Decompressive craniectomy versus conservative treatment: limits and possibilities in malignant stroke

ABSTRACT

Background: Malignant infarction of the middle cerebral artery (MCA) occurs in a subgroup of patients with ischemic stroke and early decompressive craniectomy (DC) is one of its treatments. Objective: To investigate the functional outcome of patients with malignant ischemic stroke treated with decompressive craniectomy at a neurological emergency center in Northeastern Brazil. Methods: Prospective cohort study, in which 25 patients were divided into two groups: those undergoing surgical treatment with DC and those who continued to receive standard conservative treatment (CT). Functionality was assessed using the modified Rankin Scale (mRS), at follow-up after six months. Results: A favorable outcome (mRS≤3) was observed in 37.5% of the DC patients and 29.4% of CT patients (p=0.42). Fewer patients who underwent surgical treatment died (25%), compared to those treated conservatively (52.8%); however, with no statistical significance. Nonetheless, the proportion of patients with moderate to severe disability (mRS 4–5) was higher in the surgical group (37.5%) than in the non-surgical group (17.7%). Conclusion: In absolute values, superiority in the effectiveness of DC over CT was perceived, showing that the reduction in mortality was at the expense of increased disability.

RESUMO

Introdução: O infarto maligno da artéria cerebral média (ACM) ocorre em um subgrupo de pacientes com acidente vascular cerebral (AVC) isquêmico e a craniectomia descompressiva (CD) precoce é um de seus tratamentos. Objetivo: Investigar o desfecho funcional de pacientes com acidente vascular cerebral isquêmico maligno submetidos à craniectomia descompressiva em um centro de emergência neurológica do nordeste do Brasil. Métodos: Nesta coorte prospectiva, os pacientes foram divididos em dois grupos: aqueles submetidos a tratamento cirúrgico com craniectomia descompressiva (CD) e aqueles que mantiveram tratamento conservador (TC) padrão. A funcionalidade foi avaliada por meio da Escala de Rankin modificada (ERm) ao final de seis meses de seguimento. Resultados: Evidenciou-se desfecho favorável (ERm≤3) em 37,5% dos pacientes craniectomizados e em 29,4% dos pacientes não craniectomizados (p=0,42). A mortalidade foi menor no grupo de pacientes que se submeteram a tratamento cirúrgico (25%) do que entre aqueles tratados conservadoramente (52,8%), porém sem significância estatística. Por outro lado, a proporção de pacientes com incapacidade moderada a grave (ERm 4–5) foi maior no grupo cirúrgico (37,5%) do que no grupo não cirúrgico (17,7%). Conclusão: Em valores absolutos, percebeu-se superioridade na eficácia do tratamento cirúrgico sobre o conservador, mostrando que a redução de mortalidade se dá à custa de aumento da incapacidade funcional.

Keywords:

stroke - brain edema - decompressive craniectomy

Palavras-chave:

acidente vascular cerebral - edema encefálico - craniectomia descompressiva

• References

• 1 Mohan Rajwani K, Crocker M, Moynihan B. Decompressive craniectomy for the treatment of malignant middle cerebral artery infarction. Br J Neurosurg. 2017 Aug;31(4):401-9. https://doi.org/10.1080/02688697.2017.1329518
• 2 Das S, Mitchell P, Ross N, Whitfield PC. Decompressive hemicraniectomy in the treatment of malignant middle cerebral artery infarction: a meta-analysis. World Neurosurg. 2019 Mar;123:8-16. https://doi.org/10.1016/j.wneu.2018.11.176
• 3 Algethamy HM, Samman A, Baeesa SS, Almekhlafi MA, Al Said YA, Hassan A. Decompressive hemicraniectomy for malignant middle cerebral artery infarction-Experience from the Western Province of Saudi Arabia. Neurosciences (Riyadh). 2017 Jul;22(3):192-7. https://doi.org/10.17712/nsj.2017.3.20170051
• 4 Rahme R, Curry R, Kleindorfer D, Khoury JC, Ringer AJ, Kissela BM, et al. How often are ischemic stroke patients eligible for decompressive hemicraniectomy? Stroke. 2012 Feb;43(2):550-2. https://doi.org/10.1161/STROKEAHA.111.635185
• 5 Treadwell SD, Thanvi B. Malignant middle cerebral artery (MCA) infarction: pathophysiology, diagnosis and management. Postgrad Med J. 2010 Apr;86(1014):235-42. https://doi.org/10.1136/pgmj.2009.094292
• 6 Wartenberg KE. Malignant middle cerebral artery infarction. Curr Opin Crit Care. 2012 Apr;18(2):152-63. https://doi.org/10.1097/MCC.0b013e32835075c5
• 7 Staykov D, Gupta R. Hemicraniectomy in malignant middle cerebral arter infarction. Stroke. 2011; 42:513-6. https://doi.org/10.1161/STROKEAHA.110.605642
• 8 Huttner HB, Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol. 2009 Oct;8(10):949-58. https://doi.org/10.1016/S1474-4422(09)70224-8
• 9 Wijdicks EFM, Sheth KN, Carter BS, Greer DM, Kasner SE, Kimberly WT, et al. Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014 Apr;45(4):1222-38. https://doi.org/10.1161/01.str.0000441965.15164.d6
• 10 Torbey MT, Bosel J, Rhoney DH, Rincon F, Staykov D, Amar AP, et al. Evidence-based guidelines for the management of large hemispheric infarction a statement for health care professionals from the Neurocritical Care Society and the German Society for Neuro-Intensive Care and Emergency Medicine. Neurocrit Care. 2015 Feb;22(1):146-64. https://doi.org/10.1007/s12028-014-0085-6
• 11 Hauer E-M, Stark D, Staykov D, Steigleder T, Schwab S, Bardutzky J. Early continuous hypertonic saline infusion in patients with severe cerebrovascular disease. Crit Care Med. 2011 Jul;39(7):1766-72. https://doi.org/10.1097/CCM.0b013e318218a390
• 12 Akins PT, Axelrod YV, Arshad ST, Guppy KH. Initial conservative management of severe hemispheric stroke reduces decompressive craniectomy rates. Neurocrit Care. 2016 Aug;25(1):3-9. https://doi.org/10.1007/s12028-016-0270-x
• 13 Simard JM, Sahuquillo J, Sheth KN, Kahle KT, Walcott BP. Managing malignant cerebral infarction. Curr Treat Options Neurol. 2011 Apr;13(2):217-29. https://doi.org/10.1007/s11940-010-0110-9
• 14 Zweckberger K, Juettler E, Bösel J, Unterberg WA. Surgical aspects of de compression craniectomy in malignant stroke: Review. Cerebrovasc Dis. 2014;38(5):313-23. https://doi.org/10.1159/000365864
• 15 Hofmeijer J, Amelink GJ, Algra A, van Gijn J, MaCleod RM, Kappelle LJ, et al. Hemicraniectomy After Middle cerebral artery infarction with Life-threatening Edema Trial (HAMLET). Protocol for a randomised controlled trial of decompressive surgery in space-occupying hemispheric infarction. Trials, 2006;7:29. https://doi.org/10.1186/1745-6215-7-29
• 16 Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL trial). Stroke. 2007;38(9):2506-17. https://doi.org/10.1161/STROKEAHA.107.485235
• 17 Juttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, et al. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY I): a randomized, controlled trial. Stroke. 2007 Sep;38(9):2518-25. https://doi.org/10.1161/STROKEAHA.107.485649
• 18 Vital RB, Hamamoto Filho PT, Luvizutto GJ, Ducati LG, Braga GP, Nunes HRdC, et al. Decompressive hemicraniectomy in a South American Population - morbidity and outcomes analysis. PLoS ONE. 2016 Jan;11(1): e0146747. https://doi.org/10.1371/journal.pone.0146747
• 19 Bongiorni GT, Hockmuller MCJ, Klein C, Antunes ACM. Decompressive craniotomy for the treatment of malignant infarction of the middle cerebral artery: mortality and outcomes Arq Neuropsiquiatr. 2017 Jul;75(7):424-8. https://doi.org/10.1590/0004-282X20170053
• 20 Mattos JP, Joaquim AF, Almeida JP, Albuquerque LA, Silva EG, Marenco HA, et al. Decompressive craniectomy in massive cerebral infarction. Arq Neuropsiquiatr. 2010;68(3):339-45. https://doi.org/10.1590/s0004-282x2010000300002
• 21 Fiorot Junior JA, Silva GS, Cavalheiro S, Massaro AR. Use of decompressive craniectomy in the treatment of hemispheric infarction. Arq Neuropsiquiatr. 2008;66(2A):204-8. https://doi.org/10.1590/s0004-282x2008000200012
• 22 Shah A, Almenawer S and Hawryluk G. Timing of decompressive craniectomy for ischemic stroke and traumatic brain injury: a review. Front Neurol. 2019;10:11.https://doi.org/10.3389/fneur.2019.00011
• 23 Kim B-J, Hong YR, Han Y, Hwang Y-H, Ohk B, Park J. Age-Dependent Attitudes of Ischemic Patients towards Disability after Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction, World Neurosurgery (2018). doi: 10.1016/j.wneu.2018.02.050.