Bs. Carter et al., ONE-YEAR OUTCOME AFTER DECOMPRESSIVE SURGERY FOR MASSIVE NONDOMINANT HEMISPHERIC INFARCTION, Neurosurgery, 40(6), 1997, pp. 1168-1175
OBJECTIVE: Massive cerebral infarction is often accompanied by early d
eath secondary to transtentorial herniation. We have tested the hypoth
esis that decompressive hemicraniectomy for massive nondominant cerebr
al infarction is lifesaving in a series of 14 patients presenting with
right hemispheric infarction and clinical signs of uncal herniation a
nd impending death. We have further analyzed, in prospective follow-up
examinations, the levels of physical, psychiatric, and social disabil
ities in these patients. METHODS: The methods used included retrospect
ive analysis to determine rates of immediate mortality and morbidity a
fter surgical intervention. Prospective follow-up data were obtained t
o determine the level of recovery in surviving patients after 1 year.
Standardized measures of outcome to assess physical, psychiatric, and
social recovery included the Barthel Index, Zung Depression Scale, and
Reintegration to Normal Living Index. RESULTS: With decompressive hem
icraniectomy, we were able to prevent death secondary to transtentoria
l herniation in all cases; 11 patients experienced long-term survival
after the procedure, and three deaths were related to non-neurological
causes. We observed that 8 of the 11 surviving patients were at home,
were functioning with minimal to moderate assistance, and had Barthel
scores greater than 60. The remaining three patients were severely di
sabled. Seven of the 11 survivors were able to walk at 1 year after un
dergoing the procedure. Depression and failure to reintegrate socially
were experienced by most patients. CONCLUSION: This series confirms t
he lifesaving nature of hemicraniectomy in patients deteriorating beca
use of cerebral edema after infarction. In patients younger than 50 ye
ars, recovery to a state of near-independence is possible.