Malignant middle cerebral artery infarction outcome

Malignant middle cerebral artery infarction outcome

Malignant middle cerebral artery infarction is associated with high mortality and morbidity.

The mortality rate of patients with brain edema after malignant middle cerebral artery (MCA) infarction approaches 80 % without surgical intervention 1).

Over the past 10 years in Francedecompressive craniectomy (DC) has been increasingly performed for malignant middle cerebral artery infarction (MCI) regardless of age. However, in-hospital mortality remains considerable, as about one-quarter of patients died within the first weeks. For those who survive beyond 6 months, the risk of death significantly decreases. Early mortality is especially high for comatose patients above 60 years operated in inexperienced centers. Most of those who remain in good functional status tend to undergo a cranioplasty within the year following DC 2).


Three separate studies investigated the effectiveness of decompressive craniectomy after malignant MCA infarction in controlled trials with patients less than 61 years of age 3) 4) 5). These were demonstrated that hemicraniectomy reduced the mortality rate by 49% at one year after stroke when compared with conventional medical treatments. However, the question of how applicable the results are to patients older than 60 years of age still remains unanswered.

When neurosurgeons recommend decompressive surgery for patients with malignant infarcts, patients’ relatives often refuse the operation because of the patients’ age, past medical history or comorbidity. Such a situation occurs more frequently when the patient is older than 70 years of age 6).

References

1)

Huttner HB, Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol 2009; 8:949–958.
2)

Champeaux C, Weller J. Long-Term Survival After Decompressive Craniectomy for Malignant Brain Infarction: A 10-Year Nationwide Study. Neurocrit Care. 2019 Jul 9. doi: 10.1007/s12028-019-00774-9. [Epub ahead of print] PubMed PMID: 31290068.
3)

Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp HB, et al. Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol. 2009 Apr;8(4):326–333.
4)

Jüttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, et al. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke. 2007 Sep;38(9):2518–2525.
5)

Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial) Stroke. 2007 Sep;38(9):2506–2517.
6)

Yu JW, Choi JH, Kim DH, Cha JK, Huh JT. Outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 70 years old. J Cerebrovasc Endovasc Neurosurg. 2012 Jun;14(2):65-74. doi: 10.7461/jcen.2012.14.2.65. Epub 2012 Jun 30. PubMed PMID: 23210030; PubMed Central PMCID: PMC3471258.

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