Value of early decompressive hemicraniectomy in patients with malignant infarction in the middle cerebral artery region treated with intravenous rt-PA: A retrospective analysis of six patients

BackgroundMalignant middle cerebral artery (MCA) infarction accounts for ≤10% of ischemic strokes, and is associated with 80% mortality. Decompressive hemicraniectomy is the most effective intervention to improve survival. The aim of this paper is to report on the outcomes of combined therapy with alteplase (rt-PA) and decompressive hemicraniectomy in patients with malignant MCA infarction.Methods215 patients who suffered an ischemic stroke were treated with rt-PA between 2009 and 2012. Malignant MCA infarction with space-occupying edema was diagnosed clinically with the National Institute of Health Stroke Scale (NIHSS) when the score was ≥16, including the score ≥1 for the level of consciousness (1a). Patients ≤62 years agreed to undergo hemicraniectomy procedure. Risk factors, condition of patients, time from the beginning of the stroke to the intravenous application (IV) of rt-PA, and to surgery, 30-days, 3-months, and 1-year mortality, and functional outcome using the modified Rankin scale (mRs) were analyzed. A favorable functional outcome was defined as a mRs score ≤3.ResultsMalignant MCA infarction with space-occupying edema developed in six (2.3%) patients, out of whom two were female. The mean NIHSS on admission was 15.8 points. Four patients had clinical manifestations of edema on day one, and two on day two. The NIHSS score was >15 when the patients qualified for hemicraniectomy. CT scans showed massive brain swelling, and in two patients also secondary hemorrhagic transformation before hemicraniectomy. One patient died from the brain edema on day 11, following hemicraniectomy and, one died suddenly on day 40, from heart-related problems. The four remaining patients survived in good condition (2–3 points on mRs).ConclusionDecompressive hemicraniectomy in malignant – MCA infarction – following intravenous administration of rt-PA has proved to be safe for all patients treated in this way. It appears that a hemicraniectomy performed after an earlier rt-PA treatment has contributed to the favorable functional outcome in our patients who have survived 1 year and longer after the procedure. Secondary hemorrhagic transformation after rt-PA before surgery should not be a contraindication for decompressive hemicraniectomy. Decompressive hemicraniectomy should be performed promptly when malignant brain edema develops, before herniation occurs. The procedure can be performed in every neurosurgery hospital ward.