• Christian F Freyschlag, Christian Boehme, Marlies Bauer, Johannes Kerschbaumer, Daniel Pinggera, Marina Riedmann, Claudia Unterhofer, Astrid E Grams, Michael Knoflach, and Claudius Thomé.
• Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria. Electronic address: christian.freyschlag@i-med.ac.at.
• World Neurosurg. 2019 Mar 1; 123: e515-e519.

BackgroundMalignant middle cerebral artery stroke is a life-threatening condition. The outcomes of surgical treatments have presented strong evidence in favor of decompressive hemicraniectomy (DHC). A significant subpopulation of patients still experience very poor outcomes. In particular, indication for DHC is based on few objective parameters to facilitate decision making. We hypothesized that larger ischemic brain volume would have a large impact on the outcome.MethodsA cohort study of 34 patients undergoing DHC was performed using a volumetric analysis of infarction volume (measured preoperatively and again on postoperative day [POD] 1 and POD 3). Outcomes were assessed using the modified Rankin Scale (mRS), and a favorable outcome was defined as modified Rankin Scale score ≤3.ResultsMedian age of patients was 53.5 years (range, 25-72 years), the median time from onset of first symptoms to surgical intervention was 38 hours (range, 10-150 hours), and male-to-female ratio was 2:1. The median ischemic volume was 250 cm3 preoperatively, 315 cm3 on POD1, and 349 cm3 on POD3. Modified Rankin Scale score ≤3 after 6 months was attained in 7 (20%) patients. Within the first 24 hours after DHC, ischemic volume increased significantly (P = 0.0003) and was associated with a worse outcome (P < 0.0001) after exceeding a cutoff volume of 300 cm3.ConclusionsVolumetric analysis of infarction can predict the outcome of patients. DHC should be reserved for patients with prognosticated good outcome, which was observed only in patients with a volume <301 cm3.Copyright © 2018 Elsevier Inc. All rights reserved.

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