Long-term functional outcomes and caregiver burden in survivors after decompressive hemicraniectomy for malignant hemispheric infarction: a real-world experience from South India

Background: Malignant hemispheric infarction (MHI) is associated with high early mortality when managed conservatively. Decompressive hemicraniectomy (DHC) improves survival, but long-term functional outcomes and caregiver burden in low-resource settings remain poorly characterised, particularly in India. This study aimed to evaluate long-term outcomes and caregiver burden among MHI survivors undergoing DHC at a tertiary care centre in South India. Methods: We conducted an ambispective study of adult patients who underwent DHC for MHI between 2018 and 2023 and had at least 6 months of follow-up. Functional outcome was assessed using the modified Rankin Scale (mRS) and caregiver burden was evaluated using the Zarit Burden Interview. Subgroup analyses were performed based on infarct lateralisation and timing of surgery. Logistic regression was used to identify predictors of a favourable functional outcome. Results: 66 patients (mean age 44±12.8 years; 80% male) were included, with a median follow-up of 2 years (IQR: 1-4). Overall mortality was 24.2% (n=16). Among the 50 survivors, 26 (52.0%) achieved a good functional outcome (mRS ≤3) and 13 (26.0%) achieved an excellent outcome (mRS ≤2). Infarct lateralisation did not significantly influence mortality or functional recovery. Although early surgery and higher admission Glasgow Coma Scale scores were associated with better outcomes in univariate analysis, these factors were not significant in multivariate models. Caregivers of patients with mRS >2 reported significantly higher burden, particularly in emotional, physical and social domains. Conclusions: DHC for MHI results in meaningful long-term survival and functional recovery in selected patients, regardless of hemisphere involvement. However, residual disability imposes a substantial caregiver burden. Stroke care pathways in resource-limited settings should incorporate comprehensive rehabilitation and long-term caregiver support.