Functional Outcome After Decompressive Craniectomy in Patients with Dominant or Non-Dominant Malignant Middle Cerebral Infarcts

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.

Outcome of decompressive craniectomy in traumatic closed head injury

“…[2,3] DC has been used to treat severe intracranial hypertension secondary to various causes. [4] This involves removal of a part of the calvarium, with or without duraplasty to create extra volume for intracranial contents thereby reducing ICP. [5] DC may improve oxygen delivery to brain cells by improving blood flow.…”

The Role of Decompressive Craniectomy in Limited Resource Environments

“…A study from Pakistan (47) showed that DC is beneficial in both dominant and non-dominant side infarctions. In this study the mean surgery time from diagnosis was 60.61 h, which is beyond the recommended period (within 24–48 h).…”

Cisternostomy for malignant middle cerebral artery infarction: proposed pathophysiological mechanisms and preliminary results

“… 19 Alam et al only reported a poor functional outcome (mRS >4) in patients undergoing DC with total mortality of 8.7%. 20 In Kürten series, in a 3-month follow-up, 44.6% of surgically treated patients showed moderate–severe disability (mRS 4), while 32.6% suffered a poor outcome (mRS 5). 21 In our series of 14 patients, affected by malignant MCA and underwent DC, a favourable mRS (mRs 0–3) at 9 months of follow-up was recorded in 5 patients (41.6%), while a poor functional outcome was evidenced in 7 patients (58.3%).…”

“…Gulensoy et al states that a preoperative GCS score of 7 or less than 7 does not allow to obtain favourable results 19. Alam et al only reported a poor functional outcome (mRS >4) in patients undergoing DC with total mortality of 8.7% 20. In Kürten series, in a 3-month follow-up, 44.6% of surgically treated patients showed moderate–severe disability (mRS 4), while 32.6% suffered a poor outcome (mRS 5) 21.…”