Decompressive surgery in space-occupying hemispheric infarction

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Abstract
Space-occupying hemispheric infarctions, requiring neurocritical care treatment, demonstrate high mortality and morbidity rates. This study was performed to determine the beneficial effects of decompressive craniotomy on mortality and morbidity rates. Open, nonrandomized, control trial. Outcome was rated at discharge from the hospital (Glasgow Outcome Scale) and at followup (Barthel Index, Oxford Handicap Scale). Patient recruitment from the Department of Neurology, University of Heidelberg (primary care center) over 65 months. Thirty-two patients were prospectively selected for surgical treatment; 21 patients were treated conservatively. Extended craniotomy and dura patch enlargement were performed in all surgically treated patients. At discharge, the outcome of six (18.8%) of 32 surgically treated patients was good compared with 0 (0%) of 21 conservatively treated patients. Fifteen (46.9%) of 32 surgically treated patients were moderately to severely disabled compared with five (23.8%) of 21 conservatively treated patients, and 11 (34.4%) of 32 surgically treated patients died compared with 16 (76.2%) of 21 conservatively treated patients. At follow-up in surgically treated patients, the Barthel Index (mean 62.6) showed an excellent level of daily activity in one patient, minimal assistance (Barthel Index of more than equals 60) in 15 patients, and dependency in five patients. The Oxford Handicap Scale indicated no handicap in one patient, moderate handicaps in 15 patients, and moderately severe handicaps in five patients. In the control group, all five surviving patients needed assistance and all but one patient demonstrated a moderately severe handicap. Hemicraniotomy may improve survival in massive hemispheric stroke victims, decreasing mortality rates to less than 35%. The disability rate remains high (24%), although some patients seem to benefit significantly.