Surviving space-occupying cerebral infarction A fate worse than death?

Patients with space-occupying hemispheric infarction have a poor prognosis, with case fatality rates of up to 78% if treated conservatively.1 The only treatment option of proven benefit is surgical decompression through removal of a large part of the skull ipsilateral to the infarct, followed by a duraplasty—a hemicraniectomy. A pooled analysis of 3 small randomized controlled trials2–4 showed a large reduction in case fatality (71% vs 21%; absolute risk reduction, 50%; 95% confidence interval 34%–66%) after surgical decompression within 48 hours of stroke onset, compared to medical treatment. The chance of a favorable functional outcome at 12 months, defined as a score on the modified Rankin scale (mRS) ≤3, increased from 24% to 40%. Unfortunately, this large reduction in case fatality came at the expense of an increase in severe disability (mRS 4–5) at 12 months,4 from 6% to 40%. Because of the increase in severely disabled survivors, many have expressed concern about decompressive surgery on long-term quality of life. In randomized trials, this issue has received far less attention than that of death or dependency. Quality of life was assessed among survivors in 2 …