Surgical Indications of Decompressive Craniectomy for Middle Cerebral Artery Infarction

ABSTRACT

OBJECTIVES: A significant number of acute hemispheric infarctions are associated with severe cerebral edema and even herniation as a cause of early mortality. In clinically acute hemispheric infarction, it is estimated that 7% to 15% of patients have severe cerebral edema with herniation syndromes, with 50% to 75% of mortality. This study was performed to determine clinical and radiologic factors which might affect the clinical course and the timing of surgical decompression in cerebral infarction with severe edema. PATIENTS AND METHODS: The authors prospectively studied 33 consecutive patients with acute middle cerebral artery infarction from January 1996 to December 1997. Of these, 9 patients underwent decompressive craniectomy, and 24 patients were treated conservatively. They were divided into GroupI(n=15), surgically treated patients and clinically deteriorated and died, and GroupII(n=18), clinically stable patients. Patients were evaluated and compared between groups based on following factors age, sex, consciousness level, pupillary light reflex, outcome, midline shift, enlargement of contralateral temporal horn, the maximum diameter of infarct area and the ratio of infarct area. RESULTS: In GroupI, the mean interval of the time elapsed for changing of consciousness was 2.29 day after attack. The majority of deterioration was seen on day 2 after attack. Four patients underwent decompressive craniectomy, and 5 patients decompressive craniectomy with removal of infarct area or temporal lobectomy. The method of surgery did not affect the outcome(p>0.05). The change of consciousness, preservation of pupillary light reflex, midline shift, enlargement of contralateral temporal horn, the maximum diameter of infarct area, and the ratio of infarct area were related with outcome after acute middle cerebral infarction(p10cm) and ratio(>30% of brain volume) of infarct area.