Prognosis of patients after hemicraniectomy in malignant middle cerebral artery infarction

There are unsatisfactory therapeutic options for treatment of large infarctions of the middle cerebral artery with secondary development of life threatening brain edema. In most cases, post-ischemic brain edema can not be adequately treated by conservative means. However, several studies have shown that operative procedures such as decompressive hemicraniectomy can decrease mortality. Apart from mortality, the morbidity and quality of life are major features with which to estimate therapeutic benefit. The aim of this study was to acquire follow-up data on quality of life and outcome in patients treated with hemicraniectomy after stroke.

Eighteen patients were treated with decompressive hemicraniectomy after life threatening middle cerebral artery infarction between July 1997 and April 2000 in our clinic. Six patients (33 %) died within the first six months after the procedure. All twelve surviving patients were seen in a follow-up examination 7 to 26 months after the stroke and tested using the Rankin-Scale, Barthel Index (BI), Aachener Life Quality Inventory (ALQI) and Zung Self-Rating Depression Scale.

Survivors with a mean age of 40.7 +/- 16.5 years were significantly younger than non-survivors with a mean age of 64.5 +/- 9.2 years (p = 0.006). Mean Barthel-Index of surviving patients was 61.1 +/- 26.1 points, mean Rankin-Scale 3.3 +/- 1.2 points. Two patients were able to return to work. Patients younger than 45 years (n = 7) had a significantly better outcome (BI 75.7 +/- 20.7) than patients over 45 years (n = 5) (BI 42.0 +/- 22.7 points, p = 0.026). Among five patients with an infarction of the left hemisphere, four had a slight to moderate Broca aphasia and one patient a global aphasia. Quality of life assessment by ALQI showed moderate disability (58.0 +/- 22.7 of 107 points) with no significant difference between left- and right-hemispheric infarctions. Using the Zung Self-Rating Depression Scale six patients were ranked as slightly depressive, one patient as moderately depressive and five patients as not depressive. Eleven out of twelve survivors, as well as their relatives, approved of the decision to have the operation.

The study provides evidence that hemicraniectomy as treatment of severe space occupying ischemic brain edema saves lives and results in good quality of life in a high proportion of patients, especially in the young. This conclusion is restricted by the lack of a control group, which was deemed unethical in studying a potentially life saving therapy.