Decompressive craniectomy in malignant middle cerebral artery infarction. Experience after the implementation of a response protocol

Introduction. Descompressive craniectomy (DC) for treatment of malignant infarction of the middle cerebral artery (MIMCA) reduces mortality and increases the probability of favourable outcome. Aim. To present the experience in daily practice after implantation of a clinical protocol of DC. Patients and methods. Prospective register of patients with MIMCA treated with DC. Age, stroke severity National Institute of Health Stroke Scale (NIHSS) score, basal characteristics, delay until DC, mortality, modified Rankin Scale (mRS) score at three and twelve months and questionnaire of satisfaction are recorded. Results. From February 2008 to December 2010, 15 patients were treated. Mean age: 60 years (range: 35-69); basal NIHSS, median (p25/p75): 17 (15.5/21), NIHSS before craniectomy: 20 (18/23.5). DC was performed within 48 hours in 8 patients (53.3%). 5 subjects (33.3%) died during in-hospital stay. Mortality was 25% among those treated within 48 hours and 42.9% among those treated later and 37.5% among patients <= 60 years vs 28.6% in older patients. All survivors scored <= 4 in the mRS at three months and expressed satisfaction with surgery despite sequelae. Rate of favourable outcome (mRS <= 3) was higher among patients under 60 (63%) and among those treated before 48h (50%). Conclusion. DC is safe in clinical practice and reduces mortality after MIMCA, especially if it is performed within 48 hours from stroke onset. Benefit appears to be greater in younger patients, but older people may benefit also. The decision to perform DC should be made on an individual basis.