Objective: Malignant middle cerebral artery (MCA) infarction is characterized by mortality rate of up to 80%.

Aim: To determine the role of decompressive craniectomy in patients presenting malignant MCA infarction ant to assess its outcome in patients.

Material and Method: This retrospective study included a sample of 25 patients with malignant MCA infarction who underwent decompressive craniectomy in the Department of Neurology at Geetanjali Medical College and Hospital during the period of 1^st January 2016 – 31^st January 2017. Clinical characteristics included preoperative clinical condition, timing of surgery, cause of infarction, location, and extension of infarction was analyzed. In addition, the time delay from the onset of symptoms to surgery and preoperative signs of herniation and their relation to the final outcome was analyzed. The final outcome was assessed in terms of mortality and scores such as modified Rankin scale (mRS). Functional outcome was divided into two groups: Favorable outcome (mRS score 0–3) versus poor outcome (mRS score 4–6).

Result: 25 patients of age between 21 and 80 years with mean age of 53.96 ± 10.09 years were analyzed. 64% of the patients were of age below 60 years. 48% patients were operated within 48 hours and 52% were operated after 48 hrs.  mRS between 0-3 was observed at discharge in both which was not statistically significant. But according to age,  33.33% patients with age more than 60 years and 81.25% patients with age less than 60 years had mRS 0-3 which was statistically significant.

Conclusion: Decompressive craniectomy in malignant cerebral artery infraction had reduced the mortality especially in patients of age less than 60 years and those who operated within 48 hours of stroke. Thus there is no reason to deny the surgery. 

Keywords: Decompressive craniectomy, malignant, infraction, modified Rankin Score, Glasgow coma scale.

1.      Berrouschot J, Sterker M, Bettin S, et al.: Mortality of space-occupying (‘malign-ant’) middle cerebral artery infarction under conservative intensive care. Intensive Care Med 24:620–623, 1998.

2.      Hofmeijer J, Amelink GJ, Algra A, et al.: Hemicraniectomy after middle cerebral artery infarction with life-threatening Edema trial (HAMLET). Protocol for a randomised controlled trial of decompressive surgery in space-occupying hemispheric infarction. Trials 7:29, 2006

3.      Kilincer C, Asil T, Utku U, et al.: Factors affecting the outcome of decompressive craniectomy for large hemispheric infarctions: a prospective cohort study. Acta Neurochir (Wien) 147:587–594, 2005

4.      Wijdicks EF, Diringer MN: Middle cerebral artery territory infarction and early brain swelling: progression and effect of age on outcome. Mayo Clin Proc 73:829–836, 1998

5.      Harscher S, Reichart R, Terborg C, et al.: Outcome after decompressive craniectomy in patients with severe ischemic stroke. Acta Neurochir (Wien) 148:31–37, 2006

6.      Rengachary SS, Batnitzky S, Morantz RA, et al.: Hemicraniectomy for acute massive cerebral infarction. Neurosurgery 8:321–328, 1981

7.      Holtkamp M, Buchheim K, Unterberg A, et al.: Hemicraniectomy in elderly patients with space occupying media infarction: improved survival but poor functional outcome. J Neurol Neurosurg Psychiatry 70:226–228, 2001

8.      Donkervoort M, Dekker J, Deelman BG: Sensitivity of different ADL measures to apraxia and motor impairments. Clin Rehabil 16:299–305, 2002

9.      Engelhorn T, von Kummer R, Reith W, et al.: What is effective in malignant middle cerebral artery infarction: reperfusion, craniectomy, or both? An experimental study in rats. Stroke 33:617–622, 2002

10.  Sulter G, Steen C, De Keyser J: Use of the Barthel index and modified Rankin scale in acute stroke trials. Stroke 30:1538–1541, 1999

11.  Hofmeijer J, Amelink GJ, Algra A, et al.: Hemicraniectomy after middle cerebral artery infarction with life-threatening Edema trial (HAMLET). Protocol for a randomised controlled trial of decompressive surgery in space-occupying hemispheric infarction. Trials 7:29, 2006

12.  Kalia KK, Yonas H: An aggressive approach to massive middle cerebral artery infarction. Arch Neurol 50:1293–1297, 1993

13.  Vahedi K, Vicaut E, Mateo J, et al.: Sequential-design, multicenter, randomi-zed, controlled trial of early decompr-essive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 38:2506–2517, 2007

14.  Fandino J, Keller E, Barth A, Landolt H, Yonekawa Y, Seiler RW. Decompressive craniotomy after middle cerebral artery infarction. Retrospective analysis of patients treated in three centres in Switzerland. Swiss Med Wkly. 2004; 134:423–9. 

15.  Balan C, Alliez B. Decompressive craniectomy – From option to standard – Part II. Rom Neurosurg. 2010;17:73–80.

16.  Olivecrona M, Rodling-Wahlström M, Naredi S, Koskinen LO. Effective ICP reduction by decompressive craniectomy in patients with severe traumatic brain injury treated by an ICP-targeted therapy. J Neurotrauma. 2007;24:927–35. 

17.  Syed AB, Ahmad IH, Hussain M, Al-Bya F, Solaiman A. Outcome following decompressive craniectomy in severe head injury: Rashid Hospital experience. Pan Arab J Neurosurg. 2009;1:29–35.

18.  Yu JW, Choi JH, Kim DH, Cha JK, Huh JT. Outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 70 years old. J Cerebrovasc Endovasc Neurosurg. 2012;14:65–74.

19.  Bakar B, Sumer MM, Tekkok IH. Decompressive craniectomy for intractable intracranial hypertension. J Clin Anal Med. 2012;3:383–7.

Govind Mangal

Assistant Professor, Department of Neurosciences

Geetanjali Medical College and Hospital, Udaipur