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Table of Contents    
Year : 2012  |  Volume : 60  |  Issue : 6  |  Page : 608-612

Preoperative APACHE II and GCS scores as predictors of outcomes in patients with malignant MCA infarction after decompressive hemicraniectomy

1 Department of Neurology, Tri Service General Hospital, Taipei, Taiwan, China
2 Department of Neurology, Tri Service General Hospital; Institute of Aerospace and Undersea Medicine, School of Medicine, Taipei, Taiwan, China
3 Department of Neurological Surgery, Tri Service General Hospital, Taipei, Taiwan, China
4 Department of Neurological Surgery, Tri Service General Hospital; Department of Biochemistry, National Defense Medical Center, Taipei, Taiwan, China

Date of Submission15-Nov-2012
Date of Decision18-Nov-2012
Date of Acceptance19-Nov-2012
Date of Web Publication29-Dec-2012

Correspondence Address:
Dueng-Yuan Hueng
Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.105195

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 » Abstract 

Objective: Decompressive hemicraniectomy is accepted as the most effective life-saving treatment for malignant middle cerebral artery (MCA) infarction. However, the outcome remains hard to predict. This study examined the efficacy of using the Glasgow Coma Scale (GCS) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores before emergency craniectomy for predicting clinical outcome in malignant MCA infarction. Materials and Methods: Seventy-nine consecutive patients with malignant MCA infarction treated from January 2006 to October 2010 were retrospectively analyzed. The GCS and APACHE II scores within the first 24 h of neurological deterioration or before decompressive hemicraniectomy, were used to predict short-term functional outcome rated by the modified Rankin Scale (mRS). The receiver operating characteristic (ROC) curve was obtained to determine the accuracy and best cut-off value for each scoring system. Results: At 6 months, there was dramatic life-saving effect of surgery, with a significant reduction in mortality rate (from 71% to 19%, P < 0.001). After the ROC analysis, cut-off values of pre-operative GCS > 8 (P = 0.003) and APACHE II <13 (P = 0.006) were sufficiently sensitive and specific to predict favorable outcome (mRS 0-3). Conclusions: Pre-operative GCS and APACHE II scores are useful tools in predicting outcomes for patients with malignant MCA infarction who underwent decompressive hemicraniectomy.

Keywords: APACHE, decompressive hemicraniectomy, glasgow coma scale, malignant middle cerebral artery infarction, outcome

How to cite this article:
Tsai CL, Chu H, Peng GS, Ma HI, Cheng CA, Hueng DY. Preoperative APACHE II and GCS scores as predictors of outcomes in patients with malignant MCA infarction after decompressive hemicraniectomy. Neurol India 2012;60:608-12

How to cite this URL:
Tsai CL, Chu H, Peng GS, Ma HI, Cheng CA, Hueng DY. Preoperative APACHE II and GCS scores as predictors of outcomes in patients with malignant MCA infarction after decompressive hemicraniectomy. Neurol India [serial online] 2012 [cited 2023 Mar 22];60:608-12. Available from: https://www.neurologyindia.com/text.asp?2012/60/6/608/105195

 » Introduction Top

Malignant middle cerebral artery (MCA) infarctions with significant space-occupying edema account for up to 10% of all supratentorial ischemic strokes [1],[2],[3] and are associated with mortality of nearly 80% despite the best medical treatment. [4] In these patients, decompressive hemicraniectomy has been shown to be the most effective intervention to improve survival, particularly in patients aged below 60 years. In patients older than 60 years of age, the benefits of hemicraniectomy are not all that certain. [5],[6],[7],[8],[9],[10],[11] Determining the predictors of good outcome and reliable pre-operative scoring systems is of crucial importance in facilitating decision-making regarding decompressive surgery in older patients with malignant MCA infarction and deteriorating consciousness. This study was aimed at finding the usefulness of Glasgow Coma Scale (GCS) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores before emergent craniectomy for predicting clinical outcome in malignant MCA infarction.

 » Materials and Methods Top

Patient selection, data collection, and ethics statement

Seventy-nine patients with space-occupying malignant MCA infarction treated in Tri-Service General Hospital, National Defense Medical Center between January 2006 and October 2010 were included in this retrospective analysis. The institutional review board of our hospital approved this study and waived the requirement of written and verbal informed consents.

Definition of MCA infarction

The criteria to define space-occupying malignant MCA infarction included: (1) infarction occupying at least 50% of the MCA territory as documented by computed tomography and/or magnetic resonance imaging, with the associated rapidly developing signs and symptoms and (2) evidence of brain swelling, including midline shift of the brain parenchyma and uncal herniation on neuroimaging. [12],[13]

Evaluation scores

Mental status and disease severity were assessed by the GCS and APACHE II scores. [14] All patients were followed up for assessment of functional outcome using the modified Rankin scale (mRS) at 6 months. An unfavorable outcome was defined as mRS of 4 or 5, while a favorable outcome was as mRS of 0-3.

Treatment grouping, surgical indication, and surgical procedures

Patients were divided into operation group and non-operation group, depending on whether decompressive hemicraniectomy was done or not. The surgical indications of hemicraniectomy were when medical therapies failed and neurological deteriorations developed. All surgical procedures were performed by the neurosurgeons of our hospital. Decompressive hemicraniectomy involved contralateral extra-ventricular drainage and implantation of a skull flap into the abdominal wall, a large bone flap (including portions of the frontal, parietal, and temporal bone), and opening of the dura mater ipsilateral to the infarction site. All patients in the surgical groups underwent decompressive hemicraniectomy within the first 48 h of neurological deterioration.

Statistical analysis

Statistical Package for the Social Sciences version 19.0 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis standard deviation (SD) numerical values were expressed as mean ± standard deviation (SD). Comparisons between two groups were analyzed using the Student's t-test for continuous variables and the χ2 test for categorical variables. P < 0.05 was considered statistically significant. A receiver operating characteristic (ROC) curve was constructed to identify the best cut-off value of the studied pre-operative scoring systems to maximize the sum of sensitivity and specificity. [15] Areas under the ROC curves between 0.9 and 1.0 were categorized as "outstanding," between 0.8 and 0.9 as "excellent," and between 0.7 and 0.8 as "acceptable" discrimination. [16] Survival outcomes were estimated using the Kaplan-Meier survival curve.

 » Results Top

Seventy-nine patients, including 40 males and 39 females, with mean ± SD age of 71.05 ± 15.28 years (range 25-97 years), were included in this study [Table 1]. Of the 79 patients, 39 patients had left-sided and 40 had right-sided MCA infarctions. Forty-two patients received only medical treatment and 37 underwent decompressive hemicraniectomy. Hypertension (83.5%), atrial fibrillation (53.2%), diabetes mellitus (41.8%), and smoking (35.4%) were the most common vascular risk factors in this cohort.
Table 1: Clinical characteristics in patients with malignant middle cerebral artery infarctions

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When clinical characteristics were compared between non-operation and operation groups, surgical treatment was administered more in patients with non-dominant hemisphere infarction (right vs. left: 24 vs. 16, P = 0.024) and in younger patients (65.54 ± 15.78 vs. 75.90 ± 13.81 years, P = 0.002), and in patients with lower APACHE II score and higher GCS (mean APACHE II 19 ± 5 vs. 24 ± 6, P < 0.001 and GCS 6 ± 2 vs. 7 ± 2, P = 0.022) [Table 2].
Table 2: Comparisons of the clinical characteristics in patients with malignant middle cerebral artery infarctions who underwent medical treatment only or decompressive hemicraniectomy additionally

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Six-month survival rate in the operation group was 81.1% compared to 28.6% in the non-operation group. There was dramatic life-saving effect of surgery with a highly significant 52% reduction of the mortality rate in the operation group compared to the non-operation group ( P < 0.001) [Figure 1]. At 6 months of follow-up, patients who underwent surgery had significantly higher incidence of favorable outcome ( P = 0.019). When categorized by age 60 years, only higher APACH II score and hypertension discriminated between the non-operation and operation groups. Most important of all, even though there was no significant difference in functional outcome between the two groups, the life-saving efficiency of decompressive craniectomy was still remarkable in patients older than 60 years [Table 2].
Figure 1: Kaplan-Meier survival curves for the two treatment groups, log rank (Mantel-Cox), P < 0.001

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The ROC curve analysis in the operation group showed that both GCS and APACHE II on clinical deterioration or pre-operatively had outstanding discriminatory power for predicting unfavorable outcome using area under ROC curve (AUC) [APACHE II 93.8%, 95% confidence interval (CI) 83.5-100.0, P = 0.002; GCS 96.3%, 95% CI 90.1-100.0, P = 0.001] [Figure 2]. To obtain the strongest power of prediction, the cut-off values for the scoring systems were 13 for APACHE II (sensitivity 80.0% and specificity 96.9%, P = 0.006) and 8 for GCS (sensitivity 100.0% and specificity 84.4%, P = 0.003) [Table 3].
Figure 2: ROC cures for GCS and APACHE II scores. Area under ROC curve of GCS was 96.3%, 95% confidence interval (CI) 90.1-100.0, P=0.001; Area under ROC of APACHE II was 93.8%, 95% CI 83.5-100.0, P=0.002. ROC, receiver operating characteristic; GCS, Glasgow coma scale; APACHE, Acute physiology and Chronic health evaluation

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Table 3: Comparison of the discriminatory power of APACHE II and GCS in predicting unfavorable clinical outcome in the surgical group of malignant MCA infarctions

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 » Discussion Top

Substantial improvement in the survival of patients with space-occupying MCA infarction who received decompressive hemicraniectomy is evident in recently published randomized trials. [9],[11],[17] The timing of surgical decompression done within 48 h of stroke onset, compared to medical management alone, reduces the risk of mortality at 12 months. [18],[19] Nevertheless, the efficacy of decompressive hemicraniectomy has only been proven in patients younger than 60 years of age. [20] Scant available evidence makes it difficult to recommend hemicraniectomy for malignant MCA infarction in most patients over the age of 60 and those with brain edema peaking after the first 48 h. Elderly patients are often excluded as their existing co-morbidities may possibly challenge the success of the trials. As such, it is imperative to find out a reliable scoring system to assist in decision-making when an elderly patient is being considered for emergent craniectomy. Compared to the earlier published literature, the present study demonstrates consistent results regarding the clinical course of patients with malignant MCA infarction. The mortality rate is reduced from 71% to 19% in the decompressive hemicraniectomy group compared to the maximal conservative treatment group, and the functional outcome of surgery is significantly better than medical treatment only at 6 months of follow-up. The data here not only corroborates previous reports, [20] but further confirms the life-saving effects of decompressive hemicraniectomy in patients older than 60 years of age.

Schwab et al. [4] have demonstrated that there was a better prognosis in patients who received decompressive hemicraniectomy prior to clinical deterioration. None in the non-operation group and only a minority of patients in the operation group (13.5%) had favorable outcomes (mRS ≤ 3). There are two possible explanations. First, the condition of patients who underwent medical treatment was too severe for them to undergo surgery (mean APACHE II score was 24 and GCS score was 6). Another possibility is that in situations where elderly patients suffer major stroke and the effect of surgery cannot be assured, the family may hesitate and decompressive hemicraniectomy may be delayed.

The current study specially focused on the comparison between scoring systems at the time of clinical deterioration or before surgery in predicting outcome to help to decide whether emergent craniectomy will be beneficial to a patient. To acquire the greatest predictive power based on the ROC curve analysis, the cut-off value selected is 8 for GCS and 13 for APACHE II. There may be a tendency indicating the superiority of GCS score ≤8 over APACHE II ≥13 for predicting unfavorable outcome (AUC: GCS 92.2%, 95% CI 83.4-100.0, P = 0.003; APACHE II 88.4%, 95% CI 67.2-100.0, P = 0.006).

This study has some limitations. It is a non-randomized single-centre study. Moreover, the sample size is relatively small, which precludes further analysis of several predictive variables like positive and negative likelihood ratios. The follow-up duration is limited to 6 months. Lastly, this study assessed functional outcome by mRS, which may not completely reflect the quality of life.

 » Conclusions Top

This series confirms the life-saving efficacy of decompressive hemicraniectomy in patients with malignant MCA infarction and provides evidence of the beneficial effect of surgery to patients beyond the age 60 years. However, surgical intervention may be incapable to bring favorable outcomes in malignant MCA infarction patients with poor clinical condition. Preoperative GCS is as efficacious as APACHE II score in predicting outcomes of patients with malignant MCA infarction underwent hemicraniectomy. These should be taken into account for therapy allocation in future group-randomized trials.

 » References Top

1.Moulin DE, Lo R, Chiang J, Barnett HJ. Prognosis in middle cerebral artery occlusion. Stroke 1985;16:282-4.  Back to cited text no. 1
2.Silver FL, Norris JW, Lewis AJ, Hachinski VC. Early mortality following stroke: A prospective review. Stroke 1984;15:492-6.  Back to cited text no. 2
3.Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R. 'Malignant' middle cerebral artery territory infarction: Clinical course and prognostic signs. Arch Neurol 1996;53:309-15.  Back to cited text no. 3
4.Schwab S, Steiner T, Aschoff A, Schwarz S, Steiner HH, Jansen O, et al. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 1998;29:1888-93.  Back to cited text no. 4
5.Holtkamp M, Buchheim K, Unterberg A, Hoffmann O, Schielke E, Weber JR, et al. Hemicraniectomy in elderly patients with space occupying media infarction: Improved survival but poor functional outcome. J Neurol Neurosurg Psychiatry 2001;70:226-8.  Back to cited text no. 5
6.Walz B, Zimmermann C, Bottger S, Haberl RL. Prognosis of patients after hemicraniectomy in malignant middle cerebral artery infarction. J Neurol 2002;249:1183-90.  Back to cited text no. 6
7.Foerch C, Lang JM, Krause J, Rabbe A, Sitzer M, Seifert V, et al. Functional impairment, disability, and quality of life outcome after decompressive hemicraniectomy in malignant middle cerebral artery infarction. J Neurosurg 2004;101:248-54.  Back to cited text no. 7
8.Vahedi K, Benoist L, Kurtz A, Mateo J, Blanquet A, Rossignol M, et al. Quality of life after decompressive craniectomy for malignant middle cerebral artery infarction. J Neurol Neurosurg Psychiatry 2005;76:1181-2.  Back to cited text no. 8
9.Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 2007;38:2506-17.  Back to cited text no. 9
10.Cruz-Flores S, Berge E, Whittle IR. Surgical decompression for cerebral oedema in acute ischaemic stroke. Cochrane Database Syst Rev 2012;1:CD003435.  Back to cited text no. 10
11.Juttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, et al. Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY): A randomized, controlled trial. Stroke 2007;38:2518-25.  Back to cited text no. 11
12.Lanzino DJ, Lanzino G. Decompressive craniectomy for space-occupying supratentorial infarction: Rationale, indications, and outcome. Neurosurg Focus 2000;8:e3.  Back to cited text no. 12
13.Cho DY, Chen TC, Lee HC. Ultra-early decompressive craniectomy for malignant middle cerebral artery infarction. Surg Neurol 2003;60:227-33.  Back to cited text no. 13
14.Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: A severity of disease classification system. Crit Care Med 1985;13:818-29.  Back to cited text no. 14
15.Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 1982;143:29-36.  Back to cited text no. 15
16.Hosmer D, Lemeshow S. Assessing the fit of the model. In: Applied logistic regression. New York: John Wiley and Sons; 2000. p. 160-4.  Back to cited text no. 16
17.Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp HB. Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): A multicentre, open, randomised trial. Lancet Neurol 2009;8:326-33.  Back to cited text no. 17
18.Vahedi K, Hofmeijer J, Juettler E, Vicauat E, George B, Algra A, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: A pooled analysis of three randomised controlled trials. Lancet Neurol 2007;6:215-22.  Back to cited text no. 18
19.Starling AJ, Wellik KE, Hoffman Snyder CR, Aguilar MI, Demaerschalk BM, Zimmerman RS, et al. Surgical decompression improves mortality and morbidity after large territory acute cerebral infarction: A critically appraised topic. Neurologist 2011;17:63-6.  Back to cited text no. 19
20.Walcott BP, Kuklina EV, Nahed BV, George MG, Kahle, KT, Simard JM, et al. Craniectomy for malignant cerebral infarction: Prevalence and outcomes in US hospitals. PLoS One 2011;6:e29193.  Back to cited text no. 20


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