Outcome of decompressive craniectomy for large middle cerebral artery territory infarctions: a retrospective review

Introduction

The mortality from large space-occupying infarctions involving the middle cerebral artery (MCA) has been reported as 55–80% despite maximal medical treatment, including barbiturate coma, mannitol and hyperventilation. Patients are typically alert on admission to hospital but deteriorate within 1–3 days from severe brain swelling leading to raised intracranial pressure (ICP), brain herniation and death. Decompressive craniectomy (DC) has been reported to improve survival and functional outcomes following large MCA infarctions.

Methods

We conducted a retrospective chart review of all DCs for large MCA infarctions performed at our institution from March 2000 to February 2005. The neurological status was evaluated using the Glasgow Coma Scale (GCS) and functional outcome was evaluated using the Glasgow Outcome Score (GOS) and Modified Rankin Scale (MRS).

Results

All values are expressed as the median (range) or mean ± SD. There were 16 patients studied, nine males and seven females, aged 56.9 ± 8.2 years. Three patients had left-sided MCA infarctions while the rest were right-sided. Three patients had additional infarctions involving the anterior or posterior cerebral artery territories. The GCS was 13 (10–15) at hospital admission and 7 (4–13) at the time of surgery. The time between stroke onset and decompressive surgery was 47.5 ± 29.9 hours, with six patients showing signs of uncal herniation at the time of surgery. One patient had surgery 120 hrs after symptom onset due to late hemorrhagic conversion in the infarct. Fourteen patients received ICP monitoring in the postoperative period. All patients received mannitol while nine patients needed one or more of the following for control of raised ICP: barbiturate coma, hyperventilation and hypothermia. The median duration of mechanical ventilation was 9 (3–11) days, with tracheostomy performed in eight patients. The ICU and hospital mortality rate was 12.5% (2/16) and 31.3% (5/16), respectively. The median GCS of survivors at ICU discharge was 10 (4–11), and 12 (11–15) at hospital discharge. The ICU and hospital lengths of stay were 10 (4–14) and 28 (7–60) days, respectively. At a mean follow-up period of 13 months, 82% (9/11) of survivors were cognitive with a GOS of 3 (2–3) and MRS of 4 (3–5).

Conclusion

DCs performed for large MCA infarctions with clinical deterioration resulted in lower mortality compared with rates reported elsewhere for maximal medical treatment. Most survivors regained cognition but required help with walking and activities of daily living.