Predictors of in-hospital mortality and prognosis in patients with large hemispheric stroke receiving decompressive craniectomy

Hyperdense middle cerebral artery sign predicts favorable outcome after decompressive craniectomy in patients with malignant middle cerebral artery infarction

BACKGROUND

Malignant middle cerebral artery infarction (MMI) is a life-threatening cerebral vascular event. Early decompressive craniectomy (DC) has proven to be an effective treatment strategy. However, the ideal candidate for DC continues to be debated.

PURPOSE

To investigate whether a hyperdense middle cerebral artery sign (HMCAS) provides prognostic value after DC in patients with MMI.

MATERIAL AND METHODS

We reviewed clinical information and radiological parameters on computed tomography of 42 patients with MMI who underwent DC. Functional outcome was assessed according to the modified Rankin scale (mRS) at three months as follows: favorable outcome (mRS ≤ 4) versus unfavorable outcome (mRS > 4). Logistic regression analysis was used to identify predictors of functional outcome after DC in patients with MMI.

RESULTS

Age (odds ratio [OR] = 0.87; 95% confidence interval [CI] = 0.78-0.97; P = 0.014) and HMCAS (OR = 7.40; 95% CI = 1.35-40.48; P = 0.021) were associated with functional outcome. The area under the receiver operating characteristic curve for predicting favorable outcome using the combination of age and HMCAS was 0.882, and the sensitivity and specificity were 0.947 and 0.696, respectively.

CONCLUSION

Patients with MMI with HMCAS, as well as younger patients, often showed a favorable outcome after DC in this study.

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

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.

Association of Infarct Volume Before Hemicraniectomy and Outcome After Malignant Infarction

ObjectiveTo determine the impact of infarct volume before hemicraniectomy in malignant middle cerebral artery infarction (MMI) as an independent predictor for patient selection and outcome prediction, we retrospectively analyzed data of 140 patients from a prospective multi-center study.MethodsPatients from the DESTINY-Registry that underwent hemicraniectomy after ischemic infarction of >50% of the middle cerebral artery territory were included. Functional outcome according to the modified Rankin Scale (mRS) was assessed at 12 months. Unfavorable outcome was defined as mRS 4-6. Infarct size was quantified semi-automatically from computed tomography or magnetic resonance imaging before hemicraniectomy. Subgroup analyses in patients fulfilling inclusion criteria of randomized trials in younger patients (age≤60y) were predefined.ResultsAmong 140 patients with complete datasets (34% female, mean (SD) age 54 (11) years), 105 (75%) had an unfavorable outcome (mRS > 3). Mean (SD) infarct volume was 238 (63) ml. Multivariable logistic regression identified age (OR 1.08 per 1 year increase; 95%-CI 1.02-1.13; p=0.004), infarct size (OR 1.27 per 10ml increase; 95%-CI 1.12-1.44; p<0.001) and NIHSS (OR 1.10; 95%-CI 1.01-1.20; p=0.030) before hemicraniectomy as independent predictors for unfavorable outcome. Findings were reproduced in patients fulfilling inclusion criteria of randomized trials in younger patients. Infarct volume thresholds for prediction of unfavorable outcome with high specificity (94% in overall cohort and 92% in younger patients) were more than 258 ml before hemicraniectomy.ConclusionOutcome in MMI strongly depends on age and infarct size before hemicraniectomy. Standardized volumetry may be helpful in the process of decision making concerning hemicraniectomy.

Outcome After Decompressive Craniectomy for Middle Cerebral Artery Infarction: Timing of the Intervention

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.

A nomogram for predicting the in-hospital mortality after large hemispheric infarction

BACKGROUND

Large hemispheric infarction (LHI) is a severe form of stroke with high mortality and disability rates. The purpose of this study was to explore predictive indicators of the in-hospital mortality of LHI patients treated conservatively without decompressive hemicraniectomy.

METHOD

We performed a retrospective study of 187 consecutive patients with LHI between January 1, 2016 to May 31, 2019. The receiver operating curves were preformed to evaluate predictive performance of demographics factors, biomarkers and radiologic characteristics. Significant prognostic factors were combined to build a nomogram to predict the risk of in-hospital death of individual patients.

RESULT

One hundred fifty-eight patients with LHI were finally enrolled, 58 of which died. Through multivariate logistic regression analysis, we identified that independent prognostic factors for in-hospital death were age (adjusted odds ratio [aOR] = 1.066; 95% confidence interval [CI], 1.025-1.108; P = 0.001), midline shift (MLS, aOR = 1.330, 95% CI, 1.177-1.503; P <  0.001), and neutrophil-to-lymphocyte ratio (NLR, aOR = 3.319, 95% CI, 1.542-7.144; P = 0.002). NLR may serve as a better predictor than white blood count (WBC) and neutrophil counts. Lastly, we used all of the clinical characteristics to establish a nomogram for predicting the prognosis, area under the curve (AUC) of this nomogram was 0.858 (95% CI, 0.794-0.908).

CONCLUSION

This study shows that age, MLS, and admission NLR value are independent predictors of in-hospital mortality in patients with LHI. Moreover, nomogram, serve as a precise and convenient tool for the prognosis of LHI patients.

Predictors of In-Hospital Mortality after Decompressive Hemicraniectomy for Malignant Ischemic Stroke

OBJECTIVE

The purpose of this retrospective multicenter, pooled-data analysis was to determine the factors associated with in-hospital mortality in decompressive hemicraniectomy (DHC) for malignant middle cerebral artery (MMCA) stroke.

PATIENTS AND METHODS

The authors reviewed pooled DHC database from 3 countries for patients with MMCA with hospital mortality in spite of DHC to identify factors that predicted in-hospital mortality after DHC. The identified factors were applied to the group of patients who were selected for DHC but either refused surgery and died or stabilized and did not undergo DHC.

FINDINGS

There were 137 patients who underwent DHC. Multiple logistic regression analysis showed middle cerebral artery (MCA) with additional infarcts (odds ratio [OR], 7.9: 95% confidence interval [CI], 2.4-26; P = .001), preoperative midline shift of septum pellucidum of 1 cm or more (OR, 3.83: 95% CI, 1.13-12.96; P = .031), and patients who remained unconscious on day 7 postoperatively (8.82: 95% CI; OR, 1.08-71.9; P = .042) were significant independent predictors for in-hospital mortality. The identified factors were applied to the group of MMCA patients not operated (n = 19 refused, n = 47 stabilized) single (P < .001), and two predictive factors (P < .001) were significantly more common in patients who died. Whereas two predicative factors were identified in only 9%-18.2% of survivors, the presence of all three predictive factors was seen only in patients who expired (P < .001). The Hosmer-Lemeshow goodness-of-fit statistics (chi-square = 4.65; P value = .589) indicate that the model adequately describes the data.

CONCLUSION

Direct physical factors, such as MCA with additional territory infarct, extent of midline shift, and postoperative consciousness level, bore a significant relationship to in-hospital mortality in MMCA patients undergoing DHC.