Predictive Factors of Morbidity and Mortality Following Decompressive Hemicraniectomy

Introduction: Hemicraniectomies have been established as a life-saving measure for patients predominantly experiencing malignant cerebral edema or hemorrhagic events. This procedure involves the removal of approximately 15 cm of the frontotemporoparietal cranium to allow for decompression of the brain. However, morbidity and mortality following hemicraniectomies remain high. Factors that can predict expected disability or mortality following hemicraniectomy are not well established.

Methods: We investigated all patients ≥18 years old who received a hemicraniectomy for stroke or hemorrhage at our institution between January 2017-December 2023. A retrospective chart review was performed to collect information on patient demographics, surgical characteristics, and postoperative course. Exclusion criteria included pediatric patients and patients who did not receive hemicraniectomy. Descriptive statistics for patient demographics were run using medians and means. Logistic regression analysis was performed with variables retained after backwards stepwise removal using a minimum AICc cut-off.

Results: 131 patients were included in this study. The mean age was 51.8 (+/- 13.4) years with an equal split of males (47%) vs. females (53%). The majority of patients had a history of smoking (61.1%) and hypertension (62.6%). 64.1% (83) of patients had right-sided surgery, 32.8% (43) had left-sided surgery, with the final 3.1% (4) having bilateral surgery. In total, 48.1% (63) patients experienced hemicraniectomy-related post-operative complications within 90 days of surgery. These complications included: 27.5% (36) post-operative mortality, 13.7% (18) hemorrhagic, 9.2% (11) seizures, 5.3% (7) wound-related, 5.3% (7) infectious, and 3.8% (5) hydrocephalus. Logistic regression modeling of post-operative mortality demonstrated age at operation (p = 0.0058) and estimated blood loss (EBL) (p = 0.0497) as predictive factors. Age of operation (p = 0.452) was the only variable predictive of 90-day post-operative morbidity.

Conclusion : Hemicraniectomies have been implemented as tools to increase survivability for patients requiring intracranial decompression following hemorrhage. In line with what has been shown in the literature, this single-institution, retrospective study demonstrated age at operation and EBL as predictors of 90-day mortality following decompressive hemicraniectomy.