Decompressive craniectomy versus conservative treatment: limits and possibilities in malignant stroke

ABSTRACT Background: Malignant infarction of the middle cerebral artery (MCA) occurs in a subgroup of patients with ischemic stroke and early decompressive craniectomy (DC) is one of its treatments. Objective: To investigate the functional outcome of patients with malignant ischemic stroke treated with decompressive craniectomy at a neurological emergency center in Northeastern Brazil. Methods: Prospective cohort study, in which 25 patients were divided into two groups: those undergoing surgical treatment with DC and those who continued to receive standard conservative treatment (CT). Functionality was assessed using the modified Rankin Scale (mRS), at follow-up after six months. Results: A favorable outcome (mRS≤3) was observed in 37.5% of the DC patients and 29.4% of CT patients (p=0.42). Fewer patients who underwent surgical treatment died (25%), compared to those treated conservatively (52.8%); however, with no statistical significance. Nonetheless, the proportion of patients with moderate to severe disability (mRS 4‒5) was higher in the surgical group (37.5%) than in the non-surgical group (17.7%). Conclusion: In absolute values, superiority in the effectiveness of DC over CT was perceived, showing that the reduction in mortality was at the expense of increased disability.

摘要 背景：大脑中动脉（middle cerebral artery, MCA）恶性梗死见于缺血性脑卒中的特定亚组患者，早期去骨瓣减压术（decompressive craniectomy, DC）是其治疗手段之一。目的：探究巴西东北部某神经急诊中心接受去骨瓣减压术治疗的恶性缺血性脑卒中患者的功能预后情况。方法：本研究为前瞻性队列研究，共纳入25例患者并分为两组：接受去骨瓣减压手术治疗组，以及继续接受标准保守治疗（conservative treatment, CT）组。于术后6个月随访时采用改良Rankin量表（modified Rankin Scale, mRS）评估患者功能状态。结果：去骨瓣减压组患者中37.5%获得良好预后（改良Rankin量表评分≤3分），保守治疗组为29.4%（p=0.42）。手术治疗组患者死亡率（25%）低于保守治疗组（52.8%），但差异无统计学意义。不过，手术组中中度至重度残疾（改良Rankin量表评分4~5分）患者占比（37.5%）高于非手术组（17.7%）。结论：从绝对数值来看，去骨瓣减压术相较于保守治疗的有效性更具优势，研究显示其降低死亡率的代价是残疾发生率的升高。