gms | German Medical Science

Objective: Malignant middle cerebral artery (MCA) infarction represents a life-threatening condition due to its space-occupying character. The surgical treatment outcome was assessed in multiple well-designed trials and showed strong evidence in favor of decompressive hemicraniectomy. However, the timeframe for decompressive surgery remains debatable and no objective criteria are found to facilitate the decision. We aimed to analyze imaging characteristics of patients with MCA-infarction for outcome prediction.

Methods: A retrospective analysis of 34 consecutive patients undergoing decompressive craniectomy was carried out. We used volumetric analysis through segmentation to determine the volume of the initial infarction and subsequently volumes on the first an 3^rd postoperative day (pod1 and 3). The size of craniectomy was assessed and the time between onset and surgery. Outcome was measured as modified Rankin Scale (mRS), whereas favorable outcome was set for mRS ≤3.

Results: Median age of our patients was 53.5 years (25 – 72), the median time from the onset of first symptoms to surgical intervention was 38 hours (1 – 150) and the male: female ration was 2:1. The median ischemic volume was 250 cc (106 – 418) preoperatively, 315 cc (141 – 505) on pod1 and 349 cc (177 – 617) on pod3, respectively. A mRS ≤3 after 6 months could only be reached in 7 (20%) patients. Within the first 24 hours, the volume of infarction rose significantly (p=0.0003) and was associated with a worse outcome (p<0.0001) upon univariate analysis. In multivariate analysis, the volume on pod 3 showed a significant (p=0.014) correlation with outcome, so was the age upon onset (p=0.018).

Conclusion: A total infarct volume of >300cc in native CT-scan in patients undergoing hemicraniectomy, reliably predicts worse outcome for malignant MCA-infarction.