title: Outcome following decompressive craniectomy for malignant middle cerebral artery infarction in children.
abstract: OBJECTIVE
  Mortality from malignant middle cerebral artery infarction (MMCAI) approaches 80% in adult series. Although decompressive craniectomy decreases mortality and leads to an acceptable outcome in selected adult patients, there are few data on MMCAI in children with stroke. This study evaluated the frequency of MMCAI and the use of decompressive craniectomy in children.
  
  
  METHODS
  We retrospectively reviewed cases of MMCAI from five pediatric tertiary care centers.
  
  
  RESULTS
  Ten children (two females, eight males; median age 9y 10mo, range 22mo-14y) had MMCAI, with a median Glasgow Coma Scale score of 6 (range 3-9). MMCAI represented fewer than 2% of cases of pediatric arterial ischemic stroke. Three patients who did not undergo decompression, all of whom had monitoring of intracranial pressure, developed intractable intracranial hypertension, and fulfilled criteria for brain death. In contrast, seven patients underwent decompressive craniectomy and survived, with rapid improvement in their level of consciousness postoperatively. All seven survivors now walk independently with mild to moderate residual hemiparesis and speak fluently, even though four had left-sided infarcts.
  
  
  CONCLUSIONS
  Decompressive craniectomy can lead to a moderately good outcome for children with MMCAI and should be considered, even with symptomatic stroke and deep coma. Monitoring of intracranial pressure may delay life-saving treatment.
authors.affiliation: Department of Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA. smithsa@email.chop.edu
authors.forename: Sabrina E
authors.initials: SE
authors.lastname: Smith
authors.forename: Fenella J
authors.initials: FJ
authors.lastname: Kirkham
authors.forename: Gabrielle
authors.initials: G
authors.lastname: Deveber
authors.forename: Guy
authors.initials: G
authors.lastname: Millman
authors.forename: Peter B
authors.initials: PB
authors.lastname: Dirks
authors.forename: Elaine
authors.initials: E
authors.lastname: Wirrell
authors.forename: Albert E
authors.initials: AE
authors.lastname: Telfeian
authors.forename: Kim
authors.initials: K
authors.lastname: Sykes
authors.forename: Karen
authors.initials: K
authors.lastname: Barlow
authors.forename: Rebecca
authors.initials: R
authors.lastname: Ichord
mesh_terms: D000293:Adolescent; D001794:Blood Pressure / Q000502:physiology; D001926:Brain Death; D002648:Child; D002675:Child, Preschool; D056424:Decompressive Craniectomy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D007223:Infant; D020244:Infarction, Middle Cerebral Artery / Q000503:physiopathology / Q000601:surgery*; D019586:Intracranial Hypertension / Q000209:etiology; D007427:Intracranial Pressure / Q000502:physiology; D008279:Magnetic Resonance Imaging; D008297:Male; D012189:Retrospective Studies; D016896:Treatment Outcome