Análisis de la supervivencia y del estado funcional al año de evolución de los pacientes neurocríticos tratados con craniectomía descompresiva por hipertensión intracraneal refractaria

Abstract

1. Introduction The natural evolution of neurocritical pathologies that present with refractory intracranial hypertension (HTIC) is brain herniation. Decompressive craniectomy (CD) is the last therapeutic step to avoid it. 2. Hypothesis DC improves the survival and functional outcome of patients with HTIC refractory to medical treatment. 3. Objectives Main objective: to asses the functional outcome, at one year of follow-up, of patients with refractory HTIC, treated with DC, in the different neurocritical pathologies. Secondary objectives: to asses which factors were related to an unfavorable functional state and which pathology presented the best functional state in the survivors. 4. Material and Methods: Single-center, prospective and observational study (UCI Hospital Germans Trias i Pujol, 2010-2017). Inclusion criteria: Patients with refractory HTEC who required DC. Variables analyzed. Epidemiological variables, treatment and clinical evolution. Main variable. Functional outcome at one year of follow-up. It was assessed using the dichotomized GOSE scale [Unfavorable functional outcome (UFO): GOSE 1-3 and favorable (FFO): GOSE 4-8)] and, using the dichotomized modified Rankin scale (mRS) (UFO: mRs 4-6 and FFO: mRS 0-3). When the functional outcome of the survivors was analyzed, a GOSE 4 was considered as UFO outcome. Sample size calculation. Considering a percentage of unfavorable functional outcome of 75% with medical treatment, a reduction of the same of 14% with DC, assuming an α risk of 5% with bilateral significance and a power of 80%, 93-104 patients will be necessary. Statistical analysis: Descriptive: Percentages with 95% CI for qualitative variables. Medians or means with 95% CI for quantitative variables. Bivariate: Simple logistic regression. Multivariate: Logistic regression and determination of the ROC curve. 5. Results 108 patients were included. Malignant stroke of the middle cerebral artery (MSMCA): 25; Traumatic brain injury (TBI): 30; Subarachnoid hemorrhage (SAH): 19; Supratentorial intraparenchymal hemorrhage (IH): 15; Cerebellar stroke (CS): 4; Cerebellar hemorrhage (CH): 6, tumors: 9. The most frequent CD was the right (48%). 59.3% of all pathologies presented an UFO (GOSE) at one year of follow-up. MSMCA: Men: 52%. Age: :46.5 years. Right CD: 68%. ICU mortality: 16%. UFO: mRS (66.7%) and GOSE (62.4%). The variable related to an UFO was age (RR: 1.2; 95% CI: 1.01-123.7; p= 0.03). TBI: Men: 60%. Age: 32.5 years. CD right: 40%. ICU mortality: 23.3%. UFO: mRS (58.6%) and GOSE (58.6%). The variables related to an UFO were age (RR: 1.09; 95% CI: 1.02-1.118; p=0.015) and bifrontal craniectomy (RR: 14.5; 95% CI: 1.61-30 .66, p=0.017). HSA: Women: 52.6%. Age: 47.2 years. HTA: 58%. HSA Fisher IV: 84.2%, Hunt and Hess 5: 73.7% and secondary to ruptured middle cerebral artery aneurysm (54.6%). UFO: mRS (57.9%) and GOSE (57.9%). The variable related to an UFO was hypertension (RR: 13.5; 95% CI: 1.47 – 123.7; p=0.02). IH: Men: 60%. Age: 44.5 years.

Date of Award	21 Apr 2023
Original language	Spanish
Supervisor	Jose Maria Balibrea del Castillo (Director), Pilar Marcos Neira (Director) & David Pares Martinez (Tutor)