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Predicting Factors for Survival Outcomes Following Decompressive Craniectomy for Malignant MCA Infarction: A
Jason Golmei1, Hanuman Prajapati1, B K Ojha1
1Department of Neurosurgery, King George's Medical University, Lucknow, Uttar Pradesh, India.
Background:
Malignant middle cerebral artery (MCA) infarction carries extremely high mortality due to malignant cerebral edema. Decompressive craniectomy (DC) reduces mortality, but survival predictors and functional outcomes remain poorly characterized in low- and middle-income countries (LMICs).
Materials And Methods:
We retrospectively analyzed 31 patients undergoing DC for malignant MCA infarction between January 2020 and March 2024 at a tertiary care center. Clinical and radiological parameters were evaluated. Kaplan-Meier survival analysis was performed, and subgroup comparisons were made based on admission Glasgow Coma Scale (GCS) motor scores. Functional outcomes were assessed at 6 and 12 months using the modified Rankin Scale (mRS).
Results:
Mean age was 47.9 ± 12.4 years; 77.4% were male. Hypertension (80.6%) and smoking (51.6%) were the most common comorbidities. Mean infarct volume was 119.4 mL, with a median midline shift of 6 mm. Most surgeries were late (> 120 hours, 58.1%). Kaplan-Meier analysis showed survival of 51.6% at 30 days, 45.2% at 60 and 90 days, and 41.9% at 6 and 12 months, with a plateau after 180 days. By 12 months, survival was 0% for motor GCS ≤ 4, 57.1% for motor GCS 5, and 100% for motor GCS 6. At 6 months, no patient achieved a good outcome (mRS 0-3), while 42% had poor outcome (mRS 4-5) and 58% had died. By 12 months, 32% of patients demonstrated good outcome, 10% had poor outcome, and mortality remained.
Conclusion:
DC improves survival in malignant MCA infarction, especially in patients with higher admission GCS. However, most survivors remain severely disabled at 12 months. In LMICs, delayed referrals, limited intensive care unit resources, and poor rehabilitation infrastructure constrain both survival and functional outcomes. Strengthening stroke care systems is essential to maximize the benefit of DC.