Pre-operative risk evaluation on massive cerebral infarction secondary to acute epidural hematoma and concurrent cerebral herniation / 中华神经医学杂志

ABSTRACT

Objective To develop and validate a novel preoperative risk evaluating system for surgical decision on decompressive craniectomy for patients with massive cerebral infarction (MCI) secondary to acute epidural hematoma (EDH) and concurrent cerebral herniation.Methods Clinical data of a retrospective patient cohort (from January 2006 to January 2012,n=151) were analyzed by multivariate Logistic regression analysis for the risk factors correlated with postoperative MCI so as to establish a preoperative risk scoring system,whose clinical accuracy of surgical decision-making were validated in another prospective patient cohort (from February 2012 to December 2014,n=97).Results Incidences of secondary cerebral infarction were 19.2％ (29/151) and 18.6％ (18/97) in the retrospective and prospective patient cohorts,respectively.Regression analyses indicated that 6 clinical factors were identified to be independently correlated with postoperative MCI,including temporal hematoma (P=0.005),preoperative hemorrhagic shock (P=0.003),hematoma volume greater than 100 mL (P=0.003),bilateral mydriasis (P=0.015),duration of cerebral herniation longer than 90 min (P=0.001),and Glasgow Coma Scale (GCS) scores ≤ 5 (P=0.070).A novel preoperative risk scoring system was established by totting-up the standardized partial regression coefficients of each identified risk factor (EDH-MCI scale,with total scores of 0-18).Results suggested that the incidence and mean volume of cerebral infarction increased along with risk scores in a stair-stepping manner.Therefore,three intervals were divided into low (0-9),borderline (10-12),and high risk intervals (13-18) according to the EDH-MCI scores.Clinical reliability of surgical decision-making guided by novel EDH-MCI scale was validated by a prospective clinical study.As compared with traditional empirical surgical strategy,EDH-MCI scale-guided prospective surgical strategy exhibited remarkable superiority that it significantly increased the accuracy of surgical decision (low risk interval,100.00％ vs.91.92％,P=0.046;borderline risk interval,77.78％ vs.46.67％,P=0.034;high risk interval,100.00％ vs.68.18％,P=0.023;overall accuracy,95.88％ vs.79.47％,P=0.000).Conclusion The established preoperative risk scoring system can make a precise judgment on the clinical risks of postoperative massive cerebral infarction secondary to cerebral herniation from isolated acute epidural hernatoma and thereby provide a reliable reference on the surgical decision of decompressive craniectomy.