Abstract TMP100: Hemicraniectomy for Malignant MCA Syndrome: A Review of Functional Outcomes in Two High Volume Stroke Centers
Background&Purpose: Despite recent landmark RCTs showing significant survival and functional outcome benefits with HCT compared with medical therapy (MT) in patients with malignant MCA infarction (MMCAI), HCT rates have not substantially increased in the US. It is difficult for patients’ families to reconcile the wishes of the patient with the possibility of poor functional outcome. We sought to evaluate early outcomes in patients with MMCAI who were treated with HCT (cases) in comparison to patients treated with MT due to the perception of procedural futility by families (controls).
Subjects&Methods: We evaluated in a retrospective cohort study design consecutive patients with acute MMCAI treated in two tertiary care centers during a seven-year period. Pre-treatment NIHSS, NIHSS at discharge and modified Rankin Scale (mRS) at three months were documented. Functional independence (FI) and survival without severe disability (SWSD) were defined as mRS of 0-2 and 0-4 respectively.
Results: A total of 66 patients (37 cases and 29 controls) fulfilled the study inclusion criteria [mean age 59±15 years, 52% men, median admission NIHSS-score: 19 points (IQR: 16-22]. Cases were younger (51±11 vs 68±13 years; p<0.001) and tended to have lower median admission NIHSS than controls [18 (IQR:16-20) vs 20 (IQR: 18-23); p=0.072], but the two groups did not differ significantly (p>0.05) in terms of other baseline characteristics. The rates of FI and SWSD at three months were higher in cases than controls [16% vs 0% (p=0.031) & 62% vs 0% (p<0.001)], while three-month mortality was lower (24% vs 77%; p<0.001). Multivariate Cox regression analysis identified HCT as the most important predictor of lower risk of death at three months (HR: 0.02, 95%CI: 0.01-0.10; p<0.001).
Conclusions: HCT is a critical and effective therapy for patients with MMCAI but cannot provide a gurantee of functional recovery. Refusal of HCT by medical decision makers is common and reflects the complexity of issues under consideration in terms of patient outlook beyond the reduction of mortality following acute MMCAI.
Author Disclosures: S. Male: None. G. Tsivgoulis: None. N. Goyal: None. E. Boviatsis: None. A. Pandhi: None. J. Chang: None. R. Zand: None. C. Zompola: None. L. Elijovich: None. A.W. Alexandrov: None. M.D. Malkoff: None. D. Hoit: None. A.S. Arthur: None. A.V. Alexandrov: None.
- © 2016 by American Heart Association, Inc.