Early decompressive hemicraniectomy combined with mild hypothermia treatment for malignant middle cerebral artery infarction

Background Decompressive hemicraniectomy (DHC) and mild hypothermia (MH) have been recommended as lifesaving management strategies for patients with uncontrolled intracranial pressure (ICP), such as malignant middle cerebral artery (MCA) infarction. However, relevant clinical studies to substantiate this are lacking. Methods A retrospective comparative cohort conducted at three centers between January 2017 and January 2023 enrolled 210 patients with malignant MCA infarction were treated with DHC, 119 patients who underwent DHC + MH, and another 91 patients who underwent DHC surgery alone. Information was obtained regarding patient characteristics during follow-up. Six-month clinical outcomes (6-month mRS score) and 30-day all-cause mortality were analyzed. We also explored differences in post-operative complications between the two groups. Results Both groups had comparable baseline characteristics, with no significant differences observed. Lower NIHSS scores ( OR = 0.179, 95% CI: 1.070–1.336, P = 0.002), and early DHC ( OR = 0.171, 95% CI: 1.113–1.264, P = 0.000) may be more beneficial for the patient's prognosis. At 6 months, the DHC + MH group had better mRS scores ( P = 0.025) and 30-day all-cause mortality (17.6 vs. 29.7%, P = 0.04). There were significant differences in shivering (46.2% vs. 6.6%, P = 0.000), bradycardia (68.1% vs. 38.5%, P = 0.000), electrolyte disturbance (65.5% vs. 38.5%, P = 0.002), and acidosis (35.5% vs. 18.7%, P = 0.008), and the occurrence of these complications was significantly greater in the DHC + MH group than in the DHC alone group. There was no difference in delayed intracranial hematomas, pneumonia, acute kidney injury (AKI) or coagulation disorders. Conclusions In this retrospective multi-center cohort, mild hypothermia during decompressive hemicraniectomy was associated with favorable unadjusted outcomes. Given non-randomized allocation and potential confounding, these findings are hypothesis-generating and require confirmation with adjusted analyses and prospective evaluation. The procedure needs to be validated in larger, multicenter, prospective, randomized controlled trials.