Decompressive craniectomy in malignant middle cerebral artery infarctions: outcome of 25 cases

Large space-occupying middle cerebral artery (MCA) infarctions with signs of elevated intracranial pressure and brain herniation have overall mortality rates of 80%. Several studies have suggested that decompressive surgery reduces mortality and improves outcome of these patients. The aim of this study was to evaluate the clinical and radiological outcome of decompressive craniectomy in the setting of malignant MCA infarctions. This is a prospective study conducted on patients presenting with manifestations of malignant MCA infarction. All cases were operated upon by decompressive craniectomy and duroplasty within 6 h of presentation or deterioration in Glasgow Coma Scale (GCS). Functional outcome was assessed in terms of mortality and modified Rankin Scale (mRS) for neurologic disability. Radiological outcome was assessed by comparing the midline shift in the preoperative CT and 24 to 96 h postoperatively. Twenty-five patients were included in this study. The mean age was 64.4 years. The mean preoperative GCS score was 8.14. The mean preoperative midline shift was 7.9 mm. All cases showed radiological improvement in the early follow-up period. Good functional outcome based on mRS was achieved in 64% and poor outcome in 36% of cases. The overall mortality in this study was 28%. Early decompressive hemicraniectomy had a proven role in reduction of mortality and improving functional outcome in cases with malignant MCA infarction. Among other factors, timing of surgery and the preoperative clinical condition were factors that affected the final outcome.