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Table of Contents    
Year : 2012  |  Volume : 60  |  Issue : 6  |  Page : 565-566

Outcome following decompressive hemicraniectomy in malignant middle cerebral artery infarct: Does age matters?

Department of Neurology, The Institute of Neurological Sciences, CARE Hospital, Nampally, Hyderabad, India

Date of Submission03-Dec-2012
Date of Decision03-Dec-2012
Date of Acceptance03-Dec-2012
Date of Web Publication29-Dec-2012

Correspondence Address:
J. M. K Murthy
Chief of Neurology, The Institute of Neurological Sciences, CARE Hospital, Nampally, Hyderabad - 500 001
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.105186

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How to cite this article:
Murthy J. Outcome following decompressive hemicraniectomy in malignant middle cerebral artery infarct: Does age matters?. Neurol India 2012;60:565-6

How to cite this URL:
Murthy J. Outcome following decompressive hemicraniectomy in malignant middle cerebral artery infarct: Does age matters?. Neurol India [serial online] 2012 [cited 2021 Jan 17];60:565-6. Available from:

Space occupying, malignant middle cerebral artery infarct (mMCAI) accounts for 1% and 10% of all supratentorial ischemic strokes [1],[2],[3] and is associated with about 80% case fatality rate in intensive care-based series. [4],[5] Often no medical treatment is effective in these patients. [6] Decompressive hemicraniectomy (DHC) with duroplasty is now an option for clinical management of mMCAI. [7],[8] Hemicraniectomy involves removal of a large part of cranium and this provides space to enable outward swelling of ischemic brain tissue, [9],[10] and decrease in intracranial pressure and improvement in brain tissue oxygenation and these changes occur to a greater extent after opening the dura. [11]

In the pooled analysis of the three European DHC trials, patients who (age 18-60 years, National Institute of Health Stroke Scale score (NIHSSS) >15, infarct signs on computed tomography of 50% or more of the middle cerebral artery (MCA) territory or >145 cm 3 on diffusion-weighted image had received surgery within 48 h after symptoms onset) had a favorable functional outcome (modified Rankin Scale (mRS) < 4) and survival than in the control group. The numbers needed to treat was two for survival with mRS < 4, four for survival with mRS < 3, and two for survival irrespective of functional outcome. [7]

However, one of the unresolved questions is what should be the age limit from which on the benefits of DHC are uncertain. A systematic review of 12 observational retrospective studies found age above 50 years to be a predictor of outcome. [12] Observational studies of DHC in the elderly show improved survival at the cost of poor functional outcome. [13],[14],[15] In the current issue of Neurology India, Tsai et al. [16] retrospectively analyzed the data of 79 consecutive patients with mMCAI and compared the outcomes between 37 patients in the surgical (DHC within 48 h) group and 42 patients in the nonsurgical group. At 6 months, there was a significant survival benefit with surgery. Preoperative Glasgow Coma Scale (GCS) score >8 and Acute Physiology and Chronic Health Evaluation (APACHE) II score <13 were found to be sensitive and specific predictors of favorable outcome, mRS 0-3. Patients in the surgical group had lower mean APACHE II score (19 ± 5 vs. 24 ± 6, P < 0.001) and higher GCS score (6 ± 2 vs. 7 ± 2, P = 0.022) compared with nonsurgical group. Of the 79 patients included in this study, 62 (78.5%) patients were older than 60 years, 24 (38.7%) of them in surgical group. In patients older than 60 years, more patients survived in the surgical group compared with the nonsurgical group, but with no significant difference in functional outcome. The major limitation of this study was that it was a single center retrospective analysis of nonrandomized sample. In a recent prospective, randomized, controlled study by Zhao et al. [17] in patients up to 80 years with mMCAI, DHC within 48 h of onset was not only life-saving, but also increased the possibility of surviving without severe disability (mRS = 5). Of the 47 patients enrolled in the study, 29 (61.7%) patients were older than 60 years, 16 (55%) of them in the surgical arm. The subgroup analysis in patients older than 60 years showed the risk of death was significantly lower in patients randomized to surgical arm and also these patients had lower risk of unfavorable prognosis (mRS 5-6). At 6 and 12 months follow-up, of the 16 patients older than 60 years in the surgical arm, 11 patients had moderate functional disability mRS 3-4 and none were in mRS 0-2.

The evidence reviewed above suggests that DHC in patients older than 60 years with mMCAI is associated with survival benefit. However, both the observational data and the data from the prospective randomized study suggest that most of these patients have moderate disability (mRS 3-4). At this point of time there is no hard evidence for perusing DHC routinely in all patients older than 60 years from the functional recovery point of view. In addition, there is hardly any data on cost effectiveness of DHC in this age group. We need more data on the functional outcome after DHC in this age group. Till such time DHC is recommended for cerebral edema and elevated intracranial pressure (ICP) in mMCAI within 48 h after symptom onset in patients up to 60 years of age (Class I, Level A). [7],[8]

  References Top

1.Shaw C, Alvord Jr E, Berry E. Swelling of the brain following ischemic infarction with arterial occlusion. Arch Neurol 1959;1:161-77.  Back to cited text no. 1
2.Frank JI. Large hemispheric infarction, deterioration, and intracranial pressure. Neurology 1995;45:1286-90.  Back to cited text no. 2
3.Sakai K, Iwahashi K, Terada K, Gohda Y, Sakurai M, Matsumoto Y. Outcome after external decompression for massive cerebral infarction. Neurol Med Chir Tokyo 1998;38:131-5.  Back to cited text no. 3
4.Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, Von Kummer R. Malignant middle cerebral artery territory infarction: Clinical course and prognostic signs. Arch Neurol 1996;53:309-15.  Back to cited text no. 4
5.Berrouschot J, Sterker M, Bettin S, Koster J, Schneider D. Mortality of space-occupying (malignant) middle cerebral artery infarction under Conservative intensive care. Intensive Care Med 1998;24:620-3.  Back to cited text no. 5
6.Hofmeijer J, van der Worp HB, Kappelle LJ. Treatment of space occupying cerebral infarction. Crit Care Med 2003;31:617-25.  Back to cited text no. 6
7.Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: A pooled analysis of three randomized controlled trials. Lancet Neurol 2007;6:215-22.  Back to cited text no. 7
8.European Stroke Organization: Guidelines for management of ischemic stroke and transient ischemic attack 2008. Cerebrovasc Dis 2008;25:457-507.  Back to cited text no. 8
9.Park J, Kim E, Kim GJ, Hur YK, Guthikonda M. External decompressive craniectomy including resection of temporal muscle and fascia in malignant hemispheric infarction. J Neurosurg 2009;110:101-5.  Back to cited text no. 9
10.Diedler J, Sykora M, Blatow M, Jüttler E, Unterberg A, Hacke W. Decompressive surgery for severe brain edema. J Intensive Care Med 2009;24:168-78.  Back to cited text no. 10
11.Gruber A, Dorfer C, Knosp E. Mediainfarkt und kraniektomie. Derzeitige studienlage, operationsindikationen und organisatorische aspekte. J Neurol Neurochir Psychiatr 2008;9:12-9.  Back to cited text no. 11
12.Gupta R, Connolly ES, Mayer S, Elkind MS. Hemicraniectomy for massive middle cerebral artery territory infarction: A systematic review. Stroke 2004;35:539-43.  Back to cited text no. 12
13.Holtkamp M, Buchheim K, Uterberg A, Hoffmann O, Schielke E, Weber JR, et al. Hemicraniectomy in elderly patients space occupying media infarction: Improved survival but poor functional outcome. J Neurol Neurosurg Psychiatry 2001;70:226-8.  Back to cited text no. 13
14.Uhl E, Kreth FW, Elieas B, Goldammer A, Hempelmann RG, Liefner M, et al. Ourcome and prognostic factors of hemicraniectomy for space occupying cereberal infarction. J Neurol Neurosurg Psychiatry 2004;75:270-4.  Back to cited text no. 14
15.Rabinstein AA, Mueller-Kronsat N, Maramattom BV, Zazulia AR, Bamlet WR, Diringer MN, et al. Factors predicting prognosis after decompressive hemicraniectomy for hemispheric infarction. Neurology 2006;67:891-3.  Back to cited text no. 15
16.Tsai CL, Chu H, Peng GS, Ma HI, Chun-An Cheng CA, et al. Preoperative APACHE II and GCS scores as predictors of outcomes in patients with malignant MCA infarction after decompressive hemicraniectomy. Neurol India 2012;60:608-12.  Back to cited text no. 16
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17.Zhao J, Su YY, Zhang Y, Zhang YZ, Zhao R, Wang L, et al. Decompressive hemicraniecomy in malignant middle cerebral after infarct: A randomized controlled trial enrolling patients up to 80 years old. Neurocrit Care 2012;17:161-71.  Back to cited text no. 17


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