title: [Decompressive craniectomy in malignant middle cerebral artery infarction. Experience after the implementation of a response protocol].
abstract: BACKGROUND
  Descompressive craniectomy (DC) for treatment of malignant infarction of the middle cerebral artery (MIMCA) reduces mortality and increases the probability of favourable outcome.
  
  
  OBJECTIVE
  To present the experience in daily practice after implantation of a clinical protocol of DC.
  
  
  METHODS
  Prospective register of patients with MIMCA treated with DC. Age, stroke severity -National Institute of Health Stroke Scale (NIHSS) score-, basal characteristics, delay until DC, mortality, modified Rankin Scale (mRS) score at three and twelve months and questionnaire of satisfaction are recorded.
  
  
  RESULTS
  From February 2008 to December 2010, 15 patients were treated. Mean age: 60 years (range: 35-69); basal NIHSS, median (p25/p75): 17 (15.5/21), NIHSS before craniectomy: 20 (18/23.5). DC was performed within 48 hours in 8 patients (53.3%). 5 subjects (33.3%) died during in-hospital stay. Mortality was 25% among those treated within 48 hours and 42.9% among those treated later and 37.5% among patients <= 60 years vs 28.6% in older patients. All survivors scored <= 4 in the mRS at three months and expressed satisfaction with surgery despite sequelae. Rate of favourable outcome (mRS <= 3) was higher among patients under 60 (63%) and among those treated before 48 h (50%).
  
  
  CONCLUSIONS
  DC is safe in clinical practice and reduces mortality after MIMCA, especially if it is performed within 48 hours from stroke onset. Benefit appears to be greater in younger patients, but older people may benefit also. The decision to perform DC should be made on an individual basis.
authors.affiliation: Unidad de Ictus, Servicio de Neurologia, Hospital Universitario Ramon y Cajal, IRYCIS, Madrid, España.
authors.forename: Ignacio
authors.initials: I
authors.lastname: Hernández-Medrano
authors.forename: M Consuelo
authors.initials: MC
authors.lastname: Matute
authors.forename: Federico
authors.initials: F
authors.lastname: Abreu
authors.forename: Jaime
authors.initials: J
authors.lastname: Masjuán
authors.forename: Víctor
authors.initials: V
authors.lastname: Rodríguez
authors.forename: Juan
authors.initials: J
authors.lastname: Martínez-San Millán
authors.forename: Marta
authors.initials: M
authors.lastname: Guillán
authors.forename: Alicia
authors.initials: A
authors.lastname: de Felipe
authors.forename: Diego
authors.initials: D
authors.lastname: Medina
authors.forename: María
authors.initials: M
authors.lastname: Alonso de Leciñana-Cases
mesh_terms: D000328:Adult; D000368:Aged; D002985:Clinical Protocols; D056424:Decompressive Craniectomy; D005260:Female; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies