗凝和/或血小板抑制，但未发生与凝血相关的心血管并发症。总之，心脏手术后发生 MHS 的患者在接受 DC 后可能会出现严重的神经功能障碍，这在咨询和决策时应成为一个核心方面。然而，心脏手术后复杂的凝血情况本身不应排除进行救生减压手术的选择。
