Outcome and prognostic factors of decompressive hemicraniectomy in malignant middle cerebral artery infarction

Abstract

Background: Whether decompressive hemicraniectomy is an appropriate treatment for malignant middle cerebral artery (MCA) infarction is still a controversial issue. The aims of our study were to determine survival rate and functional out-come and to determine factors associated with survival rates and functional outcome in patients with malignant MCA infarction.

Methods: From January 2000 to December 2003, 60 patients with malignant MCA infarction were included in the study. All the patients in the study underwent a large ipsilateral craniectomy and a large duroplasty for decompression. The infarction territory was evaluated by either diffusion-weighted MRI or computed tomography. Clinical neurologic presentation was evaluated using the Glasgow coma scale. Functional outcome was evaluated with the Barthel index (BI) and the Glasgow outcome scale (GOS) during the follow-up period of 12 months.

Results: Mortality was 20% (12 patients) during 30 days and 26.6% during 12 months' follow-up. The factors associated with higher mortality were age > or = 60 years, involvement of more than 1 vascular territory, clinical herniation signs before surgery and treatment after 24 hours of ictus. Mean GOS was 3.3 +/- 1.7 during the 12-month follow-up period. Mean BI was 65.1 +/- 40.1. Twenty-nine (65.9%) patients had favorable outcome (BI > or = 60). The factors associated with favorable outcome were age < 60 years, dominant hemisphere infarction, regaining of consciousness within 7 days after operation, being without respiratory failure and treatment within 24 hours of ictus before clinical signs of herniation.

Conclusion: Decompressive hemicraniectomy may be a useful procedure in patients with malignant MCA infarction. Age, clinical signs of herniation and timing of surgery were the prognostic factors associated with mortality and functional outcome.