title: Predictors of clinical failure of decompressive hemicraniectomy for malignant hemispheric infarction.
abstract: OBJECTIVE
  The aim of this study is to identify pre-operative clinical and/or radiological predictors of clinical failure of decompressive hemicraniectomy (DH) in the setting of malignant hemispheric infarction. These predictors could guide the decision for adjunctive internal brain decompression (e.g. strokectomy) at the time of the initial DH.
  
  
  METHODS
  Retrospective chart review of all patients with malignant hemispheric infarction who underwent DH at our institution, from November 2008 to January 2013. Demographics, pre- and post-operative clinical characteristics and neuroimaging data were reviewed. The surgical outcome after DH was evaluated and clinical failure was defined as follows: lack of post-operative resolution of basal cistern effacement, and/or failure to achieve a post-operative decrease in midline shift by at least 50%, and/or post-operative neurological deterioration felt to be due to persistent mass effect, with or without a second, salvage operation (strokectomy).
  
  
  RESULTS
  Out of 26 patients included in the study, 7 were considered to have clinical failure of their DH. Preoperative clinical and imaging variables were similar in the two groups, except that the presence of a nonreactive pupil immediately before surgery was associated clinical failure of the DH (p=0.0015). Patients in the clinical failure group had a lower postoperative GCS motor score and a strong but not statistically significant trend towards less favorable functional outcome (GOS 1-3).
  
  
  CONCLUSIONS
  The presence of a nonreactive pupil before surgery is associated with clinical failure of DH, and should be taken into account when deciding whether to perform strokectomy at the time of DH.
authors.affiliation: Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA.
authors.forename: Amedeo
authors.initials: A
authors.lastname: Merenda
authors.affiliation: Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA.
authors.forename: Jon
authors.initials: J
authors.lastname: Perez-Barcena
authors.affiliation: Investigation Unit, Son Espases Hospital, Palma de Mallorca, Spain.
authors.forename: Guiem
authors.initials: G
authors.lastname: Frontera
authors.affiliation: Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA. Electronic address: RBenveniste@med.miami.edu.
authors.forename: Ronald J
authors.initials: RJ
authors.lastname: Benveniste
mesh_terms: D000328:Adult; D000368:Aged; D020520:Brain Infarction / Q000601:surgery*; D003399:Craniotomy / Q000379:methods*; D019299:Decompression, Surgical / Q000379:methods*; D005260:Female; D007839:Functional Laterality / Q000502:physiology*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D015898:Tomography Scanners, X-Ray Computed; D017211:Treatment Failure; D016896:Treatment Outcome
keywords: Hemicraniectomy; Stroke; Strokectomy