Early Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction in Asian Patients: A Single-Center Study

Abstract

Introduction: Early decompression craniectomy (within 48 hours of stroke onset) in acute and malignant middle cerebral artery (MCA) ischemic stroke (IS) reduces mortality and increases the proportion of patients with favorable functional outcome. Various cultural and social issues among Asians lead to some differences in clinical practice, especially when surgical interventions are involved. Accordingly, decompressive craniectomy in Asian patients with stroke is often delayed.

Materials and methods: Data for all patients with acute IS hospitalized in our center were entered into a prospectively maintained registry. In this retrospective analysis, data for all patients with malignant MCA IS who underwent decompressive craniectomy were extracted. Various demographic, clinical, and neuroimaging factors were analyzed for identifying independent predictors of favorable functional outcome at 6 months, which was defined as modified Rankin Scale score of 0-3 points.

Results: From January 2005 to December 2014, a total of 75 patients with acute MCA IS underwent decompressive craniectomy. Median age was 55 years (interquartile range 44-64) with male preponderance (66%) and median National Institute of Health Stroke Scale score 21 points (interquartile range 18-24). A considerable proportion of these patients (38.7%) received intravenous thrombolysis. The majority (70%) of patients suffered right MCA IS, and decompressive surgery was performed within 48 hours of symptom onset in 50 (67%) of the patients. Favorable functional outcome was achieved in 25 (33.3%) patients at 6 months. Right MCA stroke (odds ratio 9.158; 95% confidence interval 1.881-44.596, P = 0.006) and early decompression surgery (odds ratio 4.011; 95% confidence interval 1.058-15.208, P = 0.041) were independent predictors of favorable functional outcome at 6 months.

Conclusions: Early decompression craniectomy, especially in right MCA ischemic stroke, is associated with better favorable functional outcome.

Keywords: Acute ischemic stroke; Decompression craniectomy; Middle cerebral artery infarct; Modified Rankin Scale; National Institute of Health Stroke Scale; Tissue plasminogen activator.