Improvement in Midline Shift Is a Positive Prognostic Predictor for Malignant Middle Cerebral Artery Infarction Patients Undergoing Decompressive Craniectomy

Abstract

Objective: The aim of this retrospective study is to evaluate the risk factors of malignant middle cerebral artery infarction (MMCAI) patients and explore an applicable prognostic predictor for MMCAI patients undergoing decompressive craniectomy (DC). Methods: Clinical data from the period 2012-2017 were retrospectively evaluated. Forty-three consecutive MMCAI patients undergoing DC were enrolled in this study. The 30-day mortality was assessed, and age, location, hypertension, pupil dilation, onset to operation duration, midline shift, and Glasgow Coma Scale (GCS) score were identified by univariate analysis and binary logistic regression. Results: In this retrospective study for DC patients, the 30-day mortality was 44.2%. In the univariate analysis, advanced age (≥60 years), right hemispheric location, hypertension, pupil dilation, shorter onset to operation duration (<48 h), improved midline shift (t = 4.214, p < 0.01), and lower pre-operation GCS score were significant predictors of death within 30 days. In binary logistic regression analysis, age [odds ratio (OR) = 1.141, 95% CI 1.011-1.287], the improvement of the midline shift (OR = 0.764, 95% CI 0.59-0.988), and pupillary dilation (OR = 15.10, 95% CI 1.374-165.954) were independent influencing factors. For the receiver operating characteristic (ROC) analysis of the relationship between post-operation outcomes and midline shift improvement, the area under the curve (AUC) was 0.844, and the cutoff point of midline shift improvement was 0.83 cm. Conclusion: Improved midline shift was a significant predictor of 30-day mortality. The improved midline shift of >0.83 cm indicated survival at 30 days.

Keywords: decompressive craniectomy; hypertensive intracerebral hemorrhage; improvement in midline shift; malignant middle cerebral artery infarction; mortality.

Figure 1

The difference between survivors and non-survivors for measurement data (30-day outcome). The distribution of age (A), pre-op GCS (B), and the retraction of midline shift (C) between survivors and non-survivors. For (C), the negative reading means worsening of midline shift after DC.

Figure 2

The difference between survivors and non-survivors for enumeration data (30-day outcome).The distribution of onset to op duration (A), location (B), hypertension (C) and pupillary dilation (D) between survivors and non-survivors.

Figure 3

The receiver operating characteristic (ROC) analysis of the relationship between 6-month outcome and midline shift improvement. The area under the curve (AUC) was 0.844, and the cutoff point of midline shift retraction was 0.83 cm.