Retrospective Consent to Hemicraniectomy after Malignant Stroke among the Elderly, Despite Impaired Functional Outcome.
BACKGROUND
Decompressive hemicraniectomy (DHC) after space-occupying strokes among patients older than 60 years has been shown to reduce mortality rates but at the cost of severe disability. There is an ongoing debate about what could be considered an acceptable outcome for these patients. Data about retrospective consent to the procedure after lengthy time periods are lacking.


METHODS
This study included 79 consecutive patients who underwent DHC during a 7.75-year period. Surviving patients were assessed for functional and psychological outcome, quality of life (QoL) and retrospective consent for the procedure. Patients younger than 60 years were compared with older patients.


RESULTS
Of our 79 patients, 44 were younger than 60 years (median 50 years, interquartile range (IQR) 19-59 years) and 35 were older (median 68 years, interquartile range 60-87 years). The 30-day mortality rate was higher for the older group, but the difference was not statistically significant. Functional outcome was significantly better in the younger group: 31% of the patients in this group vs. 10% in the older group had a modified Rankin Scale score of 0-3 (p = 0.046). The mean National Institutes of Health Stroke Scale score was 17 ± 14 for the younger group and 29 ± 15 for the older group (p = 0.002). On the 36-Item Short Form Health Survey, with the exception of the item 'General health', the older group reported higher values for all items, with statistically significant differences between the 2 groups on the items 'Role limitation emotional' (p = 0.0007) and 'Vitality' (p = 0.02). In the younger group, 29% of patients retrospectively declined consent for DHC opposed to 0% of patients in the older group (p = 0.07).


CONCLUSIONS
Despite impaired functional outcome after DHC, indicators of QoL and retrospective consent are higher for patients older than 60 years over the long term. This finding should be taken into account by those who counsel patients and caregivers with regard to this serious procedure.
Department of Neurology, Saarland University Medical Center, Homburg, Germany.
Andreas
A
Ragoschke-Schumm
Christina
C
Junk
Martin
M
Lesmeister
Silke
S
Walter
Stefanie
S
Behnke
Julia
J
Schumm
Klaus
K
Fassbender
D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001925:Brain Damage, Chronic / Q000453:epidemiology / Q000209:etiology* / Q000469:parasitology; D001929:Brain Edema / Q000209:etiology / Q000601:surgery*; D016208:Databases, Factual; D056424:Decompressive Craniectomy / Q000523:psychology; D000066498:Emotional Adjustment; D005260:Female; D005858:Germany / Q000453:epidemiology; D006801:Humans; D007258:Informed Consent; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D017060:Patient Satisfaction; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology*; D011788:Quality of Life; D020127:Recovery of Function; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D020521:Stroke / Q000150:complications* / Q000401:mortality; D017741:Survivors / Q000523:psychology; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult