Abstract WP202: Decompressive Hemicraniectomy After Malignant Middle Cerebral Artery Ischemic Stroke in a Developing Country is Associated With Poor Long Term Functional Outcome and High Mortality

Abstract

Background: Decompressive hemicraniectomy (DH) is a level IA therapy for malignant middle cerebral artery (MCA) infarction. However, randomized trials were performed in high income countries with better access to post-stroke care and rehabilitation services. We aimed to assess long term functional outcome and the associated prognostic factors of patients undergoing DH in Brazil. Methods: From January 2013 and July 2018, all patients undergoing DH for malignant MCA infarction in a single comprehensive stroke center were retrospectively identified. Outcomes were the modified Rankin Scale (mRS) (dichotomized as ≤ 4 vs. > 4) and mortality at follow-up. The mRS at follow-up was collected prospectively by telephone using a validated structured interview. Logistic regression analysis was performed to assess independent predictors of outcome. Results: Eighty patients who underwent DH for malignant MCA infarction were identified. Age ranged from 16 to 78 years (median 48 years, IQR 42 - 54,7 years), 46 (57.6%) were males and median time from stroke onset to hemicraniectomy was 30.75 hours (IQR 17.8-46.0). Hospital discharge mRS ≤ 3 and ≤ 4 was observed in 5 (6.2%) and 74 (92,5%) patients respectively. Follow-up information was available for 65 (81.2%) patients. At follow-up (raging from 1.1 to 5.6 years), mRS ≤ 4 was observed in 23 (35.3%) patients. In binary logistic regression analysis, age (OR 1.09, 95% CI 1.02 - 1.17, p=0.01), and right MCA infarction (OR 16.70, 95% CI 1.8-152.30, p=0.01) were independently associated with a worse functional outcome at follow-up. Admission NIHSS (OR 1.0 ,95% CI 0.8-1.3, p=0.45), IV rt-PA (OR 0.5, 95% CI 0.08-3.00, p=0.46) or time of hemicraniectomy (OR 1.00, 95% CI 1.00 - 1.00, p=0.94) were not associated with functional outcome at follow-up. Mortality was 26% (N=21) at hospital discharge and 46% (N=30) at follow-up. Conclusion: The large effect size of DH for malignant MCA infarction is significantly diminished in the population of patients treated under the less than ideal conditions typically found in the public healthcare system of a developing country. Poor access to post-stroke care and rehabilitation services might be possible reasons for the results observed.