Decompressive craniotomy for malignant middle cerebral artery infarction: Optimal timing and literature review.

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Decompressive craniotomy for malignant middle cerebral artery infarction: Optimal timing and literature review.

World Neurosurg. 2018 Apr 10;:

Authors: Elsawaf A, Galhom A

Abstract
OBJECT: To compare the results of early or delayed decompressive craniotomy (DC) for cases of malignant middle cerebral artery (MCA) infarction.
STUDY DESIGN: Prospective comparative study METHODS: Prospective randomized study on consecutive series of a 46 patients with malignant MCA territory infarction. Patients were divided randomly into two groups: Group I; 27 patients who were followed till obvious deterioration of conscious level happened, Group II; 19 patients who were operated prophylactically in 6 hours of presentation even with no clear deterioration of conscious level or radiology's findings. Patients were assessed clinically using Glasgow Coma Scale (GCS), motor power by British medical research council (MRC), and functionally by National Institutes of Health Stroke Scale (NIH), and modified Rankin Scale (mRS). Radiologically, patients had primary MRI on admission, followed by CT scan. Infarction behavior including volume of infarct area, midline shift, and secondary hemorrhage were calculated.
RESULTS: At final follow-up, both groups showed good improvement in conscious level, motor power, and functional outcome; however, statistically significant neurological improvement was demonstrated in group II. Functional outcome also showed statistically significant improvement (P<0.05) in this ultra-early decompression group (group II). There was a significant difference in mortality in both groups, more than half (52%) of group I died due to delay in surgery or its other consequences. Another significant difference was in the progression of infarction volume which was more observed in group I (statistically insignificant).
CONCLUSION: In spite of the possible complications from surgery, early DC - within 6 hours of ictus without waiting for neurological deterioration- has a significant impact on prognosis. Delay in transferring the case, diagnosing the condition or taking the decision of surgery, will significantly affect the mortality and overall outcome.

PMID: 29653270 [PubMed - as supplied by publisher]

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