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Infarct Volume and Age Before Hemicraniectomy Predict Outcome After Malignant Infarction

Functional outcomes after malignant middle cerebral artery infarction are strongly correlated with infarct size and age prior to hemicraniectomy, according to a prospective, multicenter study published online on April 19 in Neurology.

An infarct volume greater than 258 mL prior to hemicraniectomy was associated with unfavorable long-term outcomes with high specificity across all ages, reported Dominik Lehrieder, MD, of University of Würzburg in Germany, and colleagues.

The relationship between functional outcome and volume in malignant middle cerebral artery infarction has been assessed in a limited number of studies, using different methodologies and study designs, the researchers noted.

Prior research has reported a positive association between  infarct volumes after surgery, before surgery, or both with either MRI or CTI and complete outcome evaluation at three, six, or 12 months. However, infarct volume thresholds to determine favorable outcomes were substantially greater than that used in the current study, they noted.

“Standardized volumetry of the infarct may help to support decision making in malignant middle cerebral artery infarction, especially whether to perform hemicraniectomy or not by guiding in the estimation of  the risk-benefit ratio in individual patients. However, these decisions should, of course, never be based on one single parameter or even on a certain cut-off value alone. It can, at best, only be one parameter in the clinical decision algorithm and should also not be overrated compared to well-established predictors, such as age," they wrote.  

The research team evaluated 140 patients with complete data sets from the DESTINY-Registry who had hemicraniectomy following ischemic infarction that exceeded 50 percent of the middle cerebral artery region.

They used the modified Rankin Scale (mRS) to determine functional outcomes at 12 months follow-up. Patients with mRS scores of four to six were considered to have had unfavorable outcomes.​

Seventy-five percent of patients had unfavorable outcomes as indicated by a mRS score greater than three.  The average infarct volume was 238 mL.

Infarct size (odds ratio 1.27 per 10 mL increase; p<0.001), the NIH Stroke Scale Score (OR 1.10; p=0.030), and age (OR 1.08 per one year increase; p=0.004) before hemicraniectomy were independent indicators of unfavorable outcomes.

Limitations of the study include potential selection bias as the study had a non-randomized design, and the sample size in the cohort of patients with favorable outcomes was small, the researchers noted.

Another limitation of the study was that the inclusion of 30 low- and high-volume departments may contribute to heterogeneous imaging data, outcome measures, and treatment, they added.


Dr. Lehrieder did not report any conflicts of interest.

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Lehrieder D, Layer K, Müller HP, et al. Association of Infarct Volume Before Hemicraniectomy and Outcome After Malignant Infarction. Neurology 2021; Epub 2021 Apr 19.