Background: Decompressive hemicraniectomy (DHC) is life-saving in patients with malignant middle cerebral artery infarction (MMI), but outcome, perspectives and complications after DHC in daily practice are largely unknown. Methods: From 2008 until 2014, we extracted patient's characteristics as well as complications from our database for patients with MMI who underwent DHC. Additionally, we analysed medical records from the different rehabilitation steps. Results: We identified 48 consecutive patients (mean 57 years, 21 male, 41.7% >60 years) with MMI who underwent DHC. The decision for DHC was made on an individual basis, including patients without impaired consciousness or stroke onset >48 h. In-hospital patients achieved only marginal clinical improvement. Seventy-five percent attended an early-rehabilitation, 44% achieved post-stroke rehabilitation and 6% carried on late-stage rehabilitation. In all, 45.5% returned home after rehabilitation. In-hospital mortality was 14.6%, overall mortality was 16.7%. Surviving patients (78.9%) had a modified Rankin Scale of 4-5. Frequent neurologic complications were symptomatic epilepsy and delirium. Following DHC/bone-flap-reimplantation, wound-healing disorders, epidural hematoma and wound infections were major surgery-related complications. Pulmonary infections were frequent in the acute-phase and urinary tract infections were predominant in the late-phase. Conclusions: DHC is a life-saving technique in patients with MMI, but complications are frequent, were underestimated in randomized clinical trials and may worsen the functional outcome.

Neugebauer H, Jüttler E: Hemicraniectomy for malignant middle cerebral artery infarction: current status and future directions. Int J Stroke 2014;9:460-467.
Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R: ‘Malignant' middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol 1996;53:309-315.
Krieger DW, Demchuk AM, Kasner SE, Jauss M, Hantson L: Early clinical and radiological predictors of fatal brain swelling in ischemic stroke. Stroke 1999;30:287-292.
Kruetzelmann A, Hartmann F, Beck C, et al: Combining magnetic resonance imaging within six-hours of symptom onset with clinical follow-up at 24 h improves prediction of ‘malignant' middle cerebral artery infarction. Int J Stroke 2014;9:210-214.
Vahedi K, Vicaut E, Mateo J, et al: Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL trial). Stroke 2007;38:2506-2517.
Jüttler E, Schwab S, Schmiedek P, et al: Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY): a randomized, controlled trial. Stroke 2007;38:2518-2525.
Hofmeijer J, Kappelle LJ, Algra A, et al: Surgical decompression for space-occupying cerebral infarction (the hemicraniectomy after middle cerebral artery infarction with life-threatening edema trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol 2009;8:326-333.
Vahedi K, Hofmeijer J, Juettler E, et al: Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 2007;6:215-222.
Jüttler E, Unterberg A, Woitzik J, et al: Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 2014;370:1091-1100.
Yang MH, Lin HY, Fu J, Roodrajeetsing G, Shi SL, Xiao SW: Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: a systematic review and meta-analysis. Surgeon 2015;13:230-240.
Rahme R, Zuccarello M, Kleindorfer D, Adeoye OM, Ringer AJ: Decompressive hemicraniectomy for malignant middle cerebral artery territory infarction: is life worth living? J Neurosurg 2012;117:749-754.
Kiphuth IC, Köhrmann M, Lichy C, Schwab S, Huttner HB: Hemicraniectomy for malignant middle cerebral artery infarction: retrospective consent to decompressive surgery depends on functional long-term outcome. Neurocrit Care 2010;13:380-384.
Agarwalla PK, Stapleton CJ, Ogilvy CS: Craniectomy in acute ischemic stroke. Neurosurgery 2014;74(suppl 1):S151-S162.
Schmidt H, Heinemann T, Elster J, et al: Cognition after malignant media infarction and decompressive hemicraniectomy - a retrospective observational study. BMC Neurol 2011;11:77.
Thomalla G, Fiebach JB, Østergaard L, et al: A multicenter, randomized, double-blind, placebo-controlled trial to test efficacy and safety of magnetic resonance imaging-based thrombolysis in wake-up stroke (WAKE-UP). Int J Stroke 2014;9:829-836.
Farquharson SM, Gupta R, Heald RJ, Moran BJ: Surgical decisions in the elderly: the importance of biological age. J R Soc Med 2001;94:232-235.
Lucas C, Thines L, Dumont F, et al: Decompressive surgery for malignant middle cerebral artery infarcts: the results of randomized trials can be reproduced in daily practice. Eur Neurol 2012;68:145-149.
Suyama K, Horie N, Hayashi K, Nagata I: Nationwide survey of decompressive hemicraniectomy for malignant middle cerebral artery infarction in Japan. World Neurosurg 2014;82:1158-1163.
Rahmanian A, Seifzadeh B, Razmkon A, et al: Outcome of decompressive craniectomy in comparison to nonsurgical treatment in patients with malignant MCA infarction. Springerplus 2014;3:115.
Rai VK, Bhatia R, Prasad K, et al: Long-term outcome of decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: a prospective observational study. Neurol India 2014;62:26-31.
McKenna A, Wilson FC, Caldwell S, Curran D, Nagaria J, Convery F: Long-term neuropsychological and psychosocial outcomes of decompressive hemicraniectomy following malignant middle cerebral artery infarctions. Disabil Rehabil 2012;34:1444-1455.
Weil AG, Rahme R, Moumdjian R, Bouthillier A, Bojanowski MW: Quality of life following hemicraniectomy for malignant MCA territory infarction. Can J Neurol Sci 2011;38:434-438.
Ragoschke-Schumm A, Junk C, Lesmeister M, et al: Retrospective consent to hemicraniectomy after malignant stroke among the elderly, despite impaired functional outcome. Cerebrovasc Dis 2015;40:286-292.
Zweckberger K, Juettler E, Bösel J, Unterberg WA: Surgical aspects of decompression craniectomy in malignant stroke: review. Cerebrovasc Dis 2014;38:313-323.
Ding J, Guo Y, Tian H: The influence of decompressive craniectomy on the development of hydrocephalus: a review. Arq Neuropsiquiatr 2014;72:715-720.
Honeybul S, Ho KM: The current role of decompressive craniectomy in the management of neurological emergencies. Brain Inj 2013;27:979-991.
Klehmet J, Harms H, Richter M, et al: Stroke-induced immunodepression and post-stroke infections: lessons from the preventive antibacterial therapy in stroke trial. Neuroscience 2009;158:1184-1193.
Dirnagl U, Iadecola C, Moskowitz MA: Pathobiology of ischaemic stroke: an integrated view. Trends Neurosci 1999;22:391-397.
Durga P, Meena AK, Panigrahi MK, Sahu BP, Ramachandran G: Serious cardiac adverse events after decompressive craniectomy for malignant cerebral infarction. J Neurosurg Anesthesiol 2011;23:236-240.
Macdonald RL: Seizures after craniectomy: an under-recognised complication? J Neurol Neurosurg Psychiatry 2014;85:714.
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