Abstract
Background: The use of decompressive craniectomy (DC) has been studied in the setting of different conditions, including traumatic brain injury, subarachnoid hemorrhage, and malignant middle cerebral artery (MCA) infarction. The rationale of this study is to determine the functional outcome after DC in patients with malignant MCA infarcts.Methods: A longitudinal cohort study was performed based on patients diagnosed with malignant MCA territory infarction admitted to the Neurosurgery Department of a tertiary care hospital in Islamabad, Pakistan between July 2015 and November 2016. All patients had a clinical diagnosis of stroke according to the World Health Organization (WHO) stroke criteria.Results: A total of 34 patients participated in this study, out of which 20/31 (64.5%) were males while 11/31 (35.5%) were females with a mean age of 51.61 ± 13.96 years. The mean time from diagnosis to surgery was 60.61 ± 49.83 hours. Out of 31 patients, 18 (58.1%) had a right middle cerebral artery infarct (RMCAI) and 13 (41.9%) had a left middle cerebral artery infarct (LCAI). Logistic regression was applied to assess the association between the type of MCA infarct with the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), modified Barthel Index (mBI) scores, and upper and lower limb motor power. However, the logistic regression model was not statistically significant χ2 (4) = 3.896, p = 0.866. There was a statistically significant mild improvement of neurological scores and upper and lower motor power over a course of six months, but the overall functional outcome was poor with mBI < 60 and mRS > 4 (p < 0.001) with total mortality of 8.7%.Conclusion: Decompressive craniectomy is a life-saving surgery that appears to benefit patients with malignant MCA infarcts of either the dominant or non-dominant cerebral hemisphere. Decompressive craniectomy results in mild improvements in neurological scores but still poor functional outcome after six months.
Highlights
Logistic regression was applied to assess the association between the type of middle cerebral artery (MCA) infarct with the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale, modified Barthel Index scores, and upper and lower limb motor power
There was a statistically significant mild improvement of neurological scores and upper and lower motor power over a course of six months, but the overall functional outcome was poor with modified Barthel Index (mBI) < 60 and modified Rankin Scale (mRS) > 4 (p < 0.001) with total mortality of 8.7%
Malignant middle cerebral artery (MCA) infarction accounts for approximately 10% of all patients who present with ischemic stroke with a mortality rate up to 80% [1]
Summary
Malignant middle cerebral artery (MCA) infarction accounts for approximately 10% of all patients who present with ischemic stroke with a mortality rate up to 80% [1]. Cerebral edema in association with infarcted brain tissue causes displacement of brain tissue and leads to an increase in intracranial pressure (ICP). This secondary damage can be prevented by DC, which generates compensatory space to contain the swollen brain. The initial symptoms and signs of MCA occlusion are hemiparesis, hemiplegia, visual problems, and altered consciousness [6] These patients worsen rapidly within the first 48 hours due to the presence of mass effect that can have serious consequences [7]. The rationale of this study is to determine the functional outcome after DC in patients with malignant MCA infarcts
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