Malignant middle cerebral artery infarction which usually results from the MCA acute occlusion is considered a serious fatal condition. Life-threatening herniation and brain edema can occur within 1 week after the stroke onset leading to a mortality rate of 80% [10].
Decompressive hemicraniectomy surgery is considered as a life-saving procedure for patients experiencing malignant hemispheric infarction with refractory intracranial hypertension in spite of maximum medical therapy. It is the last resort to prevent fatal cerebral herniation and to achieve better functional outcomes [11].
Despite the effective role of DC in malignant MCA infarction, the severe disability and poor quality of life suffered by many survivors is still a serious concern [12, 13].
The optimal surgical timing should be before or immediately after the neurological deterioration that is related to brain edema. Surgery is then initiated in the first 48 h or even day 7 after stroke onset [14].
It is recommended to perform surgical decompression early before the development of major midline shift and conscious level deterioration. Some researches mentioned that patients for whom early DC was done show better functional outcomes brought about by preventing fatal brain herniation and improving cerebral hemodynamics, thereby limiting secondary injury [15]. In most cases, DC is performed within 48 h after the ischemic stroke. Thus, all patients with acute large hemispheric infarction should be monitored in an intensive care unit (ICU) or stroke unit for the expedition of the timely surgical decompression. ICP monitoring prior to DC in cases with severe neurological deterioration is one of the predicting factors of decompression surgery decision [16].
Repeated publications mentioned that DC in the management of malignant middle cerebral artery infarction revealed low fatality rate and improved functional outcome. Many cohort data reported the case fatality rates during the acute stage as varying between 18 and 35% and moderate disability (mRS 3) at 3 months as varying between 20 and 59% [17].
In our study, the fatality rate was 33%, while in destiny trials, the case fatality rate was 22% but moderate disability (mRS 3) rate was 7% and moderate-severe disability (mRS 4) rate was 32% at the 3-month follow-up [9].
We reported 9% of patients included in our research had mRS 3 and 25% had moderate-severe disability (mRS 4) at the 3-month follow-up, while poor outcome (mRS 5) was 33%.
In Kürten and colleague’s trial [18], 22.8% of patients recovered to moderate disability (mRS 3) at 3-month follow-up, 44.6% remained with moderate-severe disability (mRS 4), and 32.6% suffered a poor outcome (mRS 5).
In our series after the 12-month follow-up, two patients from the severe disability group showed functional improvement. 16.5% of patients recovered to moderate disability (mRS 3) instead of 9% at the 3 -month follow-up and 33% remained mRS 5 with poor outcome. Approximate results were obtained by Zhao and colleagues [19], a cohort who reported moderate disability (mRS 3) in 11.4% and poor outcome (mRS 5) in 24.2% of patients at 12 months. Our study demonstrates that DC improves functional outcomes at 12 months and lowers fatality rates in patients with malignant MCA infarction. Meticulous postoperative management after the decompressive surgery can increase the chance of favorable recovery.