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Master's Dissertation
DOI
https://doi.org/10.11606/D.17.2020.tde-05062020-085246
Document
Author
Full name
Luiz Fernando Rodrigues de Oliveira
E-mail
Institute/School/College
Knowledge Area
Date of Defense
Published
Ribeirão Preto, 2019
Supervisor
Committee
Pontes Neto, Octávio Marques (President)
Éckeli, Álan Luiz
Rodrigues, Guilherme Gustavo Riccioppo
Title in Portuguese
Preditores de desfecho em pacientes com infarto maligno do território da artéria cerebral média submetidos à craniectomia descompressiva
Keywords in Portuguese
Acidente Vascular Cerebral Isquêmico (AVCI)
Craniectomia descompressiva
Infarto extenso
Infarto maligno
Abstract in Portuguese
INTRODUÇÃO: O acidente vascular cerebral (AVC) isquêmico é importante causa de mortalidade em todo o mundo. Os infartos malignos do território da artéria cerebral média (IMACM) apresentam mortalidade de até 80% quando tratados clinicamente. Nesse contexto, a craniectomia descompressiva (CD) é uma medida salvadora, mas às custas de elevada morbidade entre os sobreviventes. OBJETIVOS: Avaliar os desfechos dos pacientes com IMACM submetidos a CD e seus preditores e descrever as características da população submetida a CD em um hospital universitário brasileiro. MÉTODOS: A partir de um banco de dados prospectivo, foram identificados todos os pacientes submetidos a CD devido IMACM no período de janeiro de 2014 e dezembro de 2017. Suas características demográficas e as relacionadas ao atendimento hospitalar, ao manejo agudo do AVCI e a todo o período de internação foram retrospectivamente avaliados e correlacionados por análise univariada e multivariada com os desfechos de mortalidade intra-hospitalar e ao final do período de seguimento e incapacidade funcional ao final do período de seguimento, dicotomizada em escore de Rankin modificado (mRS) > 3 e > 4. RESULTADOS: 53 pacientes foram incluídos. Homens corresponderam a 64,2%. A idade média foi de 54,6 ± 11,6 anos, sendo 64,2% menores de 60 anos. O hemisfério dominante foi o acometido em 39,6%. Os pacientes foram submetidos a CD após uma média de 36 ± 17 horas do início dos sintomas. A mortalidade intra-hospitalar foi de 30,2%. Entre os sobreviventes, a mediana do tempo de internação foi 31 [18,5-42,5] dias. Ao final do período de seguimento, 39,6% dos pacientes tinham morrido, 13,2% apresentavam mRS 5, 26,4% apresentavam mRS 4, 11,4%, mRS 3 e 9,4%, mRS 2. Idade maior que 60 anos (OR 6,05; IC 95% 1,30-28,13; p 0,022), maior NIHSS (do inglês, National Institute of Health Stroke Scale) (OR 1,21; IC 95% 1,04-1,41; p 0,012) e AVC prévio (OR 14,85; IC 95% 1,13-195,56; p 0,04) foram preditores independentes do desfecho primário, mRS 5-6. Idade (OR 1,1; IC 95% 1,01-1,21; p 0,038) e maior NIHSS (OR 1,25 (1,09-1,67; p 0,006) foram preditores independentes de mRS 4-6 ao final do seguimento, enquanto trombólise endovenosa (OR 0,08; IC 95% 0,01-0,69; 0,021) foi protetor. Maior NIHSS (OR 2,00; IC 95% 1,07-3,78/ p 0,03) e desvio da linha média (OR 1,45; IC 95% 1,05-2,00; p 0,022) foram preditores de óbito ao final do seguimento. Para mortalidade intra-hospitalar dois modelos de regressão logística foram avaliados e foram identificados os seguintes preditores: NIHSS da admissão (OR 1,27; IC 95% 1,05-1,53; p 0,013) e envolvimento da cerebral anterior (OR 5,45; IC 1,06-28,15; p 0, 043) e NIHSS da admissão (OR 1,34; IC 95% 1,06-1,69; p 0,015), crises epilépticas (OR 14,45. IC 95% 1,30-159,72; p 0,029) e desvio da linha média (OR 1,53; IC 95% 1,15-2,03; p 0,003). CONCLUSÕES: NIHSS da admissão, idade, AVC prévio, ocorrência de crises epilépticas, desvio da linha média e envolvimento pré-operatório do território da artéria cerebral anterior são preditores de pior desfecho funcional e mortalidade, enquanto trombólise endovenosa é fator protetor para mRS > 3.
Title in English
Outcome predictors for patients with malignant infarction of middle cerebral artery territory treated with decompressive craniectomy
Keywords in English
Decompressive craniectomy
Ischemic Stroke (IS)
Large infaction
Malignant infartion
Abstract in English
BACKGROUND: Ischemic stroke are important cause of death in the world. The malignant infarction of middle cerebral artery territory (MIMCA) has mortality as high as 80% when clinically treated. In this setting, decompressive craniectomy (DC) is a life-saving measure, in spite of high morbidity among survivors. OBJECTIVES: To evaluate the outcomes of patients with MIMCA treated with DC and its predictors and to describe the population characteristics in a Brazilian university hospital. METHODS: A prospective stroke database was retrospectively evaluated, and all patients treated with DC for IMACM between January 2014 and December 2017 were included. Their demographics characteristics and those related to the hospital admission, acute stroke management and in-patient period were evaluated. Statistical analysis included descriptive, univariate and multivariate to identify independent predictors of functional outcomes, measured by modified Rankin Score (mRS) > 3 and > 4, and death at the end of the follow-up period and during hospital stay. RESULTS: 53 patients were included. Men were 64,2%. The mean age was 54,6 ± 11,6 years, 64,2% had 60 yearsold or less. The dominant hemisphere was the affected in 39,6%. The DC was performed after a mean 36 ± 17 hours from symptoms onset. The in-hospital mortality was 30,2%. Among survivors, the median hospital stay was 31 [18,5-42,5] days. At the end of follow-up, 39,6% had died, 13,2% were mRS 5, 26,4% ere mRS 4, 11,4%, mRS 3 e 9,4%, mRS 2. Age of 60 years or less (OR 6,05; IC 95% 1,30-28,13; p 0,022), greater NIHSS (National Institute of Health Stroke Scale) (OR 1,21; IC 95% 1,04-1,41; p 0,012) and previous stroke (OR 14,85; IC 95% 1,13-195,56; p 0,04) were independent predictors of the primary outcome, mRS 5-6. Age (OR 1,1; IC 95% 1,01-1,21; p 0,038) and greater NIHSS (OR 1,25 (1,09-1,67; p 0,006) were independent predictors of mRS 4-6 at the end of follow-up. Intravenous thrombolysis (OR 0,08; IC 95% 0,01-0,69; 0,021) was protector. Greater NIHSS (OR 2,00; IC 95% 1,07-3,78/ p 0,03) e midline shift (OR 1,45; IC 95% 1,05-2,00; p 0,022) were predictors of death at the end of followup. To evaluate in-hospital death, two models of logistic regression were used and the following predictors were identified: NIHSS at admission (OR 1,27; IC 95% 1,05-1,53; p 0,013) and anterior cerebral artery territory infarction (OR 5,45; IC 1,06-28,15; p 0, 043) and NIHSS at admission (OR 1,34; IC 95% 1,06-1,69; p 0,015), seizures (OR 14,45. IC 95% 1,30-159,72; p 0,029) and midline shift (OR 1,53; IC 95% 1,15-2,03; p 0,003). CONCLUSIONS: NIHSS at admission, age, previous stroke, seizures, midline shift and early concomitant infarct of anterior cerebral artery territory are predictors of worst functional outcome and death. Intravenous thrombolysis is protector to mRS > 3.
 
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Publishing Date
2020-07-13
 
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