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Fifteen-Year Institutional Retrospective Case Series of Decompressive Craniectomy for Malignant Middle Cerebral
Simon Lammy1, Aaron Taylor1, Sarah Willetts1
1Department of Neurosurgery, Institute of Neurological Sciences, Glasgow, United Kingdom.
Insights
Decompressive craniectomy for malignant middle cerebral artery infarction (mMCAI) is effective, with 46% of patients achieving good functional outcomes. Early surgical intervention within 48 hours of stroke onset improves results.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Malignant middle cerebral artery infarction (mMCAI) is a severe condition requiring urgent intervention.
- Decompressive craniectomy (DC) is a crucial surgical procedure for managing increased intracranial pressure in mMCAI.
- This study updates a UK neurosurgical unit's case series on DC for mMCAI.
Purpose of the Study:
- To update a case series on decompressive craniectomy for malignant middle cerebral artery infarction.
- To analyze clinical discriminators, surgical timing, and functional outcomes in patients undergoing DC for mMCAI.
- To assess the effectiveness and safety of DC in a large UK cohort.
Main Methods:
- Retrospective analysis of 67 patients who underwent decompressive craniectomy for mMCAI between 2005 and 2020.
- Data extraction on patient demographics, Glasgow Coma Scale scores, surgical intervals, craniectomy dimensions, and functional outcomes (modified Rankin Scale).
- Analysis of 30-day mortality and long-term functional recovery.
Main Results:
- A total of 67 patients underwent DC, with a 30-day mortality rate of 17.9%.
- Early craniectomy (<48 hours from mMCAI) was performed in 63% of patients, with 89% of these done within 24 hours of neurosurgical unit admission.
- Overall, 46% of patients achieved a modified Rankin Scale score of <3, indicating good functional outcome, from discharge to 12 months postoperatively.
Conclusions:
- Local practice for decompressive craniectomy in mMCAI aligns with current evidence.
- Optimizing patient selection using advanced imaging like diffusion-weighted MRI and CT perfusion at initial admission may further improve outcomes.
- Decompressive craniectomy remains a vital treatment for mMCAI, with early intervention associated with better functional recovery.
Objective:
In the present study, we updated our previously reported case series of patients who had undergone decompressive craniectomy for malignant middle cerebral artery infarction (mMCAI) (2005-2020). To the best of our knowledge, the present case series constitutes the largest reported series from a UK neurosurgical unit of decompressive craniectomy for mMCAI.
Methods:
We extracted data regarding the clinical discriminators, surgical timescales, and functional outcomes of patients.
Results:
A total of 67 patients had undergone decompressive craniectomy. The 30-day mortality was 17.9% (n = 12). Of the 67 patients, 31 were male (46.3%) and 36 were female (53.7%). Their mean age was 45 years (range, 16-64 years). The mean age of the survivors was 43 years (range, 16-62 years) compared with 50 years (range, 38-64 years) for those who had died. The median ictal and preoperative Glasgow coma scale score was 14 (range, 7-15) and 8 (range, 3-15), respectively. The corresponding motor scores were 6 and 5. The mean interval from ictus to neurosurgical unit admission was 18.25 hours (range, 0.5-66 hours) and from admission to decompressive craniotomy was 7.30 hours (range, 0.5-46 hours). Of the 67 patients, 63% had undergone "early" craniectomy (<48 hours from mMCAI evolution), with 89% of these patients having undergone craniectomy <24 hours after neurosurgical unit admission. The mean maximum anteroposterior craniectomy diameter was 13.01 cm (range, 10.29-15.56 cm), and mean surface area was 94.38 cm2 (range, 74.75-132.32 cm2). Overall, 46% of patients had had a modified Rankin scale score of <3 (range, 0-6) from discharge to 12 months postoperatively. The median neurosurgical unit length of stay was 15 days (range, 6 hours to 365 days).
Conclusions:
The findings from the present update have confirmed that local practice has remained consistent with current evidence. However, patient selection might be optimized if diffusion-weighted magnetic resonance imaging and computed tomography perfusion were used at the original middle cerebral artery infarct admission.
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