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CC BY-NC-ND 4.0 · Arq Neuropsiquiatr 2020; 78(06): 349-356
DOI: 10.1590/0004-282X20200006
Article

Decompressive craniectomy versus conservative treatment: limits and possibilities in malignant stroke

Craniectomia descompressiva versus tratamento conservador: limites e possibilidades no AVC maligno
Isaac Holanda Mendes MAIA 
1   Hospital Geral de Fortaleza, Serviço de Neurologia, Fortaleza CE, Brazil.
,
Thaissa Pinto de MELO 
2   Hospital Geral de Fortaleza, Serviço de Enfermagem, Fortaleza CE, Brazil.
,
Fabrício Oliveira LIMA 
1   Hospital Geral de Fortaleza, Serviço de Neurologia, Fortaleza CE, Brazil.
,
João José de Freitas CARVALHO 
1   Hospital Geral de Fortaleza, Serviço de Neurologia, Fortaleza CE, Brazil.
,
Francisco José Arruda MONT’ALVERNE 
1   Hospital Geral de Fortaleza, Serviço de Neurologia, Fortaleza CE, Brazil.
,
Edson LOPES  JÚNIOR
3   Hospital Geral de Fortaleza, Serviço de Neurocirurgia, Fortaleza CE, Brazil.
,
Marcelo Bezerra DIÓGENES 
4   Universidade de Fortaleza, Centro de Ciências da Saúde, Fortaleza CE, Brazil.
,
Thaís Saraiva Leão CUNHA 
4   Universidade de Fortaleza, Centro de Ciências da Saúde, Fortaleza CE, Brazil.
,
Bárbara Matos Almeida QUEIROZ 
4   Universidade de Fortaleza, Centro de Ciências da Saúde, Fortaleza CE, Brazil.
,
Marina Franciss TAMIETTI 
4   Universidade de Fortaleza, Centro de Ciências da Saúde, Fortaleza CE, Brazil.
,
Fernanda Martins MAIA 
1   Hospital Geral de Fortaleza, Serviço de Neurologia, Fortaleza CE, Brazil.
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ABSTRACT

Background: Malignant infarction of the middle cerebral artery (MCA) occurs in a subgroup of patients with ischemic stroke and early decompressive craniectomy (DC) is one of its treatments. Objective: To investigate the functional outcome of patients with malignant ischemic stroke treated with decompressive craniectomy at a neurological emergency center in Northeastern Brazil. Methods: Prospective cohort study, in which 25 patients were divided into two groups: those undergoing surgical treatment with DC and those who continued to receive standard conservative treatment (CT). Functionality was assessed using the modified Rankin Scale (mRS), at follow-up after six months. Results: A favorable outcome (mRS≤3) was observed in 37.5% of the DC patients and 29.4% of CT patients (p=0.42). Fewer patients who underwent surgical treatment died (25%), compared to those treated conservatively (52.8%); however, with no statistical significance. Nonetheless, the proportion of patients with moderate to severe disability (mRS 4–5) was higher in the surgical group (37.5%) than in the non-surgical group (17.7%). Conclusion: In absolute values, superiority in the effectiveness of DC over CT was perceived, showing that the reduction in mortality was at the expense of increased disability.

RESUMO

Introdução: O infarto maligno da artéria cerebral média (ACM) ocorre em um subgrupo de pacientes com acidente vascular cerebral (AVC) isquêmico e a craniectomia descompressiva (CD) precoce é um de seus tratamentos. Objetivo: Investigar o desfecho funcional de pacientes com acidente vascular cerebral isquêmico maligno submetidos à craniectomia descompressiva em um centro de emergência neurológica do nordeste do Brasil. Métodos: Nesta coorte prospectiva, os pacientes foram divididos em dois grupos: aqueles submetidos a tratamento cirúrgico com craniectomia descompressiva (CD) e aqueles que mantiveram tratamento conservador (TC) padrão. A funcionalidade foi avaliada por meio da Escala de Rankin modificada (ERm) ao final de seis meses de seguimento. Resultados: Evidenciou-se desfecho favorável (ERm≤3) em 37,5% dos pacientes craniectomizados e em 29,4% dos pacientes não craniectomizados (p=0,42). A mortalidade foi menor no grupo de pacientes que se submeteram a tratamento cirúrgico (25%) do que entre aqueles tratados conservadoramente (52,8%), porém sem significância estatística. Por outro lado, a proporção de pacientes com incapacidade moderada a grave (ERm 4–5) foi maior no grupo cirúrgico (37,5%) do que no grupo não cirúrgico (17,7%). Conclusão: Em valores absolutos, percebeu-se superioridade na eficácia do tratamento cirúrgico sobre o conservador, mostrando que a redução de mortalidade se dá à custa de aumento da incapacidade funcional.

Keywords:

stroke - brain edema - decompressive craniectomy

Palavras-chave:

acidente vascular cerebral - edema encefálico - craniectomia descompressiva


Publication History

Received: 01 August 2019
Received: 27 November 2019

Accepted: 08 January 2020

Article published online:
13 June 2023

© 2020. Academia Brasileira de Neurologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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