To determine the prognostic factors influencing the results of decompressive craniectomy for large supratentorial cerebral infarction. Subject and methods: Between January 2013 and November 2016 at Choray Hospital, 75 patients were diagnosed with a large supratentorial cerebral infarction and underwent the decompressive craniectomy.
Trang 1THE PROGNOSTIC FACTORS OF DECOMPRESSIVE
CRANIECTOMY FOR LARGE SUPRATENTORIAL
INFARCTION IN CHORAY HOSPITAL
Truong Da 1 ; Bui Quang Tuyen 2 ; Vu Van Hoe 2
SUMMARY
Objectives: To determine the prognostic factors influencing the results of decompressive craniectomy for large supratentorial cerebral infarction Subject and methods: Between January 2013 and November 2016 at Choray Hospital, 75 patients were diagnosed with a large supratentorial cerebral infarction and underwent the decompressive craniectomy Results: The mean age: 53.01 ± 13.08 years Group of age < 50 years: 25 cases (alive: 23 cases; dead:
2 cases) Group of age ≥ 50 years: 50 cases (alive: 43 cases; dead: 7 cases) The decompressive craniectomy was conducted within 72 hours after stroke for 65/75 cases, there were 03 deaths (mortality rate: 4.62%) and 10 patients underwent craniectomy > 72 hours after stroke, there were
06 deaths (mortality rate: 60%) The largest open skull portion size was 16 x 12 cm (no death out of 17 cases); the smallest size was 12 x 12 cm (8 deaths out of 26 cases) GCS before surgery ≤ 8: 34 cases (alive: 26 cases; dead: 08 cases) and GCS before surgery > 8: 41 cases (alive: 40 cases; dead: 01 cases) The mortality rate at discharge: 12% Postoperative complications were 20% Conclusion: The age, time for craniectomy, size of the open skull portion, GCS before surgery are the prognostic factors affecting the result of decompressive craniectomy for large supratentorial cerebral infarction
* Keywords: Decompressive craniectomy; Large supratentorial cerebral infarction; Prognostic factors.
INTRODUCTION
Scarcella was the first person to describe
a cranial opening for cerebral infarction to
reduce intracerebral pressure and prevent
brain from herniating in 1956 According to
Zweckberger, for which internal medical
treatment is used, the mortality rate can
be up to 80% [12] Thus, Desiree (2000),
Cho (2011), Kenning (2012) and many
other neurosurgeons supposed that
decompressive craniectomy for large and
malignant cerebral infarction
is effective in reducing mortality and restricting neurological sequelae [2, 4, 6]
In the past 10 years, the Department of Neurosurgery in Choray Hospital has done the decompressive craniectomy for some patients with large cerebral infarction
in the cerebral hemisphere that has brought some good results, saved the patient’s life Therefore, we have conducted this study
aiming: To determine the prognostic factors
influenced the results of decompressive craniectomy for large supratentorial cerebral infarction
1 Cho Ray Hospital
2 103 Military Hospital
Corresponding author: Truong Da (truongda.010157@gmail.com)
Trang 2SUBJECTS AND METHODS
1 Subjects
75 patients were diagnosed with a large
supratentorial cerebral infarction and
underwent the decompressive craniectomy
at Choray Hospital from January 2013 to
September 2016
* Selection criteria: Patient were diagnosed
to have large supratentorial cerebral infarction,
indicated for a surgery and were operated
to decompress
* Exclusion criteria: Patient did not
have enough medical records, family did
not agree to participate in the study
2 Methods
A prospective, uncontrolled intervention
study of 75 patients
* Research indicators:
- Evaluation of surgery results: Alive
and dead
- Time for craniectomy: The time from
onset to decompressive hemicraniectomy
(hour)
- Size of the open skull portion:
Anterior:frontal to mid-pupillary line; posterior:
4 cm posterior to external auditory canal;
superior: superior sagital sinus The smallest
size was 12 x 12 cm
Data entered and processed by SPSS
16.0 Statistically significant when p < 0.05
RESULTS
Results (at discharge): Survival rate
was 88.0% and the mortality was 12.0%
Postoperative complications occurred
for 15/75 cases (20%), of which small
bleeding scattered in the infarction area
2/75 cases (2.67%); incision infection
8/75 cases (10.67%) - the most common complication; local seizures 3/75 cases (4%) and cardiovascular disorders 2/75 cases (2.67%) All cases were under internal medicine treatment and there were
2 deaths due to cardiovascular disorders,
acute stroke
1 The age
The mean age: 53.01 ± 13.08 years Group of age < 50 years: 25 cases (alive:
23 cases; dead: 2 cases) Group of age
≥ 50 years: 50 cases (alive: 43 cases; dead: 7 cases) There was a statistical relation between the age and result (p < 0.01)
2 Time for craniectomy
Table 1: Time for decompressive
craniectomy
Results (n, %) Time
≤ 72 hours 62 (95.38%) 3 (4.62%) 65 (86.67%)
> 72 hours 4 (40%) 6 (60%) 10 (13.33%) Total 66 (88%) 9 (12%) 75 (100%)
The highest mortality rate was 60% with the surgery time > 72 hours (with
6 deaths in 10 cases)
3 Sizes of open skull portion
Table 2:
Results (n) Open skull
portion size
Open skull portion area
No of
16 x 12 cm 192 cm 2
14 x 12 cm 168 cm 2
12 x 12 cm 144 cm 2
The mortality rate was very high (8/26 cases = 30.76%) if the size of the skull opening was 12 x 12 cm but the
Trang 3mortality rate was very low (1/49 cases =
2.04%) if the size of the skull opening was
more than 12 x 12 cm There was a
statistical difference of results between
two groups (p < 0.001)
4 GCS before surgery
Table 3:
Treatment results (n, %) GCS before
surgery
No of
patients
> 8 41 40 (97.56%) 01 (2.44%)
The mortality rate in group of GCS before
surgery ≤ 8 was 23.53% (8/34 cases) and
the mortality rate in group of GCS before
surgery > 8 was 2.44% (1/41 cases)
There was a statistical relation between
the GCS before surgery and early result
(p = 0.021 and OR = 0.018)
5 Pupil
Table 4: Symptoms of pupils
Number of patient Pupil
Total
6 The factors that are likely to affect
the modality
Table 5:
Result
(n)
Dead (n)
Age (years)
< 50
≥ 50
23
43
2
7 0.007 0.032
Sex
Male
Female
7
17
7
2 1.0 1.214
Hemisphere Right Left
28
38
2
7 0.301 0.388
GCS before surgery
≤ 8
> 8
26
40
8
1 0.021 0.018
Pupils:
Undilated Dilated
53
13
0
9
< 0.001 1.69 Midline shift
< 5 mm
≥ 5 mm
19
47
0
9
Time for craniectomy ≤ 72 h > 72 h
62
4
3
6
< 0.001 0.032
DISCUSSION
1 The age
Table 1 showed that there was a statistical relation between the age and results (p < 0.01 and OR = 0.032) The mortality rate was higher in group > 50 years
Uhl E et al (2004) studied 188 patients who underwent decompressive craniectomy for space occuping cerebral infarction and the analysis showed that age must be considered the most important pretreatment prognostic factor, and surgical treatment results in younger patients are encouraging [9]
Cho S.Y et al (2011) studied 12 patients who suffered acute large cerebral infarction and the analysis showed that the age had also been reported to be a significant prognostic factor that influences the survival after stroke [2]
2 The time for craniectomy
We realized that when performing surgery ≤ 72 hours for 65 patients, there were 3 deaths Whereas, late surgery
Trang 4> 72 hours for 10 patients, the number of
death was 6 patients Comparison was
statistically significant with p < 0.001
(table 5) Schwab studied the effects of
skull opening in 63 patients with
large-scale cerebral infarction The results
showed that the mortality rate for early
surgery (21 hours) was 16%, and for late
surgery (39 hours) was 34% Early surgery
would reduce the rate of brain herniation
(encephalocele) to only 13% compared
with 75% in late surgery
Lu (2014) suggested that early
decompressive craniectomy within 48 hours
of stroke would reduce mortality rate and
improve neurologic recovery in patients
with malignant MCA infarction [7]
The results of our study were also
consistent with the conclusion of the study
by foreign authors that early surgery
would save patients, reduce mortality rate
and improve postoperative neurologic
recovery ability
3 The skull portion size
Compared to foreign documents, our
open cranium piece size was smaller;
perhaps the skull of a foreigner is bigger
than the Vietnamese skull In fact, the
area of the injured skull was larger than
the area of the normal skull area, as we
continued to cut the skull toward the
temporal bone in the preauricular pit,
down to the skull based to prevent brain
herniation and temporal lobe herniation
into the fissure of Bichat Skull bone
portion were stored in the tissue bank of
Choray Hospital, preserved at an extreme
cold temperature of -500C
According to Wirtz C.R et al (1997) [10], of 43 decompression craniectomy cases for space-occupational hemispheric infarction treatment, it was found that the survival rates was 72.1% and no patient was under vegatative state The average size of the open skull portion was 84.3 ± 16.5 cm2 and the average distance from the margin of the defect bone edge to the middle skull pit was 1.8 ± 1.3 cm The difference between the alive and the dead patient was the size of the open skull portion and the distance to middle skull pit Thus, the authors concluded that decompression craniectomy is an effective treatment that is capable of reducing mortality rate and improving neurological recovery ability in patients with space-occupational cerebral infarction if the skull portion size is opened wide enough Curry W.T et al (2005) suggested that the skull opening size in adults was at least 13 cm for ahead-behind dimension and the 9 cm for superoinferior dimension which allowed the release of the hemisphere [3]
Zweckberger K (2014) suggested that the skull opening size of less than 12 cm was the cause for cortical damage and increased the mortality rate Some studies also supposed that the diameter of the open skull portion of even more than 14 cm,
or including the superior sagittal sinus, is favorable for good recovery prognosis, without any complications [12] Chung J
et al found that the maximal decompression size > 14 - 16 cm or > 399 cm2 compared
to a large size > 12 cm or 308 cm2 would increase the recovery rate 3 months after stroke
Trang 5Among the 75 cases in the study,
we performed decompression craniectomy
for 17 cases with the largest size of 16 x
12 cm (192 cm2) and there was no death
Of 32 cases with the size of 14 x 12 cm
(168 cm2), the number of alive patients was 31
and number of death was 1 Of 26 cases
with the size of 12 x 12 cm (144 cm2), the
number of alive patients was 18 and
number of death was 8 Through data,
we realized the skull portion size of 12 x
12 cm caused much higher mortality rate
than size of 16 x 12 cm and 14 x 12 cm
(p < 0.001) and the size of the open skull
portion is the prognostic factor affecting
the result of decompressive craniectomy
for large supratentorial cerebral infarction
In our study, there was no case with the
skull opening size of over 200 cm2 In some
cases of size > 399 cm2 and 308 cm2 as
described above, it was likely that these
authors had to open the skull through
the superior sagittal sinus With the such
large sizes, surely that the proportion of
patients who survive after the surgery will
increase dramatically
4 The GCS before surgery
Survival rate at discharge was 88.0%
The mortality rate at discharge was 12.0%
The survival rate after craniectomy at
discharge in group of GCS before surgery
> 8 was very high and there was a statistical
relation between the GCS before surgery
and early result (p = 0.021 and OR = 0.018)
Reddy A.K et al (2002) found an excellent
correlation between preoperative GCS
and the ultimate outcome Among the
32 patients studied by Reddy, those with pre-operative score of > 8, had 88% survival
On the other hand, among those with preoperative GCS below 8, the survival was only 27% [8]
5 The factors that are likely to affect the modality
There were statistical relations between the age, the GCS before surgery, the pupil, the time for surgery, the size of the skull opening and the early result (p < 0.05), but there was not statistical relation between the sex, the hemisphere of infarction, the middle shift and early result (p > 0.05) Thus, the age, the GCS before surgery, the pupil, the time for surgery, the size of the skull opening were the prognostic factors influenced the results of decompressive craniectomy for large supratentorial cerebral infarction
Chen C.C et al (2007) suggested that decompressive hemicraniectomy may
be a useful procedure in patients with malignant infarction Age, clinical signs of herniation and timing of surgery were the prognostic factors associated with mortality and functional outcome [1]
There were no statistical relation between the sex, the hemisphere of infarction, the middle shift and early result (p > 0.05)
Yu J W et al (2012) studied 131 cases who were diagnosed with malignant middle cerebral infarctions (right to left hemisphere ratio was 64.9%:35.1%) and showed that between the two hemispheres, there was no statistically significant difference
for the mortality rate (p = 0.206) [11]
Trang 6CONCLUSION
The mortality rate was 12%
The age, the GCS before surgery,
the pupil, the time for surgery, the size of
the skull opening are the prognostic factors
affecting the early result of decompressive
craniectomy for large supratentorial
cerebral infarction
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