Outcome After Decompressive Craniectomy for Middle Cerebral Artery Infarction: Timing of the Intervention.
Decompressive craniectomy
Ischemic stroke
Outcome
Prognosis
Timing of surgery
Journal
Neurosurgery
ISSN: 1524-4040
Titre abrégé: Neurosurgery
Pays: United States
ID NLM: 7802914
Informations de publication
Date de publication:
01 03 2020
01 03 2020
Historique:
received:
21
03
2019
accepted:
29
09
2019
pubmed:
17
1
2020
medline:
1
9
2020
entrez:
17
1
2020
Statut:
ppublish
Résumé
Based on randomized controlled trials (RCTs), clinical guidelines for the treatment of space-occupying hemispheric infarct employ age (≤60 yr) and time elapsed since stroke onset (≤48 h) as decisive criteria whether to perform decompressive craniectomy (DC). However, only few patients in these RCTs underwent DC after 48 h. To study the association between the timing of DC and (un)favorable outcome in patients with space-occupying middle cerebral artery (MCA) infarct undergoing DC. We performed a single-center cohort study from 2007 to 2017. Unfavorable outcome at 1 yr was defined as a Glasgow outcome scale 1 to 3. Additionally, we systematically reviewed the literature up to November 2018, including studies reporting on the timing of DC and other predictors of outcome. We performed Firth penalized likelihood and random-effects meta-analysis with odds ratio (OR) on unfavorable outcome. A total of 66 patients were enrolled. A total of 26 (39%) patients achieved favorable and 40 (61%) unfavorable outcomes (13 [20%] died). DC after 48 h since stroke diagnosis did not significantly increase the risk of unfavorable outcome (OR 0.8, 95% CI 0.3-2.3). Also, in the meta-analysis, DC after 48 h of stroke onset was not associated with a higher risk of unfavorable outcome (OR 1.11; 95% CI 0.89-1.38). The outcome of DC performed after 48 h in patients with malignant MCA infarct was not worse than the outcome of DC performed within 48 h. Contrary to current guidelines, we, therefore, advocate not to set a restriction of ≤48 h on the time elapsed since stroke onset in the decision whether to perform DC.
Sections du résumé
BACKGROUND
Based on randomized controlled trials (RCTs), clinical guidelines for the treatment of space-occupying hemispheric infarct employ age (≤60 yr) and time elapsed since stroke onset (≤48 h) as decisive criteria whether to perform decompressive craniectomy (DC). However, only few patients in these RCTs underwent DC after 48 h.
OBJECTIVE
To study the association between the timing of DC and (un)favorable outcome in patients with space-occupying middle cerebral artery (MCA) infarct undergoing DC.
METHODS
We performed a single-center cohort study from 2007 to 2017. Unfavorable outcome at 1 yr was defined as a Glasgow outcome scale 1 to 3. Additionally, we systematically reviewed the literature up to November 2018, including studies reporting on the timing of DC and other predictors of outcome. We performed Firth penalized likelihood and random-effects meta-analysis with odds ratio (OR) on unfavorable outcome.
RESULTS
A total of 66 patients were enrolled. A total of 26 (39%) patients achieved favorable and 40 (61%) unfavorable outcomes (13 [20%] died). DC after 48 h since stroke diagnosis did not significantly increase the risk of unfavorable outcome (OR 0.8, 95% CI 0.3-2.3). Also, in the meta-analysis, DC after 48 h of stroke onset was not associated with a higher risk of unfavorable outcome (OR 1.11; 95% CI 0.89-1.38).
CONCLUSION
The outcome of DC performed after 48 h in patients with malignant MCA infarct was not worse than the outcome of DC performed within 48 h. Contrary to current guidelines, we, therefore, advocate not to set a restriction of ≤48 h on the time elapsed since stroke onset in the decision whether to perform DC.
Identifiants
pubmed: 31943069
pii: 5706947
doi: 10.1093/neuros/nyz522
pmc: PMC7061200
doi:
Types de publication
Journal Article
Meta-Analysis
Systematic Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
E318-E325Commentaires et corrections
Type : CommentIn
Informations de copyright
Copyright © 2020 by the Congress of Neurological Surgeons.
Références
Neurocrit Care. 2016 Dec;25(3):371-383
pubmed: 27406817
PLoS Med. 2009 Jul 21;6(7):e1000097
pubmed: 19621072
Medicine (Baltimore). 2015 Jun;94(25):e1039
pubmed: 26107675
Cureus. 2017 Jan 26;9(1):e997
pubmed: 28286721
BMC Neurol. 2015 Aug 28;15:156
pubmed: 26311142
Stroke. 2018 Mar;49(3):e46-e110
pubmed: 29367334
Stroke. 2007 Sep;38(9):2518-25
pubmed: 17690310
N Engl J Med. 2014 Mar 20;370(12):1091-100
pubmed: 24645942
Acta Neurochir (Wien). 2016 May;158(5):865-72; discussion 873
pubmed: 26923797
J Stroke Cerebrovasc Dis. 2017 Sep;26(9):1941-1947
pubmed: 28694110
Neurol India. 2012 Nov-Dec;60(6):608-12
pubmed: 23287323
World Neurosurg. 2018 Mar;111:e722-e728
pubmed: 29317364
Acta Neurochir (Wien). 2006 Jan;148(1):31-7; discussion 37
pubmed: 16172833
J Neurol Neurosurg Psychiatry. 2004 Feb;75(2):270-4
pubmed: 14742603
Surg Neurol. 2004 Nov;62(5):420-9; discussion 429-30
pubmed: 15518850
Crit Care Med. 1995 Sep;23(9):1576-87
pubmed: 7664561
Neurology. 2007 May 15;68(20):1651-7
pubmed: 17502545
Br J Neurosurg. 2012 Aug;26(4):504-9
pubmed: 22168966
Neurocrit Care. 2012 Oct;17(2):161-71
pubmed: 22528280
J Korean Neurosurg Soc. 2007 Oct;42(4):331-6
pubmed: 19096565
Turk Neurosurg. 2016;26(5):704-8
pubmed: 27349403
J Neurosurg. 2012 Oct;117(4):749-54
pubmed: 22920962
Surg Neurol. 2005 Aug;64(2):165-9; discussion 169
pubmed: 16051014
N Engl J Med. 2015 Jan 1;372(1):11-20
pubmed: 25517348
Stroke. 2014 Mar;45(3):781-7
pubmed: 24425122
Neurol India. 2014 Jan-Feb;62(1):26-31
pubmed: 24608450
Lancet. 1975 Mar 1;1(7905):480-4
pubmed: 46957
J Neurosurg. 2004 Aug;101(2):248-54
pubmed: 15309915
Neurocrit Care. 2015 Feb;22(1):6-14
pubmed: 25127905
Crit Care Med. 2003 Jan;31(1):272-7
pubmed: 12545028
Neurology. 2006 Sep 12;67(5):891-3
pubmed: 16966561
Stroke. 2017 Mar;48(3):704-711
pubmed: 28108618
Surg Neurol Int. 2014 Jun 26;5:102
pubmed: 25101197
Medicina (Kaunas). 2012;48(10):521-4
pubmed: 23324248
Stroke. 2007 Sep;38(9):2506-17
pubmed: 17690311
Springerplus. 2014 Feb 28;3:115
pubmed: 24711983
J Clin Epidemiol. 2008 Apr;61(4):344-9
pubmed: 18313558
Lancet Neurol. 2009 Apr;8(4):326-33
pubmed: 19269254
Acta Neurochir (Wien). 2005 Jun;147(6):587-94; discussion 594
pubmed: 15739038
J Neurotrauma. 2013 Aug 15;30(16):1385-90
pubmed: 23441674
Eur J Neurol. 2018 Mar;25(3):425-433
pubmed: 29218822
J Cerebrovasc Endovasc Neurosurg. 2012 Jun;14(2):65-74
pubmed: 23210030
J Cerebrovasc Endovasc Neurosurg. 2016 Sep;18(3):175-184
pubmed: 27847759
J Clin Neurosci. 2013 Jan;20(1):49-52
pubmed: 23063497
Acta Neurochir (Wien). 2018 Jan;160(1):83-89
pubmed: 28965156
J Clin Neurosci. 2007 Apr;14(4):317-21
pubmed: 17275311
J Neurosurg. 2016 Jun;124(6):1773-9
pubmed: 26613165