Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: A real-world study


Malignant middle cerebral artery infarction (mMCA) is a devastating disease with rates
of fatality as high as 80%. Decompressive hemicraniectomy (DHC) reduces mortality,
but many survivors inevitably remain severely disabled.

This study aimed to analyze patients with mMCA undergoing DHC or best medical treatment
(BMT) baseline characteristics and factors linked to therapeutic choice and determinants
of prognosis.


We recorded clinical and radiological features of patients undergoing BMT or DHC.
The two groups were compared for epidemiology, clinical presentation, neuroimaging,
and prognosis. Regression analysis was performed to identify predictors of surgical
treatment and outcome.


One hundred twenty-five patients were included (age 67.41 ± 1.39 yo; 65 M). Patients
undergoing DHC (N=57) were younger (DHC 55.71±1.48 yo vs. BMT 77.22±1.38) and had midline shift (DHC 96.5% (55/57) vs. BMT 35.3% (24/68), a larger volume of the affected hemisphere and reduced ventricles volume as compared
to BMT.

The chance of surgery depended on age (Exp(B)=0.871, p < 0.001), clinical status at onset (NIHSS Exp(B) = 0.824, p=0.030) and volume of the ventricle of the affected hemisphere (Exp(B) = 0.736, p=0.006).

Death rate during admission was significantly lower for DHC (DHC 15% (6/41) vs BMT 71.7% (38/53), Fisher’s test = 30.234, p<0.001).


Although DHC may cause prolonged hospitalization and long-term disabled patients,
it is a lifesaving therapy that should be considered for selected patients with mMCA
but perioperative complications and cost-utility should be considered. Patients and
families should be correctly counseled about this therapeutic choice and its short-
and long-term consequences.

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