From the Departments of Neurology (S.Schwab, T.S., S.Schwarz, W.H.),
Neurosurgery (A.A., H.H.S.), and Neuroradiology (O.J.) University of
Heidelberg, Heidelberg, Germany.
Correspondence to Stefan Schwab, MD, Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany. E-mail stefan_schwab{at}ukl.uni-heidelberg.de
Background and Purpose—Malignant,
space-occupying supratentorial ischemic
stroke is characterized by a mortality rate of up to 80%. Several
reports indicate a beneficial effect of hemicraniectomy in this
situation. However, whether and when decompressive surgery is indicated
in these patients is still a matter of debate.
Methods—In an open, prospective trial we performed
hemicraniectomy in 63 patients with acute complete middle cerebral
artery infarction. Initial clinical presentation was
assessed by the Scandinavian Stroke Scale (SSS) and the Glasgow Coma
Scale (GCS). All survivors were reexamined 3 months after surgical
decompression, with the clinical evaluation graded according to the
Rankin Scale (RS) and Barthel Index (BI). We analyzed the
influence of early decompressive surgery (<24 hours after symptom
onset, based on clinical status at admission and initial CT findings)
versus late surgery (>24 hours after first reversible signs of
herniation) on mortality, functional outcome, and the length of time of
critical care therapy was needed.
Results—In total, 46 patients (73%) survived. Despite complete
hemispheric infarction, no survivor suffered from complete hemiplegia
or was permanently wheelchair bound. In patients with speech-dominant
hemispheric infarction (n=11), only mild to moderate aphasia was
present. The mean BI score was 65, and RS score revealed severe
handicap in 13% of the patients. In 31 patients with early
decompressive surgery, mortality was 16% and BI score 68.8. Early
hemicraniectomy led to a significant reduction in the length of time
critical care therapy was needed (7.4 versus 13.3 days,
P<0.05).
Conclusions—In general, the outcome of patients treated with
craniectomy in severe ischemic hemispheric infarction was
surprisingly good. In addition, early decompressive surgery may further
improve outcome in these patients.
© 1998 American Heart Association, Inc.
Original Contributions
Early Hemicraniectomy in Patients With Complete Middle Cerebral Artery Infarction
Key Words: brain edema • cerebral infarction • hemicraniectomy • intracranial pressure • rehabilitation
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