DECOMPRESSIVE SURGERY IN SPACE-OCCUPYING HEMISPHERIC INFARCTION - RESULTS OF AN OPEN, PROSPECTIVE TRIAL

Objective: Space-occupying hemispheric infarctions, requiring neurocri tical care treatment, demonstrate high mortality and morbidity rates, This study was performed to determine the beneficial effects of decomp ressive craniotomy on mortality and morbidity rates, Design: Open, non randomized, control trial, Outcome was rated at discharge from the hos pital (Glasgow Outcome Scale) and at followup (Barthel Index, Oxford H andicap Scale), Setting: Patient recruitment from the Department of Ne urology, University of Heidelberg (primary care center) over 65 months , Patients: Thirty-two patients were prospectively selected for surgic al treatment; 21 patients were treated conservatively, Interventions: Extended craniotomy and dura patch enlargement were performed in all s urgically treated patients, Measurements and Main Results: At discharg e, the outcome of six (18.8%) of 32 surgically treated patients was go od 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 pati ents, and 11 (34.4%) of 32 surgically treated patients died compared w ith 16 (76.2%) of 21 conservatively treated patients, At follow-up in surgically treated patients, the Barthel Index (mean 62.6) showed an e xcellent level of daily activity in one patient, minimal assistance (B arthel Index of greater than or equal to 60) in 15 patients, and depen dency in five patients, The Oxford Handicap Scale indicated no handica p in one patient, moderate handicaps in 15 patients, and moderately se vere handicaps in five patients, In the control group, all five surviv ing patients needed assistance and all but one patient demonstrated a moderately severe handicap. Conclusions: Hemicraniotomy may improve su rvival in massive hemispheric stroke victims, decreasing mortality rat es to <35%. The disability rate remains high (24%), although some pati ents seem to benefit significantly.