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Pranesh et al presented a series of 19 patients undergoing decompressive hemicraniectomy for large middle cerebral artery infarction with clinical and radiological signs of transtentorial herniation.1 Among these, 10 patients (53%) suffered from a dominant hemisphere stroke. Neurological state was assessed according to the National Institutes of Health Stroke scale (NIHSS) initially and one week after surgery, and functional outcome at three months' follow up using the Barthel index (BI) and Rankin scale (RS). The mean NIHSS score improved from 20.5 before surgery to 10.5 postoperatively. At last follow up mean BI was significantly better in younger patients (60.7) than in older patients (41.3). The authors conclude that hemicraniectomy may be a useful procedure on patients with large middle cerebral artery infarction.
Recently we undertook a prospective non-randomised study in 26 patients with decompressive hemicraniectomy for right sided middle cerebral artery infarction, analysing functional outcome (NIHSS, BI, RS) at one year of follow up.2 In contrast to all previous reports, neuropsychological testing was also done, focusing on right hemisphere function (evaluation of visuospatial and visuoconstructive abilities, attention, spatial span, and self rated mood). In 18 surviving patients at the one year follow up the functional outcome was good or fair in nine (BI >75, RS 2–3), moderate in six (BI 30–70, RS 4), and poor in three (BI 0–25, RS 5). Thus only nine of 26 patients (35%) were functionally independent and needed no or only minimal assistance for daily life activities. As was shown previously, 3 age was identified as a significant and independent predictive factor on outcome, with better functional results in younger patients. Neuropsychological testing was possible in 14 patients, while four were too disabled to be evaluated. All patients showed profound attention deficits, and visuospatial and visuoconstructive deficits was observed in those with less formal education. These disturbances led to a substantial handicap for professional activities.
On the basis of our functional and particularly neuropsychological results in patients with isolated non-dominant middle cerebral artery infarction, we would strongly discourage hemicraniectomy in patients with left sided, dominant hemisphere or multiterritory infarction, as there is a significantly higher risk of dependency, hopelessness, and more severe neuropsychological deficits in such cases. In our opinion decompressive hemicraniectomy should be restricted to younger patients with non-dominant hemisphere infarction. The goal of the procedure is to operate on these patients in an early stage of the disease, before additional infarction had occurred as a result of local mass effect and herniation. Up to now, we have operated on 39 patients with middle cerebral artery infarction in our institution, but our experiences do not encourage to us to act with great enthusiasm.
Pranesh et al stated correctly that this surgical procedure can be undertaken safely, however, the main difficulty is in deciding to not operate on such patients, despite the simplicity of the surgical procedure.
The points raised by Sandalcioglu et al are well taken. It was considered justified to undertake decompression even on the dominant side because, if such patients were left with a severe disability, the excellent family support system in India would be available. We do agree that the quality of life is poor after such a decompression. However, the recovery of speech function in our patients has been remarkable, apart from saving their lives which was the patients' relatives' wish.
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