title: Large Size Hemicraniectomy Reduces Early Herniation in Malignant Middle Cerebral Artery Infarction.
abstract: Decompressive hemicraniectomy (DHC) reduces mortality and improves outcome after malignant middle cerebral artery infarction (MMI) but early in-hospital mortality remains high between 22 and 33%. Possibly, this circumstance is driven by cerebral herniation due to space-occupying brain swelling despite decompressive surgery. As the size of the removed bone flap may vary considerably between surgeons, a size too small could foster herniation. Here, we investigated the effect of the additional volume created by an extended DHC (eDHC) on early in-hospital mortality in patients suffering from MMI.
  
  
  
  We performed a retrospective single-center cohort study of 97 patients with MMI that were treated either with eDHC (n = 40) or standard DHC (sDHC; n = 57) between January 2006 and June 2012. The primary study end point was defined as in-hospital mortality due to transtentorial herniation.
  
  
  
  In-hospital mortality due to transtentorial herniation was significantly lower after eDHC (0 vs. 11%; p = 0.04), which was paralleled by a significantly larger volume of the craniectomy (p < 0.001) and less cerebral swelling (eDHC 21% vs. sDHC 25%; p = 0.03). No statistically significant differences were found in surgical or non-surgical complications and postoperative intensive care treatment.
  
  
  
  Despite a more aggressive surgical approach, eDHC may reduce early in-hospital mortality and limit transtentorial herniation. Prospective studies are warranted to confirm our results and assess general safety of eDHC.
authors: Department of Neurology, University of Ulm, Ulm, Germany.
authors: Hermann
authors: H
authors: Neugebauer
authors: Ingo
authors: I
authors: Fiss
authors: Alexandra
authors: A
authors: Pinczolits
authors: Nils
authors: N
authors: Hecht
authors: Jens
authors: J
authors: Witsch
authors: Nora F
authors: NF
authors: Dengler
authors: Peter
authors: P
authors: Vajkoczy
authors: Eric
authors: E
authors: Jüttler
authors: Johannes
authors: J
authors: Woitzik
mesh_terms: D001929:Brain Edema / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D056424:Decompressive Craniectomy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D004677:Encephalocele / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D005260:Female; D005858:Germany; D017052:Hospital Mortality; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D065840:Protective Factors; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome