Jeon SB, Kwon SU, Lee S ,Park JC, Lee DH, Yun SC, Kim YJ, Ahn JS, Kwun BD, Kang DW, Choi HA, Lee K and Kim JS
Abstract
Background and purpose: Hemicraniectomy is a decompressive surgery used to remove a large bone flap to allow edematous brain tissue to bulge extracranially. However, early indicators of the decompressive effects of hemicraniectomy are unclear. We investigated whether reduction of midline shift following hemicraniectomy is associated with improved consciousness and survival in patients with malignant middle cerebral artery infarctions.
Methods: We studied 70 patients with malignant middle cerebral artery infarctions (MMI) who underwent hemicraniectomies. Midline shift was measured preoperatively and postoperatively using computed tomography (CT). Consciousness level was evaluated using the Glasgow Coma Scale on postoperative day 1. Patient survival was assessed six months after stroke onset.
Results: The median time interval between preoperative and postoperative CT was 8.3 hours (interquartile range, 6.1-10.2 hours). Reduction in midline shift was associated with higher postoperative Glasgow Coma Scale scores (P<0.05). Forty-three patients (61.4%) were alive at six months after the stroke. Patients with reductions in midline shifts following hemicraniectomy were more likely to be alive at six months post-stroke than those without (P<0.001). Reduction of midline shift was associated with lower mortality at six months after stroke, after adjusting for age, sex, National Institutes of Health Stroke Scale score, and preoperative midline shift (adjusted hazard ratio, 0.71; 95% confidence interval, 0.62-0.81; P<0.001).
Conclusions: Reduction in midline shift following hemicraniectomy was associated with improved consciousness and six-month survival in patients with MMI. Hence, it may be an early indicator of effective decompression following hemicraniectomy.
Keywords: Decompressive craniectomy; Infarction; Middle cerebral artery; Mortality.
Figure 1.
Postoperative CT measurements. Septum pellucidum shift (SPS, “E”) was determined using the distance from the midline to the septum pellucidum at the level of the fornix (A). Pineal gland shift (PGS, “F”) was determined using the distance from the midline to the pineal gland (B). Maximal size of the bone flap (“G”) was measured between opposing hemicraniectomy edges on serial axial slices on the post-hemicraniectomy CT (C). The extracranial bulging volume was measured as the volume of the brain tissue beyond the bony window (areas marked with red lines) and the extracranial bulging ratio was defined as the ratio of the extracranial bulging volume to the maximal size of the bone flap (D).
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