Decompressive hemicraniectomy for malignant middle cerebral artery territory infarction: is life worth living?

Clinical article

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  • 1 Departments of Neurosurgery and
  • | 2 Neurology, University of Cincinnati and Mayfield Clinic, Cincinnati, Ohio
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Object

Although decompressive hemicraniectomy has been shown to reduce death and improve functional outcome following malignant middle cerebral artery territory infarction, there is ongoing debate as to whether surgery should be routinely performed, considering the very high rates of disability and functional dependence in survivors. Through a systematic review of the literature, the authors sought to determine the outcome from a patient's perspective.

Methods

In September 2010, a MEDLINE search of the English-language literature was performed using various combinations of 12 key words. A total of 16 papers were reviewed and individual study data were extracted.

Results

There was significant variability in study design, patient eligibility criteria, timing of surgery, and methods of outcome assessment. There were 382 patients (59% male, 41% female) with a mean age of 50 years, 25% with dominant-hemisphere infarction. The mortality rate was 24% and the mean follow-up in survivors was 19 months (range 3–114 months). Of 156 survivors with available modified Rankin Scale (mRS) scores, 41% had favorable functional outcome (mRS Score ≤ 3), whereas 47% had moderately severe disability (mRS Score 4). Among 157 survivors with quality of life assessment, the mean overall reduction was 45%: 67% for physical aspect and 37% for psychosocial aspect. Of 114 screened survivors, depression affected 56% and was moderate or severe in 25%. Most patients and/or caregivers (77% of the 209 interviewed) were satisfied and would give consent again for the procedure.

Conclusions

Despite high rates of physical disability and depression, the vast majority of patients are satisfied with life and do not regret having undergone surgery.

Abbreviations used in this paper:

ALQI = Aachen Life Quality Inventory; BDI = Beck Depression Inventory; BI = Barthel Index; BQ = Blau QoL Questionnaire; DH = decompressive hemicraniectomy; MCA = middle cerebral artery; mRS = modified Rankin Scale; QOL = quality of life; RCT = randomized controlled trial; SA-SIP30 = Stroke-Adapted 30-Item version of the Sickness Impact Profile; SF-36 = 36-Item Short Form Health Survey; SIP = Sickness Impact Profile; SIS = Stroke Impact Scale; VAS = visual analog scale.

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