Abstract
Objectives
To observe whether medical complications, the evolution of neurological disorders and dependence and/or the discharge destinations are different for patients treated by craniectomy for malignant cerebral infarction in the middle cerebral artery compared to patients treated medically for severe or malignant cerebral infarction in the same cerebral territory, during their hospitalization in a physical medicine and rehabilitation department.
Patients and methods
This retrospective study compared patients treated by craniectomy for malignant cerebral infarction in the middle cerebral artery and patients treated medically for severe or malignant cerebral infarction in the same cerebral territory. Patients were paired according to age, lesion side and hospitalization period.
Results
Twelve patients treated by craniectomy (age 43 ± 10.44) were paired with 12 patients treated medically (age 49 ± 7.66). The two groups were comparable in terms of general undesirable medical events. The medical events related to craniectomy are described. The evolution of patient deficiencies, the length of the hospital stay (194 ± 118.93 days vs 152 ± 94.64 days), the Functional Independence Measure at discharge (87 ± 21.28 vs 95 ± 22.19) and the number of direct home discharges (7 vs 9) did not significantly differ between groups.
Discussion and conclusion
No more medical problems were observed in the patients treated by craniectomy than in the patients treated medically, except for the medical events specifically related to craniectomy, which extended the hospital stay but had no major repercussions.
Résumé
Objectifs
Observer si les patients craniectomisés pour infarctus sylvien malin posent des problèmes médicaux, suivent une évolution des déficits neurologiques ainsi que de la dépendance et ont un mode de sortie différents en comparaison à des patients non craniectomisés habituellement admis en médecine physique et de réadaptation après infarctus sylvien malin ou sévère.
Matériel et méthode
Étude rétrospective comparant des patients craniectomisés pour infarctus sylvien malin à des non craniectomisés, appariés selon l’âge, le côté de la lésion et la période d’hospitalisation.
Résultats
Douze craniectomisés (43 ± 10,44 ans) ont été appariés à 12 non craniectomisés (49 ± 7,66 ans). Les deux groupes étaient comparables en terme d’évènements médicaux indésirables généraux. Les évènements propres à la craniectomie sont décrits. L’évolution des déficiences, la durée moyenne de séjour (194 ± 118,93 jours vs 152 ± 94,64 jours), la mesure d’indépendance fonctionnelle de sortie (87 ± 21,28 vs 95 ± 22,19) et le nombre de retours directs à domicile (7 vs 9) étaient comparables.
Discussion et conclusion
Les patients craniectomisés n’ont pas posé plus de problèmes médicaux, hormis les évènements liés à la craniectomie qui ont pu allonger la durée de séjour sans retentissement majeur.
1
English version
1.1
Introduction
The term “malignant cerebral infarction in the middle cerebral artery” was first used by Hacke et al. in 1996 . This term refers to a massive cerebral infarction in the middle cerebral artery (MCA), responsible for a high early mortality rate because of cerebral edema and the risk of brain herniation.
Until 1950, decompressive craniectomy for malignant MCA infarction was only used in exceptional cases. The disappointing outcomes of medical treatment resulted in the expansion of this type of surgery, which demonstrates a significant survival benefit, since the mortality rate for malignant MCA infarction, which was 67 to 80% with traditional medical treatment, is now 0 to 34% with the use of craniectomy . The craniectomy aims to create space in order to avoid brain herniation due to ischemic edema, which could lead to death . MCA infarction is particularly severe in young adults due to the absence of cortico-sub-cortical atrophy, thus a lack of space to compensate brain swelling . Nevertheless, age is a prognosis factor in terms of survival and functional outcomes .
However, the functional outcomes following decompressive craniectomy reported in scientific literature remain open to interpretation, and doubts about the benefits of this treatment in terms of functional outcomes and quality of life persist . The recent publication of the results of random controlled trials provided evidence of an improved survival rate and also reduced the fears that the improved survival rate was at the price of persistent and unacceptable neurological sequelae . One of the most recent and most complete studies brought together three European teams (French: DECIMAL, German: DESTINY and Dutch: HAMLET) . Each team conducted a random controlled trial, using a methodology that was similar enough to allow a pooled analysis. The results give a clear indication of the superiority of early decompressive craniectomy compared with non-surgical management.
To our knowledge, no study has ever focused on the problems of patients treated by craniectomy for MCA infarction, during their stay in physical medicine and rehabilitation department following intensive care. This study does not aim to prove the efficiency of decompressive craniectomy. Rather, the objective of this observational study was to determine if patients who underwent a craniectomy for MCA infarction (CMCI) had different medical problems than patients treated medically without craniectomy (TMNC). Since both types of patients are usually hospitalized in our department, we observed the evolution of these patients in order to find out in what aspects they differed.
1.2
Patients and methods
This retrospective study compared the medical data of CMCI patients to those of TMNC patients. All patients suffered from either a malignant MCA infarction or a severe MCA infarction, and all were hospitalized in our PMR department from 2002 to 2007. For this study, we defined MCA infarction as “severe” when it concerned both the deep and superficial areas of the MCA or when the Functional Independence Measure (FIM) was lower to 75 on admission to our department.
The inclusion criterion was a single severe or malignant infarction. Exclusion criteria included a patient history of neurological and/or locomotor disorders with important functional repercussions.
Twelve CMCI patients were included, each one paired with a TMNC patient, according to the age (20–40; 40–60; over 60), lesion side and hospitalization period.
Important prognosis factors after the cerebral infarction were compiled: initial vigilance problems with or without a stay in intensive care; the initial National Institutes of Health Stroke Scale (NIHSS) Score, when available; and finally, the existence of comorbidities.
The clinical data collected included:
- •
vigilance on admission;
- •
motricity, ranked from 0 to 4 (2 for the plegic upper limb, 2 for the plegic lower limb; 0 = absence of motor impairment; 1 = moderate motor impairment; 2 = severe motor impairment);
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sensitivity, ranked from 0 to 8 (2 for the upper limb, 2 for the lower limb and for each type of sensory modalities, tactile and proprioception; 0 = absence of sensory impairment; 1 = moderate hypoesthesia; 2 = severe hypoesthesia);
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spasticity (problematic or not, as well as the treatment required);
- •
swallowing disorder, ranked from 0 to 2 (0 = absence of swallowing disorder; 1 = required precautions; 2 = nasogastric tube or gastrostomy);
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bladder dysfunction;
- •
sitting balance, defined by the ability to stay seated at the edge of the Bobath surface without human help for more than one minute, with intrinsic and extrinsic destabilization;
- •
language, ranked from 0 to 2 (0 = absence of speech disorder; 1 = speech disorder but able to communicate; 2 = very difficult or impossible to communicate);
- •
spatial neglect, which was assessed by the GEREN test series and ranked from 0 to 2 (0 = absence of neglect; 1 = moderate neglect; 2 = severe neglect).
Undesirable medical events (e.g., thrombo-embolic disorders, epilepsy, pressure sores, falls, depression, fatigability, paraosteoarthropathy) and any complications related to the craniectomy or cranioplasty during the patients’ stay in our department were also compiled. Patient deficiencies and functional independence levels were measured and recorded on admission and at discharge.
Autonomy was assessed by the Functional Independence Measure (FIM) on admission and before discharge. The global level of handicap was evaluated using the modified Rankin Scale (mRs) at discharge. Length of stay and discharge destination (e.g., number of direct home discharges) were recorded.
1.3
Data analysis
First, the normality of distributions was verified using a Shapiro-Wilk test. Then, the two groups (CMCI vs TMNC) were compared using a Student test for each variable of interest. The studied variables were age, delay before admission, FIM on admission, FIM at discharge and length of stay. For each variable, the mean value, the standard deviation (SD) and the 95% confidence interval were determined. Medical complications were not statistically analyzed because of the smallness of the sample.
1.4
Results
1.4.1
Patient baseline characteristics on admission
Twenty-four patients were included in the study: 12 CMCI and 12 TMNC. Their baseline characteristics are given in Table 1 . The two groups did not differ significantly in terms of age. The most common stoke etiology was carotid dissection, but in most cases, no cause was identified.
| CMCI Group ( n = 12) | TMNC Group ( n = 12) | p | |
|---|---|---|---|
| Age (years) | |||
| Mean ± SD | 43 ± 10 | 49 ± 7 | 0.08 |
| Sex ratio | |||
| Male/female | 3/9 | 6/6 | |
| Socioprofessional category (number of patients) a | |||
| Employees | 5 | 2 | |
| No professional activity | 3 | 1 | |
| Manual workers | 1 | 3 | |
| Intermediate professions | 1 | 0 | |
| Artisans, merchants, company leaders | 0 | 1 | |
| Managers and non-manual workers | 2 | 5 | |
| Admission delay (days) | |||
| Mean ± SD | 44 ± 21 | 23 ± 11 | 0.007 |
| Initial vigilance problems | |||
| Number of patients | 10 | 3 | |
| Initial NIHSS score b | |||
| Mean ± SD | 17.7 ± 5 | 19.3 ± 1 | 0.47 |
| Initial coma | |||
| Number of patients | 2 | 0 | |
| History (nb of patients) | |||
| Hypertension | 3 | 5 | |
| Diabetes | 1 | 2 | |
| Atrial fibrillation | 0 | 2 | |
| Stroke etiologies (number of patients) | |||
| Not determined | 5 | 4 | |
| Carotid dissection | 4 | 3 | |
| Cardioembolic | 1 | 3 | |
| Atherosclerotic | 1 | 1 | |
| Other | 1 | 1 | |
| Stroke lesion side | |||
| Right/left | 8/4 | 8/4 | |
a According to the French classification of socioprofessional categories from Insee.
Initially, vigilance problems affected 10 CMCI compared to two TMNC. Two CMCI were in a coma. In each group, two patients were hospitalized in an intensive care unit. After the craniectomy, four CMCI required intensive care for medical complications. The delay before admission to the Physical Medicine and Rehabilitation department was significantly higher for the CMCI group ( p = 0.007).
1.4.2
Assessment of neurological disorders and autonomy
The neurological disorders and autonomy levels of the two groups on admission and discharge are given in Table 2 . On admission, the neurological disorders (i.e., motricity, sensitivity, language, swallowing, balance, bladder dysfunction and spasticity) were slightly more severe in the CMCI group. One CMCI had vigilance problems. The mean FIM scores of both groups on admission were comparable.
| CMCI Group ( n = 12) | TMNC Group ( n = 12) | |||
|---|---|---|---|---|
| Admission | Discharge | Admission | Discharge | |
| Vigilance problems | ||||
| Number of patients | 1 | 0 | 0 | 0 |
| Motricity disorders: motricity score (number of patients) | ||||
| Moderate: score ≤ 2/4 | 0 | 6 | 2 | 8 |
| Severe: score = 3/4 | 5 | 4 | 3 | 2 |
| Complete hemiplegia: score = 4/4 | 7 | 2 | 7 | 2 |
| Sensitivity disorders: sensitivity score (number of patients) | ||||
| Not determined | 1 | 4 | 1 | 1 |
| Absent or minor: score between 0/8 and 1/8 | 0 | 1 | 1 | 2 |
| Moderate: score between 2/8 and 4/8 | 3 | 4 | 3 | 5 |
| Severe: score between 5/8 and 7/8 | 6 | 2 | 3 | 2 |
| Complete anesthesia: score = 8/8 | 2 | 1 | 4 | 2 |
| Language disorders: communication score (number of patients) | ||||
| Absent: score = 0/2 | 8 | 8 | 8 | 8 |
| Moderate: score = 1/2 | 0 | 0 | 1 | 3 |
| Major: score = 2/2 | 4 | 4 | 3 | 1 |
| Spatial neglect: neglect score (number of patients) | ||||
| Absent: score = 0/2 | 3 | 3 | 4 | 5 |
| Moderate: score = 1/2 | 6 | 9 | 2 | 5 |
| Major: score = 2/2 | 3 | 0 | 6 | 2 |
| Swallowing disorders: swallowing score (number of patients) | ||||
| Absent: score = 0/2 | 3 | 12 | 8 | 12 |
| Moderate: score = 1/2 | 8 | 0 | 4 | 0 |
| Major: score = 2/2 | 1 | 0 | 0 | 0 |
| Bladder dysfunction | ||||
| Number of patients | 10 | 3 | 8 | 2 |
| Sitting balance acquisition | ||||
| Number of patients | 7 | 12 | 6 | 12 |
| FIM | ||||
| Mean ± SD | 53 ± 12 * | 87 ± 21 ** | 54 ± 18 * | 95 ± 22 ** |
| mRs ≤ 3 | ||||
| Number of patients | 7 | 9 | ||
As shown in Table 2 , the evolution of the two groups was towards an improvement in motricity and sensitivity and towards a decline in spatial neglect. Aphasia remained severe in patients who underwent craniectomy: four CMCI versus one TMNC had still important language disorders at discharge. Of all the patients, only one CMCI had a gastrostomy tube, which was removed six months after his admission in our department. The less severe swallowing disorders, present in eight CMCI and four TMNC, improved during hospitalization. Four CMCI compared to three TMNC had a urinary catheter on admission, which was removed on their arrival in our department. There was no febrile urinary tract infection among these patients. At discharge, no patient had a urinary catheter, and bladder dysfunction completely disappeared in seven CMCI and six TMNC. For the others, persistent bladder dysfunction led to occasional urinary incontinence.
Spasticity sometimes required treatment with botulinum toxin injection in eight CMCI and six TMNC, and another treatment (i.e., alcohol neurolytic blocks, neuro-orthopedic surgery) for two CMCI and one TMNC. Sitting balance was achieved in all patients by discharge, and six CMCI and seven TMNC could walk without supervision. The mean FIM at discharge was a bit lower in CMCI, but the difference was statistically insignificant. At discharge, seven CMCI had a mRs ≤ 3, which is considered to be a favorable outcome, compared to nine TMNC.
1.4.3
Adverse events
The frequency of adverse events was quite similar in both groups (CMCI/TMNC: thrombo-embolic disorders 2/2; falls: 5/4; pressure sores: 0/0). Six patients had to be transferred to acute medical care during their stay in the PMR department: in the CMCI group, one was transferred for empyema, one for drowsiness, one for a nutrition disorder and one for anemia; in the TMNC group, one was transferred for heart failure and one for cholecystitis.
Three CMCI compared to one TMNC had one or more epileptic seizures before being admitted to the PMR department. Eight CMCI versus two TMNC had an anti-epileptic treatment on admission. One patient in each group had a seizure in the PMR department and one CMCI had two seizures in one year. The medical control of seizures didn’t seem more difficult in the CMCI group and did not require anti-epileptic polytherapy.
An algodystrophy, or painful shoulder, was found in two CMCI and nine TMNC. No patient had paraosteoarthropathy. During hospitalization, an abnormally bothersome fatigability was reported for five CMCI and eight TMNC.
Ten patients in each group required treatment for anxiety and depression (antidepressant therapy) during hospitalization. In addition, we noticed that the majority of patients treated by craniectomy suffered from self-image problems, and it was worse for those who had their bone flap placed in intra-abdominal position.
1.4.4
Specific evolution and medical complications of patients treated by craniectomy
Before the bone flap was replaced through cranioplasty, complications were observed in four patients. Two of the three patients whose bone flap had been placed in an intra-abdominal position complained about pain related to the flap; one of them developed sepsis that required a secondary surgical revision. One of the four patients developed a cerebrospinal fluid collection accompanied by cephalalgia; the collection had to be evacuated by lumbar punctures and compression bandages; a lomboperitoneal shunt was in the end required. Another patient, who had a brain abscess, also required a secondary surgical revision.
Cranioplasty was performed within a mean time of 241 ± 130.9 days. The amount of time before cranioplasty did not appear to influence the length of stay in the PMR department. For five patients, cranioplasty was performed after their discharge from our department, with a short rehospitalization in the neurosurgery department. After cranioplasty, three patients experienced a clear neurological improvement, particularly in terms of vigilance, participation in rehabilitation and mood. Cranioplasty-related sepsis occurred in one patient and required a secondary surgical revision. A question was raised about the cause-effect relationship between wound care and sepsis, but such a relationship could not be proved by our results.
1.4.5
Mean length of stay
The mean length of stay (LS) was 194 ± 118 days for the CMCI group, which was higher than the mean LS for the TMNC group (152 ± 94 days). However, this difference wasn’t statistically significant.
1.4.6
Discharge destination
The discharge destination was similar for both patient groups: direct home discharge for seven CMCI and nine TMNC, indirect home discharge (i.e., after a stay in another rehabilitation center) for four CMCI and two TMNC, and institutionalization for one CMCI and one TMNC.
1.5
Discussion
Decompressive craniectomy for malignant MCA infarction demonstrates a clear survival benefit and improves the functional outcomes in patients under 60 years of age . To our knowledge, no study has ever focused on the problems, specific or not, raised by patients treated for MCA infarction by craniectomy during their stay in a Physical Medicine and Rehabilitation (PMR) department. Nevertheless, since this surgery can be disquieting, it seemed important for us to verify whether or not there are severe and/or specific medical problems in patients treated by craniectomy compared to patients treated medically after severe infarction. For the most part, both types of patients are hospitalized in PMR departments after their stay in neurology. Indeed, rehabilitation in a specialized PMR unit is highly recommended, since the vital and functional benefits that can be provided by rehabilitation in such unit are considerable after a stroke, particularly a severe stroke .
In the limits of this retrospective study, we compared patients who underwent craniectomy for malignant MCA infarction to patients who had a severe or malignant MCA infarction without craniectomy. Patients were paired according to age, lesion side and hospitalization period, for a better homogeneity of therapists and rehabilitation therapy and techniques. We were not able to pair patients according to the initial NIHSS score because this data was not available for all patients.
The time before PMR admission was greater for the CMCI group. This can perhaps be explained by the more severe initial deficiencies in this group, but also by the initial vigilance problems and the adverse medical events that occurred in the period following surgery, with or without need for intensive care. These elements could explain a mean length of stay in our department that was a bit greater in the CMCI group than the TMNC group, but even though the CMCI patients had specific craniectomy-related events, which could have extended their stay, they didn’t have more general undesirable medical events than the TMNC group. However, it is important to note that we didn’t find the high rate of epilepsy reported by other authors .
The deficiencies of both the CMCI and TMNC patients evolved similarly, except in terms of their aphasia. Four CMCI patients admitted with aphasia still had severe aphasia at discharge, while in TMNC group, four patients had a severe aphasia when admitted, but only one still had severe aphasia at discharge. In the literature, we found little information that would allow us to compare our results concerning aphasia. It seems that some surgical teams hesitate to use craniectomy when the infarction is located in the left hemisphere. According to Kastrau et al. , this surgical technique is four times less used when the infarction is located in the left hemisphere than when it is located in the right hemisphere, despite the favorable outcomes.
The time before cranioplasty in our sample is greater than in other studies . This can be explained by our CMCI patient recruitment; indeed, most patients who underwent craniectomy took part in the DECIMAL protocol, in which it was decided to replace the bone flap only after 6 months to serve the needs of evaluation. Moreover, three of the patients who underwent cranioplasty showed neurological improvement – in terms of vigilance, participation in rehabilitation and mood – after the bone flap had been replaced. This improvement has been reported by other authors, who recommend early bone flap replacement, as soon as cerebral edema is resorbed . Still other authors think that time before cranioplasty doesn’t have any influence on the level of improvement. Several mechanisms involving air pressure (e.g., cerebral hemodynamics improvement, cerebral metabolism increases) could play a role in this neurological improvement , as well as, in our opinion, probably restoring the patient’s self-image.
It seems to us important to emphasize the craniectomy-related complications caused by the intra-abdominal position of the bone flap, compared to other bone flap conservation techniques. Indeed, in some of the patients in our study, in addition to the risk of infection, pain and discomfort during rehabilitation, we sometimes noticed a real psychological impact, with perplexity and anxiety, and we wonder about the disturbance of the patient’s body image and self-image that such a technique seems to create.
Unfortunately, we were not able to assess some factors, such as quality of life or the experience of relatives, whose importance has already been highlighted . It would be interesting to assess these factors in future studies, all the more because the controversy regarding functional outcomes and quality of life after craniectomy is not yet completely resolved.
1.6
Conclusion
In this study, patients who underwent craniectomy for malignant MCA infarction didn’t experience more medical problems, except for specific craniectomy-related problems, which occurred relatively infrequently during their stay in our Physical Medicine and Rehabilitation department. Slightly different on admission, the deficiencies of the two groups followed the same evolution, except for aphasia, which remained severe in four patients who underwent craniectomy. Their mean length of stay was a bit greater and their FIM at discharge was slightly lower, compared to the patients treated medically; however, the number of direct home discharges was similar.
Acknowledgements
The authors would like to thank J.-P. Regnaux for his help.
2
Version française
2.1
Introduction
Le terme d’infarctus sylvien « malin » a été utilisé pour la première fois par Hacke et al. en 1996 . Il s’applique aux infarctus sylviens massifs responsables d’un taux de mortalité précoce élevé du fait de l’œdème cérébral et du risque d’engagement.
Jusqu’en 1950, le recours à la craniectomie décompressive pour infarctus sylvien malin était exceptionnel. Devant les résultats décevants du traitement médical, cette chirurgie décompressive a pris de l’ampleur et a montré un bénéfice en termes de survie puisque le taux de mortalité qui était de 67 à 80 % après traitement conservateur est passé de 0% à 34 % après craniectomie . L’objectif de ce traitement est de créer de l’espace afin d’éviter que l’œdème cérébral ne conduise à l’engagement qui met en jeu le pronostic vital . L’infarctus malin est particulièrement sévère chez les adultes jeunes en raison d’absence d’atrophie cortico-sous-corticale et donc d’espace pour compenser l’œdème cérébral . Néanmoins, l’âge représente un facteur pronostique en termes de survie et de résultats fonctionnels .
Les résultats fonctionnels après craniectomie décompressive présentés dans la littérature restent cependant équivoques et des doutes quant au bénéfice de ce traitement sur les résultats fonctionnels et la qualité de vie ont longtemps subsisté . Certaines publications récentes d’études randomisées et contrôlées ont apporté la preuve de l’amélioration du taux de survie et ont également diminué les craintes que la réduction de la mortalité ne se fasse au prix d’un risque de persistance de séquelles neurologiques importantes et inacceptables . Une des dernières études et des plus complètes a associé trois équipes européennes (française : DECIMAL ; allemande : DESTINY et néerlandaise : HAMLET) . Chaque équipe a mené une étude randomisée contrôlée et la méthodologie des trois études était suffisamment proche pour qu’une analyse groupée soit effectuée. Leurs résultats concluent à la supériorité de la craniectomie sur l’abstention chirurgicale.
À notre connaissance, aucune étude ne s’est penchée sur les problèmes posés par des patients craniectomisés pour infarctus sylvien malin lors de leur séjour dans des services de médecine physique et de réadaptation (MPR) au décours des soins aigus. L’objectif de notre étude n’est pas de démontrer l’efficacité de la craniectomie décompressive. Il s’agit d’une étude observationnelle visant à déterminer si ces patients craniectomisés pour infarctus sylvien malin (ISMC) ont posé des problèmes médicaux différents en comparaison à des patients non craniectomisés (ISNC), habituellement admis dans le service et de préciser l’évolution différentielle entre ces patients.
2.2
Matériel et méthode
Cette étude, rétrospective, a porté sur la comparaison des dossiers de patients craniectomisés pour infarctus sylvien malin (ISMC) à des dossiers de patients non craniectomisés (ISNC groupe référence) ayant fait soit un infarctus sylvien malin, soit un infarctus sylvien sévère et admis dans le service entre 2002 et 2007. Nous avons défini l’infarctus sylvien comme sévère, lorsqu’il concernait les territoires superficiel et profond de l’artère cérébrale moyenne ou si la mesure d’indépendance fonctionnelle (MIF) à l’entrée dans le service était inférieure à 75.
Le critère d’inclusion était un infarctus unique malin ou sévère. Les critères d’exclusion étaient un antécédent de maladie neurologique ou de l’appareil locomoteur avec fort retentissement fonctionnel.
Douze patients craniectomisés ont été inclus, chacun à été apparié à un patient non craniectomisé selon le côté de l’infarctus, la tranche d’âge (20–40 ; 40–60 ; > 60 ans) et la période d’hospitalisation à plus ou moins un an.
Certains facteurs importants du pronostic après infarctus cérébral ont été répertoriés : les troubles de la vigilance initiaux avec ou sans passage en réanimation ainsi que le score du National Institutes of Health Stroke Scale (NIHSS) initial lorsque la donnée était disponible et enfin, la présence de comorbidités.
Les données cliniques recueillies ont été : la vigilance à l’entrée ; la motricité, côtée sur 4 : sur 2 pour le membre supérieur plégique, sur 2 pour le membre inférieur plégique (0 = aucun déficit moteur ; 1 = déficit moteur modéré ; 2 = sévère) ; la sensibilité, côtée sur 8 : sur 2 pour le membre supérieur, sur 2 pour le membre inférieur et pour chaque type de sensibilité, tactile et proprioceptive (0 = aucun trouble de la sensibilité ; 1 = hypoesthésie modérée ; 2 = hypoesthésie sévère ou anesthésie) ; la spasticité (gênante ou non ainsi que le traitement qu’elle a nécessité), la déglutition, cotée sur 2 (0 = aucun trouble ; 1 = précautions ; 2 = sonde nasogastrique ou gastrostomie) ; les troubles vésico-sphinctériens ; l’acquisition de l’équilibre assis, définie par la capacité à tenir assis en bord du plan de Bobath sans aide humaine durant plus d’une minute avec déstabilisations intrinsèques et extrinsèques ; le langage, coté sur 2 (0 = pas de trouble du langage ; 1 = communication possible ; 2 = communication très difficile à impossible). La négligence spatiale était évaluée par la Batterie du GEREN et cotée sur 2 (0 = aucune ; 1 = modérée ; 2 = sévère). Les évènements médicaux indésirables (accidents thrombo-emboliques, épilepsie, escarre, chute, dépression, fatigabilité, algodystrophie et paraostéoarthropathie), les complications propres aux ISMC et liées à la craniectomie ou à la cranioplastie ont été colligés durant l’hospitalisation dans le service de MPR ainsi que la mesure des déficiences et de l’indépendance fonctionnelle à l’entrée et à la sortie.
L’autonomie a été mesurée sur la MIF, effectuée à l’admission et avant la sortie dans le service. Le handicap a été évalué par l’échelle de Rankin modifiée (mRs) à la sortie . La durée moyenne de séjour et le mode de sortie (nombre de retour à domicile) ont été répertoriés.
2.2.1
Analyse des données
Après avoir vérifié la normalité des distributions par un test de Shapiro-Wilk, l’analyse statistique a consisté à faire, pour chaque variable d’intérêt pouvant faire l’objet d’une analyse statistique, la comparaison entre les 2 groupes (ISMC vs ISNC) par un test de Student. Les variables ainsi étudiées étaient l’âge, le délai d’admission (en jours), la MIF d’entrée, la MIF de sortie et la durée de séjour (en jours). Pour chacune d’elles, la moyenne, l’écart-type et l’indice de confiance à 95 % ont été déterminés. L’observation des complications médicales n’a pas fait l’objet d’analyse statistique compte tenu de la petitesse de l’échantillon.
2.3
Résultats
2.3.1
Caractéristiques générales des patients à l’entrée
Vingt-quatre patients ont été inclus : 12 ISMC et 12 ISNC. Les caractéristiques générales des patients sont présentées dans le Tableau 1 . Les groupes étaient comparables pour l’âge. L’étiologie retrouvée la plus fréquente de l’infarctus cérébral était la dissection carotidienne, mais pour la majorité des cas aucune cause n’avait été identifiée.
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