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Decompressive hemicraniectomy (DH) has been shown to reduce mortality in patients with malignant middle cerebral artery (MCA) territory infarction. However, many patients survive with moderate-to-severe disability and controversy exists as to whether this should be considered good outcome. To answer this question, we assessed the quality of life (QoL) of patients after DH for malignant MCA territory infarction in our milieu.
The outcome of all patients undergoing DH for malignant MCAterritory infarction between 2001 and 2009 was assessed using retrospective chart analysis and telephone follow-up in survivors. Functional outcome was determined using Glasgow outcome scale, modifed Rankin scale (mRS), and Barthel index (BI). The stroke impact scale was used to assess QoL.
There were 14 patients, 6 men and 8 women, with a mean age of 44 years (range 27-57). All patients had reduced level of consciousness preoperatively. Five had dominant-hemisphere stroke. Median time to surgery was 45 hours (range 1- 96). Two patients died and one was lost to follow-up. Of 11 survivors, 7 (63.6%) had a favorable functional outcome (mRS<4). No patient was in persistent vegetative state. Despite impaired QoL, particularly in physical domains, the majority of interviewed patients and caregivers (7 of 8), including those with dominant-hemisphere stroke, were satisfied after a median follow-up of 18 months (range 6-43).
Most patients report satisfactory QoL despite significant disability even in the face of moderate-to-severe disability and dominant-hemsiphere stroke. Dominant-hemisphere malignant MCA territory infarction should not be considered a contraindication to DH.
The long-term outcome after lumbar microdiscectomy (LMD) may be affected by low back pain (LBP) and segmental instability, the determinants of which remain unclear. We sought to analyze the interaction between clinical, functional, and radiological variables and their impact on patient outcome.
All patients who underwent LMD in 2004-2005 were invited to participate in this retrospective cohort study. Patients were re-evaluated clinically and radiologically after a three to five year follow-up.
Forty-one of 97 eligible patients were enrolled. Twelve patients (29.3%) reported moderate-to-severe sciatica, 12 (29.3%) had moderate LBP, and 13 (31.7%) exhibited clinical evidence of segmental instability. Thirty-eight patients (92.7%) had minimal disability and 3 (7.3%) had moderate disability. Twenty-three patients (56.1%) were fully satisfied, while 18 (43.9%) had only partial satisfaction, having expected a better outcome. Thirty-three patients (80.5%) returned to full-time work. Median disc space collapse (DSC) was 20% (range 5-66%) and L4-L5 was particularly affected. Prevalence of Modic changes increased from 46.3% to 78% with type 2 predominance. Multivariate logistic regression analysis identified the following negative prognostic factors: female sex, young age, lack of regular exercise, and chronic preoperative LBP. There was no correlation between the course of Modic changes, DSC, and patient outcome.
Although many patients may be symptomatic following LMD, significant disability and dissatisfaction are uncommon. Female sex, young age, lack of exercise, and chronic preoperative LBP may predict a worse outcome. Disc collapse is a universal finding, particularly at L4-L5. Neither DSC nor Modic changes seem to affect patient outcome.