- Department of Neurosurgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
- Department of Neurosciences, Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
Mohammad Azman Mohammed Raffiq
Department of Neurosciences, Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
DOI:10.4103/2152-7806.135342Copyright: © 2014 Raffiq MAM This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Mohammed Raffiq MA, Mohammad Haspani MS, Kandasamy R, Abdullah JM. Decompressive craniectomy for malignant middle cerebral artery infarction: Impact on mortality and functional outcome. Surg Neurol Int 26-Jun-2014;5:102
How to cite this URL: Mohammed Raffiq MA, Mohammad Haspani MS, Kandasamy R, Abdullah JM. Decompressive craniectomy for malignant middle cerebral artery infarction: Impact on mortality and functional outcome. Surg Neurol Int 26-Jun-2014;5:102. Available from: http://sni.wpengine.com/surgicalint_articles/decompressive-craniectomy-for-malignant-middle-cerebral-artery-infarction-impact-on-mortality-and-functional-outcome/
Background:Malignant middle cerebral artery (MCA) infarction is a devastating clinical entity affecting about 10% of stroke patients. Decompressive craniectomy has been found to reduce mortality rates and improve outcome in patients.
Methods:A retrospective case review study was conducted to compare patients treated with medical therapy and decompressive surgery for malignant MCA infarction in Hospital Kuala Lumpur over a period of 5 years (from January 2007 to December 2012). A total of 125 patients were included in this study; 90 (72%) patients were treated with surgery, while 35 (28%) patients were treated with medical therapy. Outcome was assessed in terms of mortality rate at 30 days, Glasgow Outcome Score (GOS) on discharge, and modified Rankin scale (mRS) at 3 and 6 months.
Results:Decompressive craniectomy resulted in a significant reduction in mortality rate at 30 days (P P P P
Conclusion:Decompressive craniectomy achieves good functional outcome in, young patients with good preoperative GCS score and favorable radiological findings treated with surgery within 24 h of ictus.
Keywords: Decompressive craniectomy, malignant cerebral infarction, middle cerebral artery infarction
Malignant middle cerebral artery (MCA) infarction is a clinical entity affecting up to 10% of all patients diagnosed with ischemic stroke. It is defined as an infarction involving an area encompassing at least two thirds of that supplied by the MCA.[
Decompressive craniectomy has been proposed as a treatment option for large hemispheric infarctions with cerebral edema.[
This study was conducted to compare the difference in outcome in terms of mortality rate at 30 days and functional outcome at discharge and 3 and 6 months following decompressive craniectomy for treatment of malignant MCA infarction and medical treatment, as well as to study the association of factors influencing outcome in patients treated with decompressive craniectomy.
A retrospective case review of patients diagnosed with malignant MCA territory infarction admitted to the neurosurgery department of Hospital Kuala Lumpur between January 2007 and January 2012 was performed. Data were collected from patients’ medical records, surgical records, and radiological images. A total of 125 patients between the ages of 18 and 65 years were included in this study. Malignant MCA territory infarction was defined as an infarction of at least two-thirds of MCA territory with evidence of space-occupying edema and mass effect on non-contrasted computed tomographic (CT) imaging of the brain. Volume of infarct was calculated using the ABC/2 method. This method has shown to rapidly and accurately estimate infarct volume size on CT scan, and has high intra-rater and inter-rater variability (71-99%).[
Sample size calculation was done using Power and Sample Size Calculation (PS) Software,[
A total of 125 patients with malignant MCA territory infarction during the study period were included in this study. The mean (±SD) age of patients was 53.8 (±7.17) years. The age range was between 34 and 65 years, with a majority of them being within 46-55 years of age (43%). Non-dominant hemisphere was involved in 66 patients (52.8%), while dominant hemisphere involvement was seen in 59 patients (47.2%). All patients had at least one scan done within 24 h of stroke onset, and a repeat scan done within the following 24-48 h. Mean time from stroke onset to brain CT scan was 10.5 h. Infarct volume ranged between 200 ml and 340 ml, and was classified as either less than or exceeding 250 ml. Infarct volume exceeding 250 ml was seen in 57% of the total population sample (72 patients). Median midline shift in this cohort was 7.34 mm, and a cut-off of 10 mm was used to stratify patients. Midline shift exceeding 10 mm was noted in 52% of the patient population.
A total of 90 patients (72%) were treated with surgery, while 35 patients (28%) were managed with medical therapy. Majority of the patients (87%) had a GCS score of between 6 and 9 before surgery. Mean time (±SD) between stroke onset and surgery was 26.8 h (±8.3). A significant difference was noted between patients treated with decompressive surgery and those treated with medical therapy in terms of mortality rate at 30 days, GOS at discharge, and mRS at 3 months and 6 months [
In patients treated with surgery, the factors significantly associated with good outcome at 6 months [
Significant predictors of good outcome at 6 months based on multivariate logistic regression analysis [
The results from this study reaffirm the beneficial role of decompressive craniectomy in reducing mortality rate and improving functional outcome in patients with malignant MCA territory infarction. Decompressive craniectomy reduced the 30-day mortality rate by 24.3% and the proportion of patients with unfavorable outcome at discharge by 34.9%. Good functional outcome (mRS 0-4) was seen in 48.9% and 64.4% at 3 months and 6 months, respectively, in patients treated with surgery, compared to 2.9% and 17.1%, respectively, in patients treated with medical treatment. Percentage of patients treated with surgery and with moderate to slight disability (mRS 0-3) was 27.8% at 3 months and 50% at 6 months, while no patients treated with medical therapy achieved an mRS score of 0-3 at 3 months and 6 months. Percentage of patients left bedridden with severe disability at the end 6 months was 4.4% with surgical treatment and 25.7% with medical treatment. At the end of the follow-up period, 67% of patients treated with surgery and 43% of patients treated with medical therapy were alive. An increase of 15% in good functional outcome from 3 to 6 months was noted in both treatment groups, similar to the observations reported by various authors. This is probably a reflection of the natural healing process by neuromodulation over time.[
Patients with a mean age of 50 years had significantly better outcome at discharge and at 3 months and 6 months, regardless of the treatment modalities (P = 0.002, P = 0.001, and P = 0.015, respectively). In patients treated with surgery, no significant association was noted between age groups and patient outcome at 6 months. The percentage of patients achieving good outcome (mRS 0-4) was comparable between patients younger than 55 years and older than 56 years. When analyzed based on mRS of 0-3, good outcome was seen in 54% of patients younger than 55 years at 6 months, as compared to 46% in patients older than 56 years (P > 0.05). A trend of improved functional outcome was noted with younger age, with 76% of patients younger than 45 years achieving good outcome at 6 months (mRS 0-4), and 68% having mRS of 0-3 at 6 months. An interesting finding in this study is an improved outcome in patients between 56 and 65 years of age compared to patients between 46 and 55 years of age, who were treated with surgery. Similar findings were also noted in the HAMLET trial.[
Good functional outcome at 6 months was seen in patients aged 56-65 years and treated with surgery (64.4% good outcome), compared to patients treated with medical therapy (25% good outcome), which suggests a potential benefit for surgery in this age group. In a recent study,[
The GCS score was used as the primary tool of assessment in this study. GCS score has a strong predictive value for early mortality and functional outcome in patients with malignant infarction.[
Results from the European trials,[
Infarct volume has been shown to be significantly associated with patient outcome. An infarct volume of more than 250 ml in patients treated with surgery was associated with poor outcome at 6 months, a significant difference when compared to an infarct volume of less than 250 ml (P < 0.05). An infarct volume of more than 240 ml was predictive of malignant transformation with 76% accuracy, and an infarct volume of more than 280 ml was associated with poor outcome.[
Hemorrhagic transformation was seen in 24% of patients treated with surgery, and this was significantly associated with outcome at 6 months (P < 0.001). Development of hemorrhagic transformation can be due to shearing injury of the brain tissue which herniates beyond the craniectomy margins, or an increase in cerebral perfusion pressure following surgery leads to reperfusion injury of ischemic or infracted brain tissue with altered autoregulation and microvascular structural defects. Postoperative hydrocephalus occurred in 21% of patients treated with surgery, and was significantly associated with poor outcome at discharge and at 3 months, but there was no significant association with outcome at 6 months. This is possibly due to treatment for hydrocephalus with CSF diversion procedures or early cranioplasty in these patients.
Decompressive craniectomy significantly reduces mortality rate and improves functional outcome. Patient selection plays a key role in translating the beneficial effects of surgery. Factors significantly influencing outcome in this study were age, GCS on admission and preoperatively, extent of infarction and mass effect, and time interval from onset to surgery. Additional vascular territory involvement and midline shift of more than 10 mm were significantly associated with poor outcome at 6 months. Dominant hemisphere involvement had no significant effect on outcome in this study. The issue of age limit remains unclear as older patients subjected to surgery had lower mortality rate compared to older patients who were treated medically in this study.
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