Introduction: Life threatening, space occupying, infarction develops in 10-15% of patients after middle cerebral artery infarction (MCAI). Conservative management is associated with an 80% mortality. Decompressive craniectomy (DC) has been shown to improve outcome in such patients. Data regarding the definitive role of DC in dominant MCAI (DMCAI) is lacking as most studies have addressed patients with non-dominant MCAI. This may reflect the reluctance of surgeons and family members to save the life of a patient who may remain hemiplegic and dysphasic. This study specifically addresses this issue.

Methods: This retrospective analysis studied patients with DMCAI undergoing DC. Glasgow outcome scale (GOS), Barthel index (BI) and improvements in language and motor function were evaluated to determine the effect of DC on functional outcome.

Results: Eighteen patients between 22-72 years of age qualified for this study. Six week, three month, six month and overall survival rates in our study were 66.6% (12/18), 64%(11/17), 62.5% (10/16) and 62.5% (10/16) respectively. Amongst the ten surviving patients with long term follow up, 60 % showed an improvement in GOS, 70% achieved a BI score >60 while 30% achieved full functional independence. In this group, motor power and language function improved in 9 and 8 patients respectively. At last follow-up, 8 of 10 surviving patients were ambulatory with (3/8) or without (5/8) support. Age <50 years corresponded with better functional outcome amongst survivors (p value- 0.0068).

Conclusions: Language and motor outcomes after DC in patients with DMCAI are not as dismal as perceived. Perhaps young patients (< 50 years) with DMCAI should be treated with the same aggressiveness that non-dominant MCAI is dealt with currently.

Patient Care: Our study was designed with the specific aim of providing neurosurgeons with the data to realistically prognosticate outcome after decompressive craniectomy in patients with dominant MCA territory infarcts. The outcome is not as grim as would be expected, which is evident from the results of our study.We feel that a subset of patients with dominant MCA infarct (<50 years of age)will benefit from decompressive craniectomy and should be treated with same aggressiveness that non-dominant MCA infarcts are now dealt with, thereby giving these patients a chance of functional independence and improvement in language function.

Learning Objectives: To assess the impact of decompressive craniectomy on the functional outcome, language funcion and prognosis in dominant middle cerebral artery infarction

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