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Hemicraniectomy for large middle cerebral artery territory infarction: outcome in 19 patients
M B Pranesh1, S Dinesh Nayak, V Mathew
1Department of Neurology, K.G.Hospital and Postgraduate Medical Institute, Coimbatore, India. sdnayak62@hotmail.com
Insights
Hemicraniectomy may improve outcomes for patients with large middle cerebral artery infarction. Younger patients experienced significantly better functional recovery after this surgical intervention for stroke.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Large space-occupying middle cerebral artery infarction presents a high mortality risk (50-80%).
- Hemicraniectomy is considered when optimal medical management for stroke proves insufficient.
Purpose of the Study:
- To evaluate the efficacy of hemicraniectomy in patients with large middle cerebral artery infarction.
- To assess functional outcomes and identify factors influencing recovery post-surgery.
Main Methods:
- Nineteen patients with large middle cerebral artery infarction underwent hemicraniectomy due to impending herniation.
- Neurological status was assessed using the NIHSS, and functional outcomes were evaluated with the Barthel Index (BI) and Rankin Scale (RS).
Main Results:
- Post-surgery, NIHSS scores significantly improved. Mean BI was 56.4, with 21% experiencing severe handicap.
- Younger patients (under 50) showed significantly better outcomes (mean BI 60.7) compared to older patients (mean BI 41.3).
- Improved speech function, particularly comprehension, was observed in patients with dominant hemisphere strokes.
Conclusions:
- Hemicraniectomy appears to be a beneficial procedure for large middle cerebral artery territory infarctions.
- Younger patient age is associated with better functional outcomes.
- Further investigation via a randomized controlled trial is recommended to confirm these findings.
Background:
Large space-occupying middle cerebral artery infarction accounts for 10-15% of all supratentorial infarctions and carries a mortality of 50% to 80%. Hemicraniectomy may be useful when optimal medical management has failed.
Methods:
Between June 1997 and June 2000, 19 patients who fulfilled the clinical and imaging criteria for large middle cerebral artery infarction underwent hemicraniectomy because of impending herniation despite best medical therapy. The National Institute of Health Stroke Scale (NIHSS) assessed neurological status on admission and at one week after surgery. At 3 month follow up, The Barthel Index (BI) and Rankin Scale (RS) were used to assess the functional outcome among survivors.
Results:
There were 15 males and 4 females with a mean age of 46.5 years (range 27-76 years). Ten patients (53%) had dominant hemisphere stroke. The mean interval between stroke onset and surgery was 60.3 hours (range 20-103 hours). The mean NIHSS score before surgery was 20.5 (range 17-26) and 10.5 (range 6-22) after surgery. One patient (5.2%) died due to post-operative meningitis. At follow up, mean BI was 56.4 (range 25-90) and RS revealed severe handicap in 4 patients (21%). Patients under 50 years of age had a significantly better outcome with mean BI of 60.7 as compared to only 41.3 (p=<0.048) in older patients. Speech function, especially comprehension improved in all patients with dominant hemisphere infarction.
Conclusion:
These findings add to previous studies suggesting hemicraniectomy may be a useful procedure in patients with large middle cerebral artery territory infarction. The functional outcome is good in younger patients. A randomised controlled trial is required to substantiate these findings.