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NEUROSAE 2018 ANNUAL MEETING EDITION (VOLUME 10, ISSUE 3)
QUESTION 38 OF 100

38.
A 68-year-old woman presents with global aphasia, with left gaze preference and right hemiplegia 24 hours after she was last seen normal. Initial CT scan shows a malignant left middle cerebral artery (MCA) acute infarct. Ten hours later, her level of consciousness decreases markedly, and repeat head CT scan shows infarction throughout the entire left MCA territory, with near complete effacement of the left lateral ventricle and 8 mm of midline shift to the right. The patient must undergo an emergent hemicraniectomy but the family is concerned about risk and outcome for function and quality of life. Which of the following statements best describes the anticipated outcome for patients this age following decompressive hemicraniectomy?

A. Patients who survive following DH have a greater chance of complete recovery.
B. Clinical outcome following DH is independent of patient age
C. Patients who survive following DH have significant disability even if treated. **
D. DH does not increase the chance of survival in patients in this age group.
E. Medical management is associated with a better outcome for patients in this age group.
** = Your answer
Decompressive hemicraniectomy (DH) improves survival in patients with large middle cerebral artery strokes associated with significant cerebral edema (so-called malignant infarctions). Data indicate that patients age 60 years and older report a higher likelihood of improved outcome following DH than patients treated with intensive medical management alone as measured primarily by the modified Rankin scale. Survivors, however, are left with considerable disability. In one study of patients age <60 years, no subjects had a Rankin score <2, and in a more recent study, patients age >60 years, no subjects had a Rankin score <3. A likely outcome of survival with considerable disability must be factored into shared decision making with patients and families when discussing risks associated with DH.
References
* Juttler E et al. Hemicraniectomy in older adults with extensive middle cerebral artery stroke. N Engl J Med. 2014; 370:1091-1100.

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