Hemicraniectomy-iconAn interesting study on outcomes for hemicraniectomies after extensive middle-cerebral-artery stroke. Hemicranectomies in cerebral oedema is not new, and has shown improved survival, but at the cost of severe disability. But what do the patients say?

Crunch time
Well, some of the surviving patients say nothing at all. They can’t communicate with the outside world in any meaningful way. The rest are, a little surprisingly, greatly in favour of the intervention that saved them from death, despite the now severe disability.

The study shows improved survival in the hemicraniectomy group, but not surprisingly, the survivors are severely disabled. They’ve had the most extensive strokes, producing the greatest oedeama, saved by the hemicraniectomy. So the craniectomy doesn’t seem to do any neurological damage, but rather just saving more of the really sick ones. Unfortunately, the stroke damage already done is irreparable.

On a Modified Rankin Scale, some of the extra survivors get a 3, but most get a 4 – Moderately severe disability: Unable to attend to own bodily needs without assistance, and unable to walk unassisted. That’s tough.

Medicine and ethics
It opens up a Pandora’s Box of ethics. I think many of us would turn down the hemicraniectomy a priori. When we’re healthy, we can’t imagine being severely disabled, not being able to move around on our own and take care of our own basic needs, maybe not even speak. But in retrospect, it might look quite different. Being alive might be worth the price after all, according to the survivors in this study. Then again, the positive answers could be coloured by the fact that you’re trying to cope with surviving with severe disability.

So, should you try doing a hemicraniectomy on a previously healthy 70-year-old with a now extensive stroke, when you know he’ll end up with severe disabilities? Would the patient want that? Statistics say yes, but for the individual patient it’s either yes or no.

Hemicraniectomy — To Halve or Halve Not, Editorial, NEJM, Mar 2014.

Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke, NEJM, Mar 2014.

Decompressive hemicraniectomy for malignant middle cerebral artery territory infarction: is life worth living?, J Neurosurg, 2012.

Decompressive hemicraniectomy for malignant middle cerebral artery infarction: an update, Neurology 2009.

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