What is the optimum time to decompressive surgery in the patients with malignant middle cerebral artery infarction?

Abstract

Aim: In the patients with malignant middle cerebral artery (MCA) infarctions, the mortality was as high as 70% with conservativetreatment. Decompressive craniectomy (DC) was shown to decrease mortality especially in 48 hours. We aimed to investigate boththe effect of decompression time and the size of craniectomy on the mortality in this patient group.Material and Methods: 45 adult patients underwent to DC due to malignant MCA infarction were evaluated in this study. Thedemographic and clinical features were recorded retrospectively. The patients were splitted into three groups: Group 1, DC in the first24 hours; group 2, in 24-48th hours; group3, in 48-96th hours of the admission. The size of craniectomy was the same as the infarct(standard), or it was two centimeters larger than the size of infarct (larger).Results: Of all patients, 53.3% (n=24) was female; and mean age of the sample was 67.38±4.76. 66.7% (n=30) of the patients died dueto malign MCA infarction. The size of craniectomy was larger in 26.7% (n=12), and was standard in the others. Mean time to surgerywas 43.07±29.87 hours. Mortality rate was minimum in group 2 (p=0.01). The patients undergoing to larger craniectomy survivedlonger than the others, but the difference was non-significant (p=0.06).Conclusion: We suggested that not the approach of “surgery as soon as possible” but the surgery between 24-48th hours of theadmission would be the optimal approach. This issue is especially important, because earlier or later interventions not only have aless benefit on the outcome but also may lead several unnecessary complications.