Elsevier

World Neurosurgery

Volume 111, March 2018, Pages e722-e728
World Neurosurgery

Original Article
Early Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction in Asian Patients: A Single-Center Study

https://doi.org/10.1016/j.wneu.2017.12.157Get rights and content

Introduction

Early decompression craniectomy (within 48 hours of stroke onset) in acute and malignant middle cerebral artery (MCA) ischemic stroke (IS) reduces mortality and increases the proportion of patients with favorable functional outcome. Various cultural and social issues among Asians lead to some differences in clinical practice, especially when surgical interventions are involved. Accordingly, decompressive craniectomy in Asian patients with stroke is often delayed.

Materials and Methods

Data for all patients with acute IS hospitalized in our center were entered into a prospectively maintained registry. In this retrospective analysis, data for all patients with malignant MCA IS who underwent decompressive craniectomy were extracted. Various demographic, clinical, and neuroimaging factors were analyzed for identifying independent predictors of favorable functional outcome at 6 months, which was defined as modified Rankin Scale score of 0–3 points.

Results

From January 2005 to December 2014, a total of 75 patients with acute MCA IS underwent decompressive craniectomy. Median age was 55 years (interquartile range 44–64) with male preponderance (66%) and median National Institute of Health Stroke Scale score 21 points (interquartile range 18–24). A considerable proportion of these patients (38.7%) received intravenous thrombolysis. The majority (70%) of patients suffered right MCA IS, and decompressive surgery was performed within 48 hours of symptom onset in 50 (67%) of the patients. Favorable functional outcome was achieved in 25 (33.3%) patients at 6 months. Right MCA stroke (odds ratio 9.158; 95% confidence interval 1.881–44.596, P = 0.006) and early decompression surgery (odds ratio 4.011; 95% confidence interval 1.058–15.208, P = 0.041) were independent predictors of favorable functional outcome at 6 months.

Conclusions

Early decompression craniectomy, especially in right MCA ischemic stroke, is associated with better favorable functional outcome.

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.

References (44)

  • T.G. Jovin et al.

    Thrombectomy within 8 hours after symptom onset in ischemic stroke

    N Engl J Med

    (2015)
  • A.I. Qureshi et al.

    Timing of neurologic deterioration in massive middle cerebral artery infarction: a multicenter review

    Crit Care Med

    (2003)
  • J. Berrouschot et al.

    Mortality of space-occupying (‘malignant’) middle cerebral artery infarction under conservative intensive care

    Intensive Care Med

    (1998)
  • E.F. Wijdicks et al.

    Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association

    Stroke

    (2014)
  • J.I. Frank

    Large hemispheric infarction, deterioration, and intracranial pressure

    Neurology

    (1995)
  • W.K. Guerra et al.

    Surgical decompression for traumatic brain swelling: indications and results

    J Neurosurg

    (1999)
  • R. Gupta et al.

    Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review

    Stroke

    (2004)
  • E. Jüttler et al.

    Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY): a randomized, controlled trial

    Stroke

    (2007)
  • K. Vahedi et al.

    Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial)

    Stroke

    (2007)
  • E. Jüttler et al.

    Hemicraniectomy in older patients with extensive middle cerebral-artery stroke

    N Engl J Med

    (2014)
  • J.I. Frank et al.

    Hemicraniectomy and durotomy upon deterioration from infarction-related swelling trial: randomized pilot clinical trial

    Stroke

    (2014)
  • H.P. Adams et al.

    Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment

    Stroke

    (1993)
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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.

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