Decompressive Hemicraniectomy versus Intensive Medical Management in Patients with Malignant Middle Cerebral Artery Infarction

Introduction: Decompressive Hemicraniectomy (DHC) is a surgical technique which involves the removal of some part of skull to relieve the raised intracranial pressure, in setting of large cerebral mass effect. Some of the recent randomised clinical trials in western world have well established the role of 'DHC' in malignant Middle Cerebral Artery Infarction (mMCAI) to reduce death risk. However, Indian data regarding the same is scarce. Aim: The present study aimed to compare the outcomes of 'DHC' and best medical management in mMCAI. Materials and Methods: This study was a prospective, nonrandomised intervention study conducted at the Neurology department of 'Sri Venkateswara Institute of Medical Sciences', Tirupati from November 2015 to October 2016. The study comprised of 60 patients having mMCAI out of which 20 underwent surgery and 40 received the best medical management alone. DHC was performed within 48 hours of the stroke onset. Both the groups were followed-up for six months and observed for difference in mortality and disability using modified Rankin Score (mRS). Good functional outcome was defined as mRS <= 3. Split data analysis was performed for patients with age <= 60 and >60 years. Results: Cumulative death rate at the end of six months in medical and surgical group was 55% and 30% respectively, with a non-significant Absolute Risk Reduction (ARR) of 25% with surgery. Subgroup analysis revealed a significant mortality reduction at six months with surgery in patients with age <= 60 years (14% vs 68%, p=0.004). On the contrary, patients older than 60 years who underwent surgery had a non-significantly higher death rate at six months (67% vs 39%). Good functional outcome as defined by mRS <= 3 at six months was more frequent in surgery group (6/20, 30%) as compared with medical management group (10/40, 25%). This difference was not statistically significant. Conclusion: DHC in mMCAI is life-saving in Indian patients with age <= 60 years, per contra, may increase the chances of death in patients older than 60 years.