Decompressive Craniotomy for Malignant Middle Cerebral Artery Infarction: Optimal Timing and Literature Review

To compare the results of early or delayed decompressive craniotomy for patients with malignant middle cerebral artery infarction.

A prospective randomized study was carried out of a series of 46 consecutive patients with malignant middle cerebral artery territory infarction. Patients were divided randomly into 2 groups: group I, 27 patients who were followed until obvious deterioration of level of consciousness; group II, 19 patients who were operated on prophylactically in 6 hours of presentation even with no clear deterioration of level of consciousness or radiologic findings. Patients were assessed clinically using the Glasgow Coma Scale, motor power by the United Kingdom Medical Research Council, and functionally by the National Institutes of Health Stroke Scale and modified Rankin Scale. Radiologically, patients had primary magnetic resonance imaging on admission, followed by computed tomography scan. Infarction behavior including volume of infarct area, midline shift, and secondary hemorrhage were calculated.

At final follow-up, both groups showed good improvement in level of consciousness, motor power, and functional outcome; however, statistically significant neurologic improvement was shown in group II. Functional outcome also showed statistically significant improvement (P < 0.05) in this ultraearly decompression group (group II). There was a significant difference in mortality in both groups; more than half (52%) of group I died as a result of delay in surgery or its other consequences. Another significant difference was in the progression of infarction volume, which was observed more in group I (statistically insignificant).

Despite the possible complications from surgery, early decompressive craniotomy (within 6 hours of ictus without waiting for neurologic deterioration) has a significant impact on prognosis. Delay in transferring the patient, diagnosing the condition, or taking the decision of surgery significantly affects mortality and overall outcome.