Massive Cerebral Infarction:Clinical Characteristics,Short Term Prognosis,and Investigation Of Factiors Affecting The Outcome Of Decompressive Craniectomy

Objective:Massive cerebral infarction is usually refers to the main trunks of middle cerebral artery and internal carotid artery or cortex branches of the completeness of the stroke.Massive cerebral infarction accounted for1%-10%of all the stroke patients.the incidence is about10-20every100000people every year,and other than patients with cerebral infarction,massive cerebral infarction patients often do not have a history of stroke.and prone to women than men.More important is Massive cerebral infarction are younger, the mortality rate and morbidity rate were higher.almost reach80%if only treatmented by medical treatment. At present medical treatments have anticoagulation, thrombolysis, dehydration,drop fiber.resistence to oxgen free radicals,fight against irritability amino acids and reducing irritability neurotransmitters released.But the clinical effects have dabates. Hemicraniectomy can reduce the mortality of the MCI patients is accepted by the publics. However, there are still some problems needs to be studied further.①Whether decompressive craniectomy is better than medical treatment in lower the mortality and improve the neural function recovery.②Which clinical chararcteristics or imaging characteristics can predict a malignant clinical evolution process.③The time to accept surgery whether have some influences in the prognosis.④Whether age is a surgery contraindication.⑤Factors which have effects on neural recovery of patients who accept Hemicraniectomy.So we analysed the clinical features、radiographic performance,auxiliary examination.and clinical curative effect respectively.In order to find the clinical indicators that can predict a adverse clinical evalution process.The short term prognosis of MCI patients and the factors that have influence to the treatment effects of hemicraniectomy.Methods:Part Ⅰ The preliminary analysis of clinical datas of patients who suffered from massive cerebral infarction.1、The clinical features, laboratory datas.characters of imaginology, therapy and prognosis of31cases in our hospital from May2005to August2011were analyzed retrospectively.2、Clinical datas There were15males and16females.age from32to82,with a midian age of60.7years.There were28patients have hypertension,11have diabetes,26have hyperlipidemia,14have coronary heart disease,3have rheumatic heart disease. All of the31patients are acute onset.27patients outbreak in quiescent condition.28patients outburst with the symptom of conscious disturbance..25patients have physical sign of gaze palsy. Most of the patients developed hernia within48-72hours after ictus.3、Laboratory findings The amount of white cells are larger than10*109in18patients. Twelve hours after ictus there are still25patients whose systolic blood pressure are large than180mmHg.4、Neuroimaging Two or more cerebral vessels are involved in23patients,The infarction areas of all of the patients are larger than200cmJ.5n treatments There were12patients who accepted surgery,7died.19patients accepted medical therapy,16died.PartⅡ The preliminary analysis of the effects of medical and decompressive craniectomy in treating patients with massive cerebral infarction.1、The clinical datas, radiological findings,Glasgow Coma Scale (GCS), and modified Rankin Scale (mRS) of the56patients were analyzed retrospectively.2、Clinical datas The surgery group have26patients,12males,14females. The medical treatment group have30patients.14males,16females.3、Neuroimaging All of the MCI patients were testified by the CT or MRI in admission.In the surgery group.there were18patients have MCA involved,ACA+MCA7patients,PCA+MCA1patients.18patents in the right hemisphere,8in the left.In the medical treatment group, there were21patients have MCA involved,ACA+MCA9patients.l7patents in the right hemisphere,13in the left.4、Treatments There were26patients who accepted surgery,9died.3O patients accepted medical therapy,16died.5、Patients assessment Recording the mRS score9months after the symptoms onset.We also classified the mRS scores to three group.mRS=6means died,mRS=4or5means poor prognosis,mRS=0-3means good prognosis.6、Statistic analysis ALL data are expressed as mean±standard diviation.The physiological measurements within groups were analyzed by the student t test for paired data.Results were analysed for statistical significance using the chi-square(x2)test.the Mann-Whitney rank sum(U)test,and discriminate analysis,with P<0.05considered significant.Statistical software,SPSS Release13.0was used for these statistical analyses. PartⅢ The preliminary analysis of decompressive craniectomy in treating patients with massive cerebral infarction.1、We retrospectively analyzed the clinical data, radiological findings.Glasgow Coma Scale (GCS),time between symptome onset and operation, the presence of herniation or not, consciousness level, and modified Rankin Scale (mRS) of26patients with massive cerebral infarction who underwent decompressive craniectomy from May2005to December2010.2、Clinical datas In the surgery group there are12males and14females.the range of the age is35-75years.the mean age is57.31±11.74years.In the medical treatment group there are there are12males and14females.the range of the age is32-83years.the mean age is62.30±1.78years.3、Grouping methods The prognosis in patients elder than60years and younger than60were analyzed.meanwhile,we also analyzed wherther hernia,brain atropy and infarction area have influence on the prognosis.4、Neuroimaging The same as the part Ⅱ.5、Therapeutic methods In brief,the technique for decompressive surgery required bone flap with a diameter of12cm(including the frontal,parietal.temporal,and parts of the occipital squama)be removed so that the floor of the middle cerebral fossa could be explored.The dura was fixed at the edge of the craniectomy to prevent epidural bleeding.and resection temporal lobe if indicated.then have the dura expand repaired.6、Patients assessment Recording the midline shift preopration and postoperation.GCS score preoperation and1week after operation.At the same time,Recording the mRS score9months after the symptoms onset.We also classified the mRS scores to three group.mRS=6means died,mRS=4or5means poor prognosis,mRS=0-3means good prognosis.7、Statistic analysis ALL data are expressed as mean±standard diviation.The physiological measurements within groups were analyzed by the student t test for paired data.Results of subgroups classified by the age,hernia,rain atropy and infarction area were analysed for statistical significance using the chi-square(x2)test.the Mann-Whitney rank sum(U)test,and discriminate analysis.with P<0.05considered significant.Statistical software.SPSS Release13.0was used for these statistical analyses.Results:1、the most important pathogen of massive cerebral infarction is thrombosis(83.8%).All of the31patients are acute onset.27patients outbreak in quiescent condition.2、28patients outburst with the symptom of conscious disturbance.25patients have gaze palsy.3、The amount of white cells are larger than10×109in18patients. Twelve hours after ictus there are still25patients whose systolic blood pressure are large than180mmHg.4、wo or more cerebral vessels are involved in23patients. Most of the patients developed hernia within48-72hours after ictus.The infarction areas of all of the patients are larger than200cm35、Most of the patients had significant increase of GCS after surgery (P=0.010).6、Patients with cerebral herniation had poorer prognosis than those without (P=0.005).The prognosis in patients elder than60years and younger than60had no statistical difference (P=0.846). Patients in whom the infarction volume is larger than250cnrs had poorer prognosis(P=0.009).The number of mortalities of the surgical and medical groups were16and9, but there is no statistical difference (P=0.085) between them. 7、When the infarction size is more than200cmJ. The mortalities of the two groups were69.6%and37.5%. The mortality and prognosis of the two groups had statistical significance(P=0.011). ICD≥19mm VS ICD<19mm, The mortality and prognosis of the two groups had statistical significance(P=0.02).8、when the infarction area is discontinuous,the shape of the infarction is not the class elliptic and involving several layers.the traditional measuring method with a larger measurement error.Conclusions:1、Patients with conscious disturbance, gaze palsy and the infarction areas is larger than200cm’1may develop hernia in the end.2、Most of the patients developed hernia within48-72hours after ictus.the standard decompressive craniectomy is a life-saving procedure for massive cerebral infarction.3、Carefully selection of patients and early operation when indicated may improve the survival rate and functional outcome. Especially.when the infarction size is more than200cmJ.Age should not to be contraindication for surgery.4、Patients whose infarction volume is larger than250cmJ and who developed cerebral herniation may have a poor prognosis.5、ICD≥19mm maybe a poorer indictor for massive cerebral infarction patients. when we use the tranditonal method to measure the infarction sizes,we have to pay attention to the errors of this method.