Decompressive craniectomy is a life-saving procedure in malignant MCA infarction

Objectives:To investigate the indications, timings, and outcomes of decompressive craniectomy (DC) performed for malignant middle cerebral artery (MCA) infarctions at our tertiary care center.Methods:This retrospective case series involved patients who underwent DC for malignant MCA infarction at King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, between January 2012 and December 2018. Demographic, clinical, and radiological data were collected, and stroke- and surgery-related complications and discharge outcomes were assessed.Results:Eighteen patients (mean age: 50±10 years), of whom 13 (72%) were men, underwent DC during the study period. Of the patients, 9 (50%) had severe stroke (NIHSS 16–25), 10 (56%) had right MCA infarction, and 11 (61%) received either intravenous thrombolysis or endovascular thrombectomy or their combination. Indications for surgery included clinical deterioration as seen in 16 (89%) patients, ipsilateral pupillary dilatation as seen in 11 (61%) patients, and signs of raised intracranial pressure in 6 (33%) patients. Surgery was performed within 48 h in 14 (78%) patients. The mean Intensive Care Unit stay was 15±7 days. Seven (39%) patients were discharged home and 3 (17%) were transferred to an inpatient rehabilitation unit, and 2 (11%) patients died. All patients had stroke-related complications; one (6%) patient developed cerebrospinal fluid leak, 3 (17%) had sunken skin flap syndrome and wound infection each, and 2 (11%) developed epidural hematoma.Conclusion:The DC was life-saving in the our patients with malignant MCA infarction. Most of the patients had surgery within 48 hours. More than one-third of the patients were discharged home, while mortality occurred in only 2 patients. Moreover, stroke- and surgery-related complications were common in our cohort.

Stroke is one of the leading causes of death and adult disability worldwide.^1,2 The burden of stroke is increasing and is a significant challenge for health care systems across the globe.² Ischemic stroke due to occlusion of proximal middle cerebral artery (MCA), usually involve large portions of a hemisphere and may cause space-occupying cerebral edema, leading to rapid neurological deterioration and cerebral herniation.^2,3 Nearly 35 years ago, Hacke et al⁴ coined the term “malignant” for acute and complete MCA territory infarction involving a space-occupying cerebral edema and subsequently a considerably rapid neurological deterioration and herniation. Malignant MCA infarction involves more than 50% of and often the entire MCA territory.^3-5 In the early phase of malignant MCA infarction, cytotoxic edema develops followed by the development of vasogenic edema.³ Approximately 1-10% of all MCA strokes can turn into malignant MCA infarction with a mortality risk of up to 80% within the first week.^2,3 Acute brain swelling occuring within 48 hours results in elevated intracranial pressure (ICP) or brain herniation, which in turn leads to the deterioration of consciousness or death usually within the first week.^2,3,6 The clinical predictors of malignant transformation include high NIHSS (National Institute of Health Stroke Scale) score, young age, female gender, as well as history of hypertension, ischemic heart disease, and congestive heart failure.^2,6 The radiological predictors of malignant transformation are >66% perfusion deficit, >50% involvement of MCA territory on initial CT scan, and combined involvement of internal carotid artery and MCA, among many others.⁶Control of ICP remains an important challenge in patients with severe post-stroke or post-traumatic brain edema. The medical management for raised ICP include head-of-bed elevation, hyperventilation, osmotic therapy, and sedation.^6,7 Although osmotic therapy has failed to improve treatment outcomes, it can be used to bridge time until definitive surgical treatment can be performed.³ Systemic hypothermia in raised ICP due to malignant MCA infarction has been associated with multiple complications without any clear benefit on outcome.⁶Trephination, an ancient treatment method of brain diseases, may be the earliest form of decompressive craniectomy.⁸ Decompressive craniectomy (DC) was described more than a century ago, but it did not receive acceptance for most of the 20th century.^8,9 One of the earliest reports on DC for malignant MCA infarction was published in 1951.¹⁰ A pooled analysis of three randomized trials conducted in the early part of this century showed for the first time the benefit of early DC in malignant MCA infarction.¹¹ These 3 initial European trials, namely, DECIMAL, DESTINY, and HAMLET, were the first to prove that DC was associated with decreased mortality and with the increased number of patients with favorable outcome.^11-14 The mortality rates decreased from 78% in historical controls to as low as 16% in surgically treated patients, with the number needed to treat (NNT) as low as 2 for survival with mRS (modified Rankin Scale) of ≤4.¹³The DC involves the removal of a part of the skull referred to as bone flap; along with opening of dura to accommodate brain swelling.^8,9 In malignant MCA infarction, only unilateral decompression, also termed as decompressive hemicraniectomy, is performed.⁸ The DC allows an edematous brain tissue to herniate outside, thus preventing neuronal damage in other regions of the brain.^2,8 A meta-analysis of 8 randomized trials and 4 observational studies confirmed the mortality benefit of DC in malignant MCA infarction.⁷ Patients and caregivers were satisfied with their QALY despite the disability of the patients; however, professionals did not consider surgery as favorable treatment due to the high disability rates post-surgery.⁷There is one prior published study about decompressive craniectomy in malignant MCA infarction from Saudi Arabia describing 6 patients undergoing DC.¹⁵ Our study aimed to investigate the indications, timings, and outcomes of DC performed for malignant MCA infarctions at our tertiary care center. We believe that this work will add to the limited literature about this condition from the region.