Malignant Middle Cerebral Artery Infarction Decompressive Craniectomy Score: A Prognostic Model for Malignant Middle Cerebral Artery Infarction Patients Treated with Decompressive Craniectomy.

Abstract

Malignant middle cerebral artery infarction (MMI) is a severe condition caused by space-occupying brain edema due to ischemia. While decompressive hemicraniectomy (DC) improves outcome, many survivors experience lasting disabilities, and tools to predict outcome are lacking. We aimed to identify independent predictors of outcome following DC in MMI and to create a pragmatic, bedside tool for patient prognostication. This retrospective, multicenter study analyzed 318 MMI patients treated with DC at 4 Swedish university hospitals (2008-2022). Demographic, preoperative, and postoperative variables were collected from medical records. Six-month modified Rankin Scale (mRS) was the primary endpoint, with favorable outcome defined as mRS 0-3. Univariable and multivariable ordinal logistic regressions were employed to identify independent predictors of mRS. Significant independent preoperative variables were included in the malignant middle cerebral artery infarction DC (MAD) score. Median age was 56 (interquartile range: 48-61) years; 75% were male. At 6 months, median mRS was 4 (4-5), 24% achieved favorable outcome, and 17% were deceased. MAD score assigned 1 point to each independent preoperative predictor of worse outcome: higher age (≥ 60 years), female sex, lower Glasgow Coma Scale Motor score (< 4), and impaired pupillary reactivity (all P ≤ 0.03). MAD-stratified outcome, ordered from 0 to 4 points, was 32%, 25%, 15%, 0%, and 0% (favorable outcome) and 9%, 16%, 23%, 40%, and 100% (mortality). A large proportion of MMI patients recover unfavorably following DC. The presented MAD score was an internally reliable prognostic tool for MMI patients treated with DC. External validity of MAD and predictive value of female sex should be further explored.