The prognostic factors of decompressive craniectomy for large supratentorial infarction in choray hospital – Truong Da

Journal of military pharmaco-medicine n o 9-2018 179 THE PROGNOSTIC FACTORS OF DECOMPRESSIVE CRANIECTOMY FOR LARGE SUPRATENTORIAL INFARCTION IN CHORAY HOSPITAL Truong Da1; Bui Quang Tuyen2; Vu Van Hoe2 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) Date received: 10/10/2018 Date accepted: 30/11/2018 Journal of military pharmaco-medicine n o 9-2018 180 SUBJECTS 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 Alive Dead Total ≤ 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 patients Alive Dead 16 x 12 cm 192 cm2 17 17 0 14 x 12 cm 168 cm2 32 31 1 12 x 12 cm 144 cm2 26 18 8 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 Journal of military pharmaco-medicine n o 9-2018 181 mortality 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 Alive Dead ≤ 8 34 26 (76.47%) 08 (23.53%) > 8 41 40 (97.56%) 01 (2.44%) Total 75 66 (88%) 09 (12%) 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 Alive Dead Total Undilated 53 0 53 Dilated 13 9 22 Total 66 9 75 6. The factors that are likely to affect the modality. Table 5: Result Factors Alive (n) Dead (n) p OR 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 1.01 0.84 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 Journal of military pharmaco-medicine n o 9-2018 182 > 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. Journal of military pharmaco-medicine n o 9-2018 183 Among 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]. Journal of military pharmaco-medicine n o 9-2018 184 CONCLUSION 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. REFERENCE 1. Chen C.C, Cho D.Y, Tsai S.C. Outcome and prognostic factors of decompressive hemicraniectomy in malignant middle cerebral artery infarction. J Chin Med Assoc. 2007, 70 (2), pp.56-60. 2. Cho S.Y et al. The prognostic factors that influence the long-time survival in acute large cerebral infarction. J Korean Neurosur Soc. 2011, 49, pp.92-96. 3. Curry W.T, Sethi M.K et al. Factors associated with outcome after hemicraniectomy for large middle cerebral artery territory infarction. Neurosurgery. 2005, 56, pp.681-692. 4. Desiree J.L, Giuseppe L. Decompressive craniectomy for space occupying supratentorial infarct: rational, indication and outcome. Neurosurg Focus. 2000, 8 (5). 5. Heiss W.D et al. Malignant MCA infarction: Pathophysiology and imaging for early diagnosis and management decisions. Cerebrovasc Dis. 2016, 41, pp.1-7. 6. Kenning T.J, Gooch M.R et al. Cranial decompression for the treatment of malignant intracranial hypertension after ischemic cerebral infarction: decompressive craniectomy and hinge craniotomy. J. Neurosurg. 2012, Vol. 116, Jun, pp.1289-1298. 7. Lu X.C, Huang B.S et al. Decompressive craniectomy for the treatment of malignant infarction of the middle cerebral artery. Scientific Reports. 2014, 4: 7070|DOI: 10.1038/srep07070. 8. Reddy A.K, Saradhi V, Panigrahi M, Rao T.N, Tripathi P, Meena A.K. Decompressive craniectomy for stroke: indications and results. Neurology India. 2002, Vol. 50 (Suppl. 1), Dec, pp.66-69. 9. Uhl E, Kreth F.W et al. Outcome and prognostic factors of hemicraniectomy for space occupying cerebral infarction. J Neurol Neurosurg Psychiatry. 2004, 75, pp.270-274. 10. 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