Bongiorni, Gianise Toboliski; Hockmuller, Marjeane Cristina Jaques; Klein, Cristini; Antunes, Ápio Cláudio Martins

doi:10.1590/0004-282X20170053

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Sumário

ARTICLES • Arq. Neuro-Psiquiatr. 75 (7) • Jul 2017 • https://doi.org/10.1590/0004-282X20170053 copiar

Craniotomia descompressiva para tratamento do infarto maligno da artéria cerebral media: mortalidade e desfecho

Autoria SCIMAGO INSTITUTIONS RANKINGS

RESUMO

Objetivo

Avaliar a capacidade funcional de pacientes com acidente vascular cerebral isquêmico no território da artéria cerebral média (ACM) submetidos à craniotomia descompressiva (CD) no período de 30 dias pela escala de Rankin.

Métodos

Estudo transversal em um hospital universitário. Entre junho de 2007 e dezembro de 2014, analisados retrospectivamente os registros de todos os pacientes submetidos a CD devido a enfarte maligno na ACM. A taxa de mortalidade foi definida durante o período de internação. O resultado da estratificação da qualidade de vida foi através da escala Rankin modificado (mRS) mensurado em 30 dias após o procedimento.

Resultados

A taxa de mortalidade CD foi de 30% (IC 95% 14,5-51,9) para os 20 pacientes relatados. A mRS 30 dias de pós-operatório foi => 4 [3,3-6] para todos os pacientes.

Conclusão

CD deve ser considerada uma alternativa real para o tratamento de pacientes com enfarte isquêmico no território da ACM.

craniotomia; infarto cerebral; hipertensão intracraniana

Protocol inclusion criteria
National Institutes of Health Stroke Scale (NIHSS) > 15, clinical evidence of MCA extensive infarction (complete hemiparesis contralateral to the lesion, homonymous hemianopsia contralateral to the lesion, tendency for oculocephalic deviation towards the lesion, language alteration, heminegligence);
Age ≤ 60 years (in patients older than 60 years, the decision must be individualized);
Tomographic evidence of early hypodensity involving cortico-subcortical topography > 50% of the MCA territory.

Protocol exclusion criteria

Other previous incapacitating diseases (skeletal muscle, neurologic or clinical);
Signs of severe neurological deterioration at the time of surgical indication (unilateral or bilateral pupil dilatation, with mydriasis or absence of photo-reaction, and/or signs of pathological extension or flexion);
Severe clinical complications;
Terminal illness;
mRS ≥ 3;
Clotting disorders;
Unavailability of the intensive care unit (ICU) beds;
Hemodynamic instability at the time of surgical indication.

Patient initial follow-up

Second CT between 6–12 hours after patient arrival, or less, in the case of neurological deterioration – early detection of the malignant evolution;
After the second CT: new CT every six to eight hours.

Indication for decompressive surgery

Any neurological deterioration in relation to the admission or history of neurological deterioration since the beginning of the symptoms;
Any tomographic worsening (extension of the infarction or worsening of the space-occupying effect).

Levels of evidence of the recommendations

Early DC is recommended for the treatment of MCA space occupying cerebral infarction in patients up to 60 years of age, before the manifestation of clinical or radiological signs of cerebral herniation, within the time span of 48 hours (evidence level 1, recommendation grade A - Systematic Review (with homogeneity) of controlled and randomized clinical trials).
The decision of DC for patients older than 60 years of age or after 48 hours must be individualized. (evidence level 4, recommendation grade C - case reports (including cohort or case control of lesser quality).
The independent variables studied were: age, sex, marital status, time elapsed between ictus and surgery, first CT and surgery and the score of the National Institutes of Health Stroke Scale (NIHSS) upon admission.
The mRS evaluates the functionality of the individual after a CVA (either ischemic or hemorrhagic) and it became an important clinical tool capable of estimating the prognosis and the outcome. It comprises seven items, with a score of zero being considered without symptoms, and a score of 6 being death (Addendum 1).
The primary regarded outcomes were death and hospital discharge: surgical deaths were considered up to 30 days after the DC operation. For every patient, the mRS scores were measured: those that died scored 6; patients discharged from hospital within 30 days had their score measured at that time.

Demographic variables	n = 20
Age (years)*	52.7 ± 7.4
Sex (%)**
Male	11 (55)
Female	9 (45)
Skin color (%)**
White	15 (75)
Black	5 (25)

Variables	n = 20
Ictus time x admission (hours)*	13.2 ± 1.4
Hospitalization NIHSS (score)*	17.6 ± 3.2
NCI evaluation x surgery (hours)**	2.9 [1.9–4.4]
Ictus time x surgery (hours)**	28.1 [21.2–50.6]
Clinical worsening after 1st NCI evaluation (%)***	13 (65)
Nº of CTs before surgery**	2 [1.2–3]
Time interval between surgery and last CT (hours)**	7.7 [2.3–14.8]
Rankin (30 days score)**	4 [3.3–6]
Rankin (discharge score)**	4 [3–4]
Discharge rate (%)***	14 (70)
Death rate (%)***	6 (30)
Hospitalization time (days)**	21.5 [9.5–34.5]

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[1] Correspondence: Gianise Toboliski Bongiorni; Hospital de Clínicas de Porto Alegre; Rua Ramiro Barcelos, 2350; 90035-007 Porto Alegre RS, Brasil; E-mail: gianise1@hotmail.com