Factors Affecting Acceptable Behavior Toward Decompressive Craniectomy For Malignant Middle Cerebral Artery Infarction

Abstract

Background: Malignant MCA infarction is a very severe neurological disease with high mortality rates and poor clinical outcomes. Recent clinical trials have demonstrated that an early decompressive craniectomy reduces mortality rates and improves functional outcomes. In clinical practice, however, it is difficult to get caregivers to consent to this operation. This study assessed factors leading to the acceptance of decompressive craniectomy in patients with a malignant MCA infarction. Methods: We reviewed all of the clinical and radiological data of 343 acute ischemic strokes patients with initial NIHSS scores > 10 points, discharged from our stroke center during approximately 3 years. Among them, 89 patients were diagnosed with malignant MCA infarctions. We did not recommend decompressive craniectomy in 17 patients for various reasons, and 15 of remaining 72 patients agreed to the surgery but 57 patients refused. We compared variables between the two groups. We investigated the poor outcome (modified Rankin Scale, mRS≥4 and ≥5) at discharge. Results: The surgery group (n=15) was significantly younger than non-surgery group (n=57) (62.9±11.6 vs. 76.1±9.6 years, P<0.001). It had a higher proportion of the right involvement (86.7% vs. 49.1%, P=0.008) and a lower stroke severity on baseline NIH stroke scale (NIHSS, 15.5±3.4 vs. 18.1±3.9, P=0.021). However, the non-surgery group had more co-morbidity with chronic illness (43.9% vs. 7.0%, P=0.006). The non-surgery group was more prevalent for poor outcome at discharge (100.0% vs. 80.0%, P=0.001 for mRS≥4; 91.2% vs. 53.3%, P<0.001 for mRS≥5). Conclusion: The age, infarction site, and health status before the index stroke are the main factors affecting the acceptance of decompressive craniectomy in patients with a malignant MCA infarction. Key Words: Cerebral infarction; Craniectomy; Middle cerebral artery