Fifteen-Year Institutional Retrospective Case Series of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction

OBJECTIVE: In the present study, we updated our previously reported case series of patients who had undergone decompressive craniectomy for malignant middle cerebral artery infarction (mMCAI) (2005-2020). To the best of our knowledge, the present case series constitutes the largest reported series from a UK neurosurgical unit of decompressive craniectomy for mMCAI. METHODS: We extracted data regarding the clinical discriminators, surgical timescales, and functional outcomes of patients. RESULTS: A total of 67 patients had undergone decompressive craniectomy. The 30-day mortality was 17.9% (n = 12). Of the 67 patients, 31 were male (46.3%) and 36 were female (53.7%). Their mean age was 45 years (range, 16-64 years). The mean age of the survivors was 43 years (range, 16-62 years) compared with 50 years (range, 38-64 years) for those who had died. The median ictal and preoperative Glasgow coma scale score was 14 (range, 7-15) and 8 (range, 3-15), respectively. The corresponding motor scores were 6 and 5. The mean interval from ictus to neurosurgical nit admission was 18.25 hours (range, 0.5-66 hours) and from admission to decompressive craniotomy was 7.30 hours (range, 0.5-46 hours). Of the 67 patients, 63% had undergone "early" craniectomy (<48 hours from mMCAI evolution), with 89% of these patients having undergone craniectomy <24 hours after neurosurgical unit admission. The mean maximum anteroposterior craniectomy diameter was 13.01 cm (range, 10.29-15.56 cm), and mean surface area was 94.38 cm(2) (range, 74.75-132.32 cm(2)). Overall, 46% of patients had had a modified Rankin scale score of <3 (range, 0-6) from discharge to 12 months postoperatively. The median neurosurgical unit length of stay was 15 days (range, 6 hours to 365 days). CONCLUSIONS: The findings from the present update have confirmed that local practice has remained consistent with current evidence. However, patient selection might be optimized if diffusion-weighted magnetic resonance imaging and computed tomography perfusion were used at the original middle cerebral artery infarct admission.