Original ArticleEarly Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction in Asian Patients: A Single-Center Study
Introduction
Acute ischemic stroke (IS) is a leading cause of death and morbidity. Despite various advances in treatment,1, 2, 3, 4, 5, 6 a considerable proportion of patients with IS achieve poor functional outcomes. Approximately 10%–15% of all supratentorial IS involve a large area of middle cerebral artery (MCA) territory.7 These patients are susceptible to the development of severe cerebral edema, seen commonly between 3 and 5 days of symptom onset.8, 9 However, in some cases, the edema evolves faster and becomes severe within first 24 hours, described as malignant MCA infarction,10 which carries high mortality (70%–80%) despite aggressive medical management.11 In addition to the large parenchymal damage, poor prognosis in malignant MCA stroke is also contributed by the pressure effects, herniation, and secondary neuronal injury due to increasing intracranial pressure (ICP).12
Decompression surgery was first described by Kocher in 1901 for traumatic brain injury.13 It was subsequently attempted for severe acute IS.14 Timely surgical decompression reduces ICP and prevents downward and subfalcine herniation. The benefits of decompressive hemicraniectomy in malignant MCA infarction toward reducing mortality have been demonstrated in the initial randomized clinical trials as well as pooled analysis.15, 16, 17, 18 Similar observations were reported from the recent Destiny II trial, when decompressive craniectomy was performed within 48 hours of symptom onset in patients with malignant MCA IS.19 In addition to a significant reduction in mortality, the trial showed better functional outcomes in the surgical group, defined as modified Rankin score (mRS) of 0–4 points. However, these findings were challenged by findings from the Hemicraniectomy and Durotomy Upon Deterioration From Infarction-Related Swelling Trial (HeADDFIRST).20 This trial did not observe any significant improvement in the neurologic outcome or mortality at 6 months after surgical decompression. We aimed at evaluating the role of decompression surgery for anterior circulation IS in our Asian cohort.
Section snippets
Materials and Methods
Data for consecutive patients with acute IS admitted to our tertiary center were prospectively entered in the stroke registry. We extracted data for all patients who underwent decompression craniectomy for anterior circulation IS from January 2005 to December 2014. In addition to the demographic data, information about various cardiovascular risk factors was recorded. Patients eligible for thrombolysis were treated with standard-dose (0.9 mg/kg body-weight, 10% as initial bolus; maximum 90 mg)
Results
A total of 7281 patients with acute anterior circulation IS were admitted to our tertiary center during the study period, of whom 75 (1.03%) underwent decompressive craniectomy.
Various demographic characteristics and vascular risk factors are presented in Table 1. Briefly, the median age of our patients was 55 years (interquartile range [IQR] 44–64) with a male preponderance (67%). Hypertension was the most common vascular risk factor, noted in 52 patients (70%). Median NIHSS score on
Discussion
Our study suggests that early decompressive craniectomy (performed within 48 hours from stroke onset) and right MCA infarction are independently associated with favorable functional outcome at 6 months. In patients with large anterior circulation IS, cerebral edema reaches its peak by 3–5 days.8, 9 The resultant secondary neuronal injury and worsening cerebral perfusion due to increasing ICP may be prevented by early decompressive surgery. However, previous studies have used variable time
Conclusions
In conclusion, our study suggests that early decompressive surgery within 48 hours from stroke onset and right-sided infarction are independent predictors of favorable functional outcome in patients with malignant MCA IS.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.