Department of Cerebrovascular Diseases, Guangyuan Central Hospital, Guangyuan, China.
Department of Neurology, The First Affiliated Hospital of Henan Polytechnic University (Jiaozuo Second People's Hospital), Jiaozuo, China.
J Stroke Cerebrovasc Dis. 2024 Aug;33(8):107719. doi: 10.1016/j.jstrokecerebrovasdis.2024.107719. Epub 2024 Apr 10.
Decompressive craniectomy (DC) reduces mortality without increasing the risk of very severe disability among patients with life-threatening massive cerebral infarction. However, its efficacy was demonstrated before the era of endovascular thrombectomy trials. It remains uncertain whether DC improves the prognosis of patients with malignant middle cerebral artery (MCA) infarction receiving endovascular therapy.
We pooled data from two trials (DEVT and RESCUE BT studies in China) and patients with malignant MCA infarction were included to assess outcomes and heterogeneity of DC therapy effect. Patients with herniation were dichotomized into DC and conservative groups according to their treatment strategy. The primary outcome was the rate of mortality at 90 days. Secondary outcomes included disability level at 90 days as measured by the modified Rankin Scale score (mRS) and quality-of-life score. The associations of DC with clinical outcomes were performed using multivariable logistic regression.
Of 98 patients with herniation, 37 received DC surgery and 61 received conservative treatment. The median (interquartile range) was 70 (62-76) years and 40.8% of the patients were women. The mortality rate at 90 days was 59.5% in the DC group compared with 85.2% in the conservative group (adjusted odds ratio, 0.31 [95% confidence interval (CI), 0.10-0.94]; P=0.04). There were 21.6% of patients in the DC group and 6.6% in the conservative group who had a mRS score of 4 (moderately severe disability); and 10.8% and 4.9%, respectively, had a score of 5 (severe disability). The quality-of-life score was higher in the DC group (0.00 [0.00-0.14] vs 0.00 [0.00-0.00], P=0.004), but DC treatment was not associated with better quality-of-life score in multivariable analyses (adjusted β Coefficient, 0.02 [95% CI, -0.08-0.11]; p=0.75).
DC was associated with decreased mortality among patients with malignant MCA infarction who received endovascular therapy. The majority of survivors remained moderately severe disability and required improvement on quality of life.
The DEVT trial: http://www.chictr.org. Identifier, ChiCTR-IOR-17013568. The RESCUE BT trial: URL: http://www.chictr.org. Identifier, ChiCTR-INR-17014167.
去骨瓣减压术 (DC) 可降低致命性大面积脑梗死患者的死亡率，而不会增加极重度残疾的风险。然而，其疗效是在血管内取栓术试验之前得到证实的。对于接受血管内治疗的恶性大脑中动脉（MCA）梗死患者，DC 是否能改善预后仍不确定。
我们汇总了两项试验（中国的 DEVT 和 RESCUE BT 研究）的数据，并纳入了恶性 MCA 梗死患者，以评估 DC 治疗效果的结局和异质性。根据治疗策略，将有脑疝的患者分为 DC 组和保守组。主要结局为 90 天时的死亡率。次要结局包括 90 天时改良 Rankin 量表评分（mRS）和生活质量评分所测的残疾程度。使用多变量逻辑回归分析 DC 与临床结局的相关性。
98 例有脑疝的患者中，37 例接受 DC 手术，61 例接受保守治疗。中位数（四分位距）为 70（62-76）岁，40.8%的患者为女性。90 天时 DC 组的死亡率为 59.5%，而保守组为 85.2%（调整后的优势比，0.31[95%置信区间（CI），0.10-0.94]；P=0.04）。DC 组中有 21.6%的患者和保守组中有 6.6%的患者 mRS 评分为 4（中度残疾）；分别有 10.8%和 4.9%的患者 mRS 评分为 5（重度残疾）。DC 组的生活质量评分较高（0.00[0.00-0.14] vs 0.00[0.00-0.00]，P=0.004），但多变量分析显示 DC 治疗与更好的生活质量评分无关（调整后的β系数，0.02[95%CI，-0.08-0.11]；P=0.75）。
对于接受血管内治疗的恶性 MCA 梗死患者，DC 可降低死亡率。大多数存活者仍处于中度残疾状态，生活质量有待提高。
DEVT 试验：http://www.chictr.org. 标识符，ChiCTR-IOR-17013568。RESCUE BT 试验：网址：http://www.chictr.org. 标识符，ChiCTR-INR-17014167。
