Hemicraniectomy in elderly patients with space occupying media infarction: improved survival but poor functional outcome

OBJECTIVE: To assess the survival rate and functional outcome in elderly patients with space occupying supratentorial infarction who underwent hemicraniectomy compared with those who received medical treatment alone. METHODS: All patients older than 55 years with space occupying middle cerebral artery (MCA) infarction treated in our clinic between January 1998 and July 1999 were included in this retrospective analysis. Patients were eligible for decompressive surgery if they were younger than 75 and had no severe comorbidity. Hemicraniectomy was performed regardless of the affected hemisphere. All patients were followed up for assessment of functional outcome; data were assessed according to the Barthel index and modified Rankin scale and cover a period of 3 to 9 months after infarction. RESULTS: Twelve out of 24 patients underwent hemicraniectomy. Eight patients who were operated on survived; only one patient died of transtentorial herniation, three other deaths were due to medical complications. None of the survivors had a Barthel score above 60 or a Rankin score below 4. Nine out of 12 medically treated patients died of transtentorial herniation, one patient died of medical complications. The two surviving patients had a Barthel score below 60 and a Rankin score of 4. CONCLUSIONS: Craniectomy in elderly patients with space occupying MCA infarction improves survival rates compared with medical treatment alone. However, functional outcome and level of independence are poor. Craniectomy in elderly patients should not be performed unless a prospective randomised trial proves beneficial.     

大骨瓣减压术抢救恶性大脑中动脉梗塞疗效分析

目的　总结大骨瓣减压术抢救恶性大脑中动脉梗塞 (mMCAI)的临床经验。方法　总结我院经头颅CT证实并进行大骨瓣减压术的 16例mMCAI患者的临床资料、辅助检查、治疗等 ,以分析手术时机及其他因素与预后的相关性。结果　死亡 6例 (6 / 16 )。死亡和存活患者的中线结构移位的中位数分别为 10 .5mm和 7mm ,手术距脑疝的时间中位数分别为 15 .5h和 4h。手术前加强脱水后瞳孔一度回缩的患者有 7例 ,其中 6例存活。手术前 12h内TCD检查示MCA主干闭塞的 3例患者均死亡 ,部分再通的 5例患者全部存活。 3个月时存活患者BI评分 ,仅有 1例严重残疾。结论　大骨瓣减压术治疗mMCAI是重要的救命措施 ,但要把握手术时机 ,术前强力脱水后瞳孔能短时回缩及TCD监测MCA有部分再通的患者预后较好。     

Factors predictive of fatality in massive middle cerebral artery territory infarction and clinical experience of decompressive hemicraniectomy

To determine the factors predictive of fatality in massive middle cerebral artery (MCA) territory infarction and outcome of decompressive hemicraniectomy, 62 patients who were retrospectively verified with first event massive MCA infarctions were enrolled in this study. Amongst them, 21 received decompressive hemicraniectomy during hospitalization. Clinical data between early and late hemicraniectomy groups were also compared. Significant deterioration occurred in 40 cases, 21 of whom received decompressive hemicraniectomy. The other 19 received conservative treatment. The mortality rate of these 40 cases between decompressive hemicraniectomy and conservative treatment was 29% (six of 21) and 42% (eight of 19), respectively. Factors that predicted fatalities in our massive MCA infarction patients with or without decompressive hemicraniectomy were total scores of baseline GCS at the time of admission, associated with coronary artery diseases, and significant deterioration during hospitalization. This study confirms the lifesaving procedure of hemicraniectomy that prevents death in patients deteriorating because of cerebral edema after infarction, although it may produce severe disability with an unacceptably poor quality of life in survival. Despite high mortality and morbidity, decompressive hemicraniectomy to prevent cerebral herniation when significant deterioration is demonstrated are essential for maximizing the potential for survival.     

Quality of life and neurobehavioral changes in survivors of malignant middle cerebral artery infarction

Malignant middle cerebral artery (MMCA) infarction is associated with a mortality rate of 80% under conservative treatment. Decompressive hemicraniectomy (DH) reduces mortality and improves the functional outcome of surviving patients. The purpose of this study was to examine quality of life (QoL) and neurobehavioral deficits in patients with space-occupying infarctions of the right- or left-sided hemisphere at 6 months after stroke. The Sickness Impact Profile (SIP) was used to assess QoL in 19 out of 29 consecutive patients that underwent DH after a malignant MCA infarction (14 on the right and 5 on the left hemisphere). Behavioral changes were evaluated with the Frontal Behavioral Inventory and the Beck Depression Inventory. Patients and relatives were also asked if, knowing the present outcome, they would agree again, in retrospect, to a DH. Barthel Index >60 was seen in 37% of our patients. Functional outcome was related to age. We found a higher reduction in the SIP’s physical domain than in the psychosocial domain. Depressive symptoms were present in 50% of the patients. We didn’t find significant differences in QoL or functional outcome between patients with right or left-sided infarctions. The most frequent neurobehavioral symptoms were decreased speech output, apathy, reduced spontaneity and irritability. Most patients and their relatives would again give consent to hemicraniectomy. The results show that younger patients had a significantly better outcome. QoL seems to be acceptable in both left- and right-sided infarctions, and retrospective agreement to hemicraniectomy is high in both patients and their relatives.     

Surgical Management of Massive Cerebral Infarction

Objective

The aim of this study was to analyze the treatment results and prognostic factors in patients with massive cerebral infarction who underwent decompressive craniectomy.

Methods

From January 2000 to December 2005, we performed decompressive craniectomy in 24 patients with massive cerebral infarction. We retrospectively reviewed the medical records, radiological findings, initial clinical assessment using the Glasgow Coma Scale, serial computerized tomography (CT) with measurement of midline and septum pellucidum shift, and cerebral infarction territories. Patients were evaluated based on the following factors : the pre- and post-operative midline shifting on CT scan, infarction area or its dominancy, consciousness level, pupillary light reflex and Glasgow Outcome Scale.

Results

All 24 patients (11 men, 13 women; mean age, 63 years; right middle cerebral artery (MCA) territory, 17 patients; left MCA territory, 7 patients) were treated with large decompressive craniectomy and duroplasty. The average time interval between the onset of symptoms and surgical decompression was 2.5 days. The mean Glasgow Coma Scale was 12.4 on admission and 8.3 preoperatively. Of the 24 surgically treated patients, the good outcome group (Group 2 : GOS 4-5) comprised 9 cases and the poor outcome group (Group1 : GOS 1-3) comprised 15 cases.

Conclusion

We consider decompressive craniectomy for large hemispheric infarction as a life-saving procedure. Good preoperative GCS, late clinical deterioration, small size of the infarction area, absence of anisocoria, and preoperative midline shift less than 11mm were considered to be positive predictors of good outcome. Careful patient selection based on the above-mentioned factors and early operation may improve the functional outcome of surgical management for large hemispheric infarction.     

Post-Traumatic Cerebral Infarction : Outcome after Decompressive Hemicraniectomy for the Treatment of Traumatic Brain Injury

Objective

Posttraumatic cerebral infarction (PTCI), an infarction in well-defined arterial distributions after head trauma, is a known complication in patients with severe head trauma. The primary aims of this study were to evaluate the clinical and radiographic characteristics of PTCI, and to assess the effect on outcome of decompressive hemicraniectomy (DHC) in patients with PTCI.

Methods

We present a retrospective analysis of 20 patients with PTCI who were treated between January 2003 and August 2005. Twelve patients among them showed malignant PTCI, which is defined as PTCI including the territory of Middle Cerebral Artery (MCA). Medical records and radiologic imaging studies of patients were reviewed.

Results

Infarction of posterior cerebral artery distribution was the most common site of PTCI. Fourteen patients underwent DHC an average of 16 hours after trauma. The overall mortality rate was 75%. Glasgow outcome scale (GOS) of survivors showed that one patient was remained in a persistent vegetative state, two patients were severely disabled and only two patients were moderately disabled at the time of discharge. Despite aggressive treatments, all patients with malignant PTCI had died. Malignant PTCI was the indicator of poor clinical outcome. Furthermore, Glasgow coma scale (GCS) at the admission was the most valuable prognostic factor. Significant correlation was observed between a GCS less than 5 on admission and high mortality (p<0.05).

Conclusion

In patients who developed non-malignant PTCI and GCS higher than 5 after head injury, early DHC and duroplasty should be considered, before occurrence of irreversible ischemic brain damage. High mortality rate was observed in patients with malignant PTCI or PTCI with a GCS of 3-5 at the admission. A large prospective randomized controlled study will be required to justify for aggressive treatments including DHC and medical treatment in these patients.     

Postoperative midline shift as secondary screening for the long-term outcomes of surgical decompression of malignant middle cerebral artery infarcts

Decompressive hemicraniectomy (DC) can save the lives of patients with malignant middle cerebral artery (MCA) infarction. We proposed that postoperative midline shift is important for the long-term outcome of patients with MCA infarction. We conducted a retrospective study of DC in 38 patients with malignant MCA infarction. The long-term outcome was assessed one year after surgery using the modified Rankin Scale (mRS) score. Patients who had midline shift less than the optimal diagnostic cut-off point on the fourth postoperative day were classified as having a successful decompression and the remaining patients were classified in the failed decompression group. The successful decompression group mRS score was 4.20±0.89 one year after surgery and the failed decompression group mRS score was 5.11±0.76 (p<0.0001). Successful decompression, resulting in postoperative midline shift of less than 5mm, was a key factor for beneficial, long-term functional outcomes in patients with malignant MCA infarction.     

Computed tomographic parameters predicting fatal outcome in large middle cerebral artery infarction

BACKGROUND: Large middle cerebral artery (MCA) ischaemic stroke when associated with extensive mass effect can result in brain herniation and neurological death. As yet there are few guidelines to aid the selection of patients for aggressive interventional therapies, such as decompression hemicraniectomy and/or hypothermia. METHODS: We studied a cohort of patients from seven centres with large MCA infarction requiring neurocritical care. The purpose of this analysis was to assess the use of early radiological signs on follow-up computed tomographic (CT) signs performed within 48 h of stroke onset for predicting mortality at 30 days. The CT parameters assessed included horizontal displacement of the septum pellucidum, pineal shift, complete or partial infarction of the temporal lobe, involvement of additional vascular territories, and the presence of hydrocephalus. The primary outcome measure was in-hospital death within 30 days. RESULTS: One hundred and thirty-five patients who had follow-up CT scans within 48 h were identified from a total of 201 patients with large MCA infarction that received conventional medical therapy alone. The median age was 68 (range 29-99), 56% were female, and the median NIHSS category was 26-30 at 48 h. Among CT variables in univariable analysis, anteroseptal shift >/=5 mm, pineal shift >/=2 mm, complete temporal lobe infarction, involvement beyond the MCA territory, and moderate or severe hydrocephalus were equally predictive of death. Multivariable analysis adjusting for time to CT scan revealed the following predictors of fatal outcome: anteroseptal shift >/=5 mm (OR 10.9; 95% CI 3.2-37.6), NIHSS within 48 h >20 (OR 6.6; 95% CI 2.3-19.3), and infarction beyond the MCA territory (OR 4.9; 95% CI 1.6-15.0). CONCLUSIONS: We identified the role of early CT signs in predicting death following massive MCA infarction. The CT parameters anteroseptal shift (>5 versus /=2 mm, hydrocephalus, temporal lobe infarction, and other vascular territory infarction if present were predictive of fatal outcome. These CT parameters require prospective validation before they should be considered reliable markers for decision-making.     

外伤后急性半球脑肿胀的手术治疗

目的 探讨外伤后急性大脑半球肿胀（ACHS）的治疗效果以及影响疗效的主要因素.方法 对38例外伤后急性半球脑肿胀病人的资料进行回顾性分析.所有患者均接受了去骨瓣减压手术.结果 大骨瓣减压术后,CT影像显示脑中线结构无明显移位、环池结构清晰.术后6个月按GOS评分标准评估：良好14例（占36.8%）、中残9例（占23.7%）、重残5例（占13.2%）、植物生存4例（占10.5%）、死亡6例（占15.8%）.结论 早期去骨瓣减压手术可改善患者预后,而脑肿胀合并急性硬膜下血肿、手术后出血性脑挫伤处血肿量明显增加以及出现创伤后大面积脑梗死的患者预后较差.     

Hemicraniectomy and durotomy for malignant middle cerebral artery infarction

Decompressive surgery with hemicraniectomy and durotomy for malignant MCA infarction remains a salvage procedure but can be associated with reasonable clinical outcomes in highly selected patients. This selection of patients appropriate for intervention is of the utmost importance, but exact criteria remain to be defined; older age and increased numbers of associated medical comorbidities seem to define a group of patients who would not derive long term benefit, however. The determination as to whether or not surgery is equally beneficial for dominant or nondominant hemispheric infarction is hampered by lack of good comparative data, but selected case series suggest that some patients who have dominant hemispheric infarction achieve a reasonable degree of independence. Although a well-defined principle of stroke practice is that "time is brain," there are no clear data as to when intervention should be done, as there are some patients who have large MCA infarction and who may not progress to cerebral herniation. Clinicians managing the growing population of patient status post hemicraniectomy should also be aware of this process of the syndrome of the trephined and the potential for resolution that may prompt earlier cranial reconstruction. At present, the decision to proceed with this aggressive intervention of hemicraniectomy and durotomy for large ischemic infarction remains a case-by-case individualized approach, based on patient and family preferences and clinicians' subjective perspective as to patients' potential for clinical recovery.     

Physician awareness of decompressive hemicraniectomy for malignant middle cerebral artery infarction in Saudi Arabia and the Gulf countries

Objectives:To explore the perspective on Decompressive craniectomy (DH) of each of these specialties to establish common grounds for improved clinical practice.Method:An electronic survey was distributed via email and social media groups to members of these specialties in Kingdom of Saudi Arabia and the Gulf countries. Local practices, common triggers for referral for DH, perceived outcomes of these procedures, individual impression of what constitutes good clinical outcomes were explored.Results:There are 89 physicians participated: 41 (46.1%) neurologists, 34 (38.2%) neurosurgeons, and 14 (15.7%) intensivests. Participants are mostly practicing in intermediate volume centers or high volume centers. Half of the neurosurgeons preferred to be consulted immediately on candidates with large middle cerebral artery (MCA) strokes. The most important referral trigger for DH was clinical changes. The modified Rankin Scale (mRS) cutoff for good clinical outcome was 3 for 73.6% of respondents. There was agreement that DH only improves survival (64.4%). A third of the neurologists considered it to improve functional outcome compared to 15.4% of intensivests and 14.8% of neurosurgeons. There was agreement (66.7%) that patients older than 60 years with involvement of more than one territory should be excluded from DH. Only 7.7% of neurosurgeons excluded patients with dominant hemispheric strokes.Conclusion:Our physicians’ views are variable in what’s called acceptable outcome, and further studies are needed to to test the characteristics that helps in decision making such as hemisphere dominancy, time onset of stroke and vital radiological signs. This is seen despite the literature being full of data that supports the DC over medical management in malignant MCA infarction. Better multidisciplinary education initiatives are needed to unify the understanding and help improve the practices in this challenging subset of patients.

The middle cerebral artery (MCA) supplies most of the cerebral hemisphere and most of its functional areas and its infarctions related to its occlusion are considered the most common vascular territory affected in ischemic strokes. Less than 20% of middle cerebral artery infarction patients’ recover to independent living with very few achieving complete recovery.1,2 A subset of patients with massive stroke in the MCA territory undergo cytotoxic edema which ends up with elevated intracranial pressure (ICP), decreases cerebral perfusion pressure (CPP) and either fatal herniation up to 80% of the cases or severe disability. Surgical management of malignant MCA stroke is standardized as a hemispheric Decompressive craniectomy (DC) with expansive duraplasty. This type of surgery results in significant reduction of the intracranial pressure from the brain edema and prevent herniation by allowing the brain to swell outward without causing midline shift and uncle herniation. This method may reduce mortality and morbidity if performed in the first 48 hours of the MCA insult.3The decision whether to perform DC remains a controversial issue despite supporting evidence form randomized trials with no definitive evidence-based guideline is available to date.4 Five randomized clinical trials studied the mortality and morbidity in hemicraniectomy as compared to non-surgical management. The DECIMAL1 trial was an open, prospective, randomized, multi-center trial that included 38 patients. While HAMLET4 trail was also an open, randomized multicenter trial but included 68 patients. Another trial called DISTENY5 was a controlled, prospective, randomized clinical trial enrolled 32 patients. However, these studies were subject to different interpretation given their small sample sizes and the relatively low number of patients with independent recovery as opposed to those with moderate disability. Thus, their findings did not widely translate into a describable change in medical practice. The aim of this study is to explore the perspective on DC of different specialties involved in the management decisions and the care of stroke patients, and to study the factors that influence the decision based on perceived or actual effectors.     

Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives

Space-occupying, malignant middle cerebral artery (MCA) infarctions are still one of the most devastating forms of ischaemic stroke, with a mortality of up to 80% in untreated patients. An early diagnosis is essential and depends on CT and MRI to aid the prediction of a malignant course. Several pharmacological strategies have been proposed but the efficacy of these approaches has not been supported by adequate evidence from clinical trials and, until recently, treatment of malignant MCA infarctions has been a major unmet need. Over the past 3 years, results from randomised controlled trials and their pooled analyses have provided evidence that an early hemicraniectomy leads to a substantial decrease in mortality at 6 and 12 months and is likely to improve functional outcome. Hemicraniectomy is now in routine use for the clinical management of malignant MCA infarction in patients younger than 60 years of age. However, there are still important questions about the individual indication for decompressive surgery, particularly with regard to the ideal timing of hemicraniectomy, a potential cut-off age for the procedure, the hemisphere affected, and ethical considerations about functional outcome in surviving patients.     

Decompressive hemicraniectomy in a 2-year-old girl with a left middle cerebral artery infarct

Introduction We report on the case of a 2-year 5-month-old girl with congenital heart disease who developed left middle cerebral artery occlusion and cerebral hemorrhagic infarction a day after ventricular septal defect patch closure.Results Cranial computed tomography scan revealed an acute hemorrhagic infarct over the left middle cerebral artery territory with midline shift to the right. Since medical treatment failed, decompressive hemicraniectomy with duraplasty was performed, successfully reversing herniation. Decompressive surgery allows extracranial expansion of the swollen brain and relieves CSF space compression. We believe this to be the youngest reported patient to undergo decompressive hemicraniectomy for middle cerebral artery territory infarction. Although the patient survived, her functional outcome was poor.Conclusion Decompressive hemicraniectomy can be lifesaving and should be considered as an alternative therapy for patients with brain swelling refractory to medical management.     

Hemicraniectomy for large middle cerebral artery territory infarction: outcome in 19 patients

BACKGROUND: Large space-occupying middle cerebral artery infarction accounts for 10-15% of all supratentorial infarctions and carries a mortality of 50% to 80%. Hemicraniectomy may be useful when optimal medical management has failed. METHODS: Between June 1997 and June 2000, 19 patients who fulfilled the clinical and imaging criteria for large middle cerebral artery infarction underwent hemicraniectomy because of impending herniation despite best medical therapy. The National Institute of Health Stroke Scale (NIHSS) assessed neurological status on admission and at one week after surgery. At 3 month follow up, The Barthel Index (BI) and Rankin Scale (RS) were used to assess the functional outcome among survivors. RESULTS: There were 15 males and 4 females with a mean age of 46.5 years (range 27-76 years). Ten patients (53%) had dominant hemisphere stroke. The mean interval between stroke onset and surgery was 60.3 hours (range 20-103 hours). The mean NIHSS score before surgery was 20.5 (range 17-26) and 10.5 (range 6-22) after surgery. One patient (5.2%) died due to post-operative meningitis. At follow up, mean BI was 56.4 (range 25-90) and RS revealed severe handicap in 4 patients (21%). Patients under 50 years of age had a significantly better outcome with mean BI of 60.7 as compared to only 41.3 (p=<0.048) in older patients. Speech function, especially comprehension improved in all patients with dominant hemisphere infarction. CONCLUSION: These findings add to previous studies suggesting hemicraniectomy may be a useful procedure in patients with large middle cerebral artery territory infarction. The functional outcome is good in younger patients. A randomised controlled trial is required to substantiate these findings.     

Decompressive hemicraniectomy in children with severe ischemic stroke and life-threatening cerebral edema

Decompressive hemicraniectomy has been discussed as a treatment option that increases survival in adults with malignant stroke. This approach has not been studied extensively in children. From a prospective cohort, we identified 4 children who underwent decompressive hemicraniectomy for malignant infarctions with life-threatening cerebral edema within 72 hours of their stroke. All 4 children had different causes for their stroke and experienced severe cerebral edema with increasing intracranial pressure and an impending fatal outcome. Despite massive cerebral infarction, all patients were ambulant and able to speak at the time of follow-up. Although a limited experience, decompressive hemicraniectomy is a life-saving approach for malignant stroke in children.     

Hemicraniectomy in the management of space-occupying ischemic stroke

A space-occupying mass effect is a common finding in several stroke subtypes. A large, intracranial mass is a potentially life-threatening complication, irrespective of its underlying origin, with transtentorial or transforaminal herniation being the common endpoint and often the cause of death. Prompt and adequate intervention is therefore required. Although sufficient data on the management of large haematomas are lacking, there is good evidence from randomized trials that in younger patients with life-threatening, space-occupying, so-called “malignant” middle cerebral artery (MCA) infarctions, early hemicraniectomy decreases mortality without increasing the number of severely disabled survivors. Yet many questions concerning hemicraniectomy in malignant MCA infarction remain open: the definition of a malignant MCA infarct within the first hours, optimal timing of surgery, quality of life and acceptance of remaining disability, the role of aphasia in patients with dominant hemispheric infarcts, the effect of age, and the influence of the pre-morbid status on decision making. The joint efforts of neurologists, neurosurgeons, intensive care physicians, and rehabilitation physicians are needed to design and conduct studies that might answer these questions.     

Hemicraniectomy for massive cerebral infarction: Evoked potentials as presurgical prognostic factors.

In patients with massive hemispheric infarctions, mortality exceeds 80% with medical therapy alone. In certain conditions hemicraniectomy may result in meaningful survival. We studied presurgical clinical and electrophysiological parameters that may serve as prognostic factors to assess efficacy of decompressive surgery. We evaluated 26 consecutive patients with severe focal neurological deficit, deterioration of consciousness, and massive hemispheric infarction by cranial computerized tomography who underwent hemicraniectomy. Clinical examination included pupillary size and reaction, and determination of level of consciousness on an hourly basis. Median nerve somatosensory evoked potentials and brainstem auditory evoked potentials were obtained before and after hemicraniectomy. Outcome was assessed by using the Barthel Index. Clinical and evoked potential data were correlated with the outcome. Fisher's Exact Test was applied to establish statistical significance. With surgery 18 of 26 patients survived on an average intensive care treatment of 29.6 (+/-27.5) days. Barthel Index at discharge was 61.7 (+/-24.4) in survivors. Presurgical pupillary reaction, level of consciousness, and somatosensory evoked potentials were not found to correlate with outcome. In contrast, presurgical brainstem auditory evoked potentials showed a significant correlation with survival (P<.05). All patients with good outcomes (Barthel Index >/=60: n=12, 46.1%) had normal brainstem auditory evoked potentials before surgery. Clinical parameters did not reliably forecast prognosis in patients with massive cerebral infarction treated with hemicraniectomy.     

"Malignant" middle cerebral artery territory infarction

The pathology, clinical course, outcome, diagnosis, treatment and prognosis of dramatic malignant middle cerebral artery territory infarction were presented. About 10% of stroke patients suffer from malignant middle cerebral artery territory infarction, mainly due to brain edema and herniation. This syndrome causes high mortality. The newest conservative and surgical treatment was presented.     

Long-term outcome after hemicraniectomy for space occupying right hemispheric MCA infarction

OBJECTIVE: To examine the long-term prognosis in patients with 'malignant' supratentorial ischemia of the right hemisphere treated with hemicraniectomy, especially in respect to depression, with a focus on age as a possible predictor of outcome. METHODS: We performed a prospective, long-term, follow-up examination in 23 survivors of 32 patients (mortality 28.1%) treated with hemicraniectomy for malignant middle cerebral artery (MCA) infarction of the right hemisphere, who were identified in our data bank since 1993. Long-term was defined as at least 20 months after craniectomy. Outcome data consisted of the items functionality, depression and quality of life. Tests applied included the Barthel Index (BI), the modified Rankin Scale (mRS), Beck Depression Inventory (BDI) and stroke-specific quality of life (QoL) scale. RESULTS: Of the 23 patients 15 (65.2%) had a BI>or=60, 11 (47.8%) a mRS<4 and 9 (39.1%) a SS-QOL>or=60%, each representing a favourable outcome. In retrospect, 14 (60.9%) patients approved the surgery. Depression, i.e. a BDI>9, was diagnosed in 13 (56.5%) patients and 5 (38.5%) of them were treated with antidepressants. In a multiple linear regression analysis age at craniectomy was a predictor of a low BI (beta=-0.863; p=0.031), but not of the other outcome parameters. CONCLUSIONS: Depression is a common and rarely treated long-term complication after 'malignant' right hemispheric ischemia. While high age is a strong predictor of poor functional outcome, it has no impact on depression and retrospective approval of craniectomy.     

Treatment of right hemispheric cerebral infarction by hemicraniectomy

An anecdotal series of nine patients (three men and six women with an average age of 57 years) presented with progressive neurologic deterioration while on medical therapy for large right hemispheric cerebral infarction. Clinical signs of uncal herniation (anisocoria or fixed and dilated pupils, and/or left hemiplegia with right decerebrate posturing) were present in seven of these nine patients. Computerized tomography of the head confirmed mass effect from cerebral edema. It was the clinical judgment of the treating neurologists and neurosurgeons that each of these nine patients would perish unless surgical decompression of the infarcted brain was performed. Accordingly, each was treated with right hemicraniectomy and dural augmentation. Six patients demonstrated neurologic improvement on the first postoperative day. One patient, with a postoperative diagnosis of lung cancer, died 1 month after surgery. The remaining eight patients are currently living with their families with a follow-up period ranging from 5 to 25 months. Patient outcome as evaluated by the Barthel Index indicates that three individuals are functioning with minimal assistance and that the remaining six patients are functionally dependent. After rehabilitative therapy, four patients returned for elective cranioplasty. These results suggest that hemicraniectomy can be an effective lifesaving procedure for malignant cerebral edema after large hemispheric infarction.