Decompressive craniotomy after middle cerebral artery infarction. Retrospective analysis of patients treated in three centres in Switzerland

QUESTIONS UNDER STUDY / PRINCIPLES: Several studies have reported an improved outcome in patients presenting with complete middle cerebral artery (MCA) infarction treated by decompressive hemicraniectomy. Although this palliative treatment form has gained popularity in Switzerland since 2000, the results of these series have not been reported. The aim of this study is, firstly, to report factors influencing the outcome of our patients, in order to create awareness of the indications and decision-making processes in our departments, and, secondly, to analyse therapeutic strategies which are open to improvement and standardisation. METHODS: This retrospective study included a total of 28 patients (age 51 +/- 12 years) who underwent decompressive craniectomy after MCA between January 2000 and May 2002 at the Departments of Neurosurgery of Aarau (n: 6), Bern (n: 10), and Zurich (n: 12). Demographic characteristics included preoperative clinical condition (NIHSS and GCS), timing of surgery, cause, location, and extension of infarction. Additionally, the time delay from the onset of symptoms to surgery and preoperative signs of herniation and their relation to final outcome was analysed. The final outcome was assessed in terms of mortality and scores such as modified Rankin scale and Barthel index. RESULTS: The preoperative clinical condition according to NIHSS was 20.2 +/- 4.7 and GCS was 10.6 +/- 3.6. The mean time in hours to surgery after onset of symptoms was 35 +/- 24. Twelve patients (42.8%) underwent "early" surgery (within 24 hours) and 21 (75%) suffered non-dominant stroke. The follow-up period was 22 +/- 13 months and 17% of the patients died within this period. Outcome did not differ significantly between institutions. The overall mean Barthel index was 47 +/- 25 and modified Rankin scale was 4 +/- 1.3. CONCLUSIONS: The outcome in patients undergoing decompressive craniectomy after MCA infarction in Switzerland is less favourable than in other series recently reported. Less favourable preoperative clinical condition, inclusion of dominant hemispheric infarction, poorly defined protocols and late involvement of neurosurgeons on these patients' admission may explain the results