Discussion
herniation, malignant infarction, osmotherapy, deaths, infarct
MUSCLE RELAXATION, INFARCT, MIDDLE CEREBRAL ARTERY INFARCT, COMPLICATIONS
Despite early prophylactic hemicraniectomy almost 20% of patients who suffer a malignant middle cerebral artery infarction still die. Most deaths occur early and are due to herniation which raises the question if some patients might benefit from a larger hemicraniectomy or if a larger hemicraniectomy in general could be beneficial [Mortality in this study population was similar compared to patients treated with hemicraniectomy in the pooled analysis of RCTs in younger patients with malignant infarction [Since infarct volume can predict outcome after decompressive hemicraniectomy [In RCTs, the rates of hemicraniectomy-related complications were comparatively lower (9% and 7%, respectively) [In our cohort osmotherapy and muscle relaxation were applied more frequently in the standard hemicraniectomy group. Although both treatments had no impact on functional outcome in multivariable analyses, the increased use of osmotherapy and muscle relaxation in patients with smaller hemicraniectomies may be indicative of a poorer control of intracranial pressure compared to patients with larger bone flaps.Despite the strengths of a prospective multicenter registry, our study is not without limitations: it is a non-randomized study and the decision of timing, diameter, and technique of the hemicraniectomy was left at the discretion of the treating neurosurgeon. Hemicraniectomy with duraplasty as a procedure was not standardized [In conclusion, our results do not provide evidence that large hemicraniectomy is beneficial regarding functional outcome or mortality as compared to standard hemicraniectomy in unselected patients with malignant middle cerebral artery infarction treated by hemicraniectomy. Although our results indicate that standard hemicraniectomy may be associated with less complications and is sufficient in most cases, selected patients may still benefit from a larger diameter hemicraniectomy to achieve the best possible outcome. This relevant question should be addressed in a randomized controlled trial.