Long-term outcome of decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: A prospective observational study

Background: Malignant middle cerebral artery (MCA) infarction is associated with high mortality and morbidity. Decompressive hemicraniectomy (DH) reduces mortality significantly but evidence for long-term functional benefit is sparse and contradictory. Materials and Methods: A total of 60 patients with malignant MCA infarction were prospectively enrolled. 36 (60%) patients underwent DH and 24 (40%) patients received best medical therapy alone. Both groups were followed-up for 1 year for improvement in disability and aphasia using modified Rankin score (mRS) and Western Aphasia Battery respectively. Good outcome was defined as mRS <= 3. Secondary analysis using mRS <= 4 was also performed. Results: An absolute risk reduction of 45% was observed in mortality at 1 year; 38% (14/36) in the surgical group died versus 83% (20/24) in the medical group. Good outcome at 1 year was achieved in 20% (7/35) patients in the surgical group compared with none in the medical group (P = 0.025). Repeated measures regression suggested increased proportion of patients improving over time (discharge, 3, 6 and 12 months). Surgery reduced the odds of moderate to severe disability (mRS >= 4) by 93.5% (odds ratio: 0.064, 95% confidence interval: 0.01-0.045, P = 0.006). Conclusions: DH in malignant MCA infarction not only reduces mortality but also increases chances of a better functional outcome. The benefit of surgery in motor and aphasia recovery is progressive and sustained until 1 year.