title: The Swedish Malignant Middle cerebral artery Infarction Study: long-term results from a prospective study of hemicraniectomy combined with standardized neurointensive care.
abstract: OBJECTIVE
  Hemicraniectomy in patients with malignant middle cerebral artery (mMCA) infarct may be life-saving. The long-term prognosis is unknown.
  
  
  METHODS
  Patients with mMCA infarct treated with hemicraniectomy between 1998 and 2002 at three hospitals were included. The criterion for surgical intervention was if the patients deteriorated from awake to being responding to painful stimuli only. All patients were followed for at least 1 year. Outcome was defined as alive/dead, walkers/non-walkers or modified Rankin Scale (mRS) score <or=2.
  
  
  RESULTS
  Thirty patients were included (median age at stroke onset 49 years, range 17-67 years). Fourteen patients had mMCA infarct on the left side and 16 patients on the right side. Fourteen patients had pupil dilatation before surgery. Hemicraniectomy was performed at a median of 52 h (range 13-235 h) after stroke onset. Nine patients died within 1 month after surgery because of cerebral herniation (n = 6), myocardial infarction (n = 1) or intensive care complications (n = 2). No further deaths occurred during follow-up, which was at median 3.4 years after surgery. Status for the 21 survivors at the last follow-up was: mRS 2 or less (n = 6) and mRS 3-5 (n = 15). The oldest patient with mRS 2 or less was 53 years at stroke onset. Thirteen patients (43%) could walk without substantial aid.
  
  
  CONCLUSIONS
  The long-term survival after mMCA infarction treated with hemicraniectomy seems to be favourable if the patient survives the acute phase. The outcome as measured with mRS may be better among younger patients.
authors.affiliation: Department of Clinical Neuroscience, University Hospital, Umeå, Sweden. Jan.Malm@neuro.umu.se
authors.forename: J
authors.initials: J
authors.lastname: Malm
authors.forename: A T
authors.initials: AT
authors.lastname: Bergenheim
authors.forename: P
authors.initials: P
authors.lastname: Enblad
authors.forename: H-G
authors.initials: HG
authors.lastname: Hårdemark
authors.forename: L-O D
authors.initials: LO
authors.lastname: Koskinen
authors.forename: S
authors.initials: S
authors.lastname: Naredi
authors.forename: C-H
authors.initials: CH
authors.lastname: Nordström
authors.forename: B
authors.initials: B
authors.lastname: Norrving
authors.forename: J
authors.initials: J
authors.lastname: Uhlin
authors.forename: A
authors.initials: A
authors.lastname: Lindgren
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000368:Aged; D003131:Combined Modality Therapy; D003399:Craniotomy; D003422:Critical Care; D019299:Decompression, Surgical; D004185:Disability Evaluation; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000401:mortality / Q000601:surgery* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011182:Postoperative Care; D011379:Prognosis; D011446:Prospective Studies; D015996:Survival Rate; D013548:Sweden; D013997:Time Factors