Association Between Preoperative Midline Shift Growing Rate and Outcomes of Decompressive Craniectomy in Patients with Malignant Middle Cerebral Artery Infarction

Author(s): Ruozhen Yuan, Simiao Wu, Yajun Cheng, Kaili Ye, Zilong Hao, Shihong Zhang, Yi Liu, Ming Liu*

Journal Name: Current Neurovascular Research

Volume 17 , Issue 2 , 2020

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Background: Whether preoperative midline shift and its growing rate are associated with outcomes of decompressive craniectomy in patients with malignant middle cerebral artery infarction is unknown.

Methods: We retrospectively included patients: 1) who underwent decompressive craniectomy for malignant middle cerebral artery infarction in West China Hospital from August 2010 to December 2, 2018) who had at least two brain computed tomography scans before decompressive craniectomy. Midline shift was measured on the first and last preoperative computed tomography scans. Midline shift growing rate was calculated by dividing Δmidline shift value using Δ time. The primary outcome was inadequate decompression of the mass effect. Secondary outcomes were 3 month death and unfavorable outcomes.

Results: Sixty-one patients (mean age 53.7 years, 57.4% (35/61) male) were included. Median time from onset to decompressive craniectomy was 51.8 h (interquartile range: 39.7-77.8). Rates of inadequate decompression, 3 month death, 3 month modified Rankin Scale 5-6 and 4-6 were 50.8% (31/61), 50.9% (29/57), 64.9% (37/57) and 84.2% (48/57), respectively. The inadequate decompression group had a higher midline shift growing rate than the adequate decompression group (median: 2.7 mm/8 h vs. 1.4 mm/8 h, P=0.041). No intergroup difference of 3 month outcomes was found in terms of preoperative midline shift growing rate.

Conclusion: Higher preoperative midline shift growing rate was associated with inadequate decompression of decompressive craniectomy in patients with malignant middle cerebral artery infarction.

Keywords: Malignant middle cerebral artery infarction, decompressive craniectomy, midline shift, outcome, stroke, edema.

Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R. ‘Malignant’ middle cerebral artery territory infarction: Clinical course and prognostic signs. Arch Neurol 1996; 53(4): 309-15.
[] [PMID: 8929152]
Heiss WD. Malignant MCA infarction: Pathophysiology and imaging for early diagnosis and management decisions. Cerebrovasc Dis 2016; 41(1-2): 1-7.
[] [PMID: 26581023]
Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2018; 49(3): e46-e110.
[] [PMID: 29367334]
Schwake M, Schipmann S, Müther M, et al. Second-look strokectomy of cerebral infarction areas in patients with severe herniation. J Neurosurg 2019; 1: 1-9.
[PMID: 30611135]
Cho DY, Chen TC, Lee HC. Ultra-early decompressive craniectomy for malignant middle cerebral artery infarction. Surg Neurol 2003; 60(3): 227-32.
[] [PMID: 12922040]
Merenda A, Perez-Barcena J, Frontera G, Benveniste RJ. Predictors of clinical failure of decompressive hemicraniectomy for malignant hemispheric infarction. J Neurol Sci 2015; 355(1-2): 54-8.
[] [PMID: 26071890]
Jeon SB, Kwon SU, Park JC, et al. Reduction of midline shift following decompressive hemicraniectomy for malignant middle cerebral artery infarction. J Stroke 2016; 18(3): 328-36.
[] [PMID: 27733025]
Sauvigny T, Gottsche J, Vettorazzi E, Westphal M, Regelsberger J. New radiologic parameters predict clinical outcome after decompressive craniectomy. World Neurosurg 2016; 88: 519-25 e1.
Tu PH, Liu ZH, Chuang CC, Yang TC, Wu CT, Lee ST. Postoperative midline shift as secondary screening for the long-term outcomes of surgical decompression of malignant middle cerebral artery infarcts. J Clin Neurosci 2012; 19(5): 661-4.
[] [PMID: 22377637]
Liao CC, Chen YF, Xiao F. Brain Midline shift measurement and its automation: A review of techniques and algorithms. Int J Biomed Imag 2018; 20184303161
[] [PMID: 29849536]
Hecht N, Neugebauer H, Fiss I, et al. Infarct volume predicts outcome after decompressive hemicraniectomy for malignant hemispheric stroke. J Cereb Blood Flow Metab 2018; 38(6): 1096-103.
[] [PMID: 28665171]
Kürten S, Munoz C, Beseoglu K, Fischer I, Perrin J, Steiger HJ. Decompressive hemicraniectomy for malignant middle cerebral artery infarction including patients with additional involvement of the anterior and/or posterior cerebral artery territory-outcome analysis and definition of prognostic factors. Acta Neurochir (Wien) 2018; 160(1): 83-9.
[] [PMID: 28965156]
Kamran S, Salam A, Akhtar N, et al. Predictors of in-hospital mortality after decompressive hemicraniectomy for malignant ischemic stroke. J Stroke Cerebrovasc Dis 2017; 26(9): 1941-7.
[] [PMID: 28694110]
Daou B, Kent AP, Montano M, et al. Decompressive hemicraniectomy: predictors of functional outcome in patients with ischemic stroke. J Neurosurg 2016; 124(6): 1773-9.
[] [PMID: 26613165]
Goedemans T, Verbaan D, Coert BA, et al. Neurologic outcome after decompressive craniectomy: predictors of outcome in different pathologic conditions. World Neurosurg 2017; 105: 765-74.
[] [PMID: 28642178]
Huang P, Lin FC, Su YF, Khor GT, Chen CH, Lin RT. Predictors of in-hospital mortality and prognosis in patients with large hemispheric stroke receiving decompressive craniectomy. Br J Neurosurg 2012; 26(4): 504-9.
[] [PMID: 22168966]
Rabinstein AA, Mueller-Kronast N, Maramattom BV, et al. Factors predicting prognosis after decompressive hemicraniectomy for hemispheric infarction. Neurology 2006; 67(5): 891-3.
[] [PMID: 16966561]
Diedler J, Sykora M, Jüttler E, Veltkamp R, Steiner T, Rupp A. EEG power spectrum to predict prognosis after hemicraniectomy for space-occupying middle cerebral artery infarction. Cerebrovasc Dis 2010; 29(2): 162-9.
[] [PMID: 19955741]
von Olnhausen O, Thorén M, von Vogelsang AC, Svensson M, Schechtmann G. Predictive factors for decompressive hemicraniectomy in malignant middle cerebral artery infarction. Acta Neurochir (Wien) 2016; 158(5): 865-72.
[] [PMID: 26923797]
Vahedi K, Hofmeijer J, Juettler E, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: A pooled analysis of three randomised controlled trials. Lancet Neurol 2007; 6(3): 215-22.
[] [PMID: 17303527]
Burghaus L, Liu WC, Dohmen C, Bosche B, Haupt WF. Evoked potentials in acute ischemic stroke within the first 24 h: possible predictor of a malignant course. Neurocrit Care 2008; 9(1): 13-6.
[] [PMID: 17982737]
Kurland DB, Khaladj-Ghom A, Stokum JA, et al. Complications Associated with Decompressive Craniectomy: A Systematic Review. Neurocrit Care 2015; 23(2): 292-304.
[] [PMID: 26032808]
Simard JM, Kent TA, Chen M, Tarasov KV, Gerzanich V. Brain oedema in focal ischaemia: molecular pathophysiology and theoretical implications. Lancet Neurol 2007; 6(3): 258-68.
[] [PMID: 17303532]
Marklund N. Decompressive craniectomy, ICP monitoring and secondary necrosectomy as treatment options in patients presenting with malignant ischemic infarctions extending beyond the middle cerebral artery territory. Acta Neurochir (Wien) 2018; 160(1): 91-3.
[] [PMID: 28963681]
Kwak Y, Kim BJ, Park J. Maximum decompressive hemicraniectomy for patients with malignant hemispheric infarction. J Cerebrovasc Endovasc Neurosurg 2019; 21(3): 138-43.
[] [PMID: 31886148]
Fehnel CR, Lee Y, Wendell LC, Thompson BB, Stevenson Potter N, Mor V. Utilization of long-term care after decompressive hemicraniectomy for severe stroke among older patients. Aging Clin Exp Res 2017; 29(4): 631-8.
[] [PMID: 27495258]
Bar M, Mikulik R, Skoloudik D, et al. Decompressive surgery for malignant supratentorial infarction remains underutilized after guideline publication. J Neurol 2011; 258(9): 1689-94.
[] [PMID: 21431893]
Hao Z, Chang X, Zhou H, Lin S, Liu M. A cohort study of decompressive craniectomy for malignant middle cerebral artery infarction: A real-world experience in clinical practice. Medicine (Baltimore) 2015; 94(25): e1039.
[] [PMID: 26107675]
Jüttler E, Bösel J, Amiri H, et al. DESTINY II: DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY II. Int J Stroke 2011; 6(1): 79-86.
[] [PMID: 21205246]
Elsawaf A, Galhom A. Decompressive craniotomy for malignant middle cerebral artery infarction: Optimal timing and literature review. World Neurosurg 2018; 116: e71-8.
[] [PMID: 29653270]
Chen CC, Cho DY, Tsai SC. Outcome of and prognostic factors for decompressive hemicraniectomy in malignant middle cerebral artery infarction. J Clin Neurosci 2007; 14(4): 317-21.
[] [PMID: 17275311]
Wilson MH. Monro-Kellie 2.0: The dynamic vascular and venous pathophysiological components of intracranial pressure. J Cereb Blood Flow Metab 2016; 36(8): 1338-50.
[] [PMID: 27174995]
Verma U, Grabowska ME, Batchala PP, et al. New CT measurements to assess decompression after hemicraniectomy: A two-center reliability study. Clin Neurol Neurosurg 2020 2020; 188105601
[] [PMID: 31756618]

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Article Details

Year: 2020
Published on: 04 August, 2020
Page: [131 - 139]
Pages: 9
DOI: 10.2174/1567202617666200207125552
Price: $65

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