Abstract / Summary
Abstract Randomized trials established decompressive hemicraniectomy (DHC) as standard treatment for malignant middle cerebral artery (MCA) infarction but excluded patients with hemorrhagic transformation (HT). As HT occurs frequently after reperfusion therapies, evidence guiding surgical decision-making in this subgroup remains limited. Thus, we evaluated functional outcomes and the impact of quantitative infarct and hemorrhage burden in patients undergoing DHC for malignant infarction with preoperative HT. In this retrospective multicenter study, consecutive adults undergoing DHC for malignant MCA infarction with HT were included. Infarct and hemorrhage volumes were quantified using semiautomated region-of-interest analysis. The primary endpoint was 90 day modified Rankin Scale (mRS), analyzed using proportional odds regression. Binary logistic regression (mRS 2–4 versus 5–6) served as sensitivity analysis. Models were adjusted for age, treatment modality, infarct volume, and hemorrhage volume. Among 125 patients, in-hospital mortality was 27%. Ninety-day follow-up was available in 110 patients: 61% had mRS 5–6 and 39% achieved mRS 2–4. In adjusted proportional odds regression, infarct volume (OR 1.28 per 50 mL, 95% CI 1.05–1.56; p = 0.015) and hemorrhage volume (OR 1.13 per 10 mL, 95% CI 1.01–1.27; p = 0.037) were independently associated with worse 90-day mRS. In binary analysis, infarct volume remained significant (OR 1.23 per 50 mL; p = 0.042), while hemorrhage volume showed a consistent effect size (OR 1.11 per 10 mL; p = 0.064). Outcomes after DHC for malignant infarction with preoperative HT are poor and largely driven by cumulative structural injury.