J Neurointensive Care.  2021 Apr;4(1):13-20. 10.32587/jnic.2021.00332.

Volumetric Analysis of Malignant Middle Cerebral Infarction (MMI): Infarction Volume Before Decompressive Hemicraniectomy for MMI is Associated With Poor Consciousness

• Kim DW
• Roh H
• Yoon WK
• Kwon TH
• Kim JH

• KMID: 2555045
• DOI: http://doi.org/10.32587/jnic.2021.00332

Abstract

Objective
In patients with malignant middle cerebral infarction (MMI), early decompressive hemicraniectomy (DHC) is well-known to reduce mortality and improve clinical outcome. Nevertheless, its effectiveness in clinical outcomes has only been confirmed by defining outcomes in terms of the modified Rankin scale (mRS), and many studies have already suggested that survival with severe dependency, such as mRS 4 or 5, is not acceptable. However, several other important domains are closely related to quality of life, such as consciousness or cognition, and these are not directly measured in the mRS. Therefore, the present study aimed to identify significant factors associated with poor consciousness, such as minimally conscious state (MCS) or vegetative state (VS) in patients undergoing DHC to treat MMI.
Methods
Between January 2011 and December 2017, 22 patients who survived from MMI after DHC and had more than 6 months of follow-up were enrolled our study. Clinical outcomes 6 months after DHC were measured, and the patients were divided into two groups based on their level of consciousness. Preserved consciousness was categorized as a favorable outcome, while poor consciousness such as MCS or VS constituted an unfavorable outcome. Clinical and radiological variables using volumetric measurement were analyzed to identify factors that were significantly associated with unfavorable outcome.
Results
Of the entire cohort, eight patients (36.36%) were placed in the unfavorable outcome (MCS or VS) 6 months after DHC to treat MMI. In univariate and multivariate logistic analysis, only infarction volume in the preoperative CT was a significant independent predictor of unfavorable outcome (odds ratio: 1.021, 95% confidence interval: 1.001–1.042, p = 0.023).
Conclusion
The present study suggested that defining unfavorable outcome based on level of consciousness to reflect quality of life should be considered. We identified infarction volume as a significant predictor of poor consciousness.

Keyword

Decompressive craniectomy; MCA infarction; Outcome; Consciousness; mRS