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As the oedema spreads&#44; it compromises regional blood flow&#44; culminating in a large infarction&#44; which exerts a mass effect&#46; This leads to an uncontrolled increase in intracranial pressure&#44; which affects the rest of the parenchyma and brainstem&#44; leading to severe neurological deterioration&#44; followed by cerebral herniation and death&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Once this process has begun&#44; we know that even with the best intensive medical management&#44; the mortality rate is close to 80&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a> Consequently&#44; at this point one last surgical treatment step is considered as the only chance of saving life&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The procedure is decompressive craniectomy&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a> where part of the skull is removed to allow a swelling brain the room to expand&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Performing this procedure on patients with already established severe neurological damage&#44; with high chances of severe sequelae and the lack of precise clinical pathways to follow&#44; can be extremely disconcerting for healthcare professionals having to make multidisciplinary decisions about how to approach malignant infarction&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We present here a retrospective review of decompressive craniectomies performed to treat malignant infarction in our centre&#46; We assessed the functional prognosis&#44; the impact and the utility of the surgery&#46; Our aim was to obtain an overall view of the process&#44; to be able to use the data in future cases when considering this procedure&#44; and so offer more objective information to the families and healthcare professionals involved in making such an important decision&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Inclusion criteria</span><p id="par0035" class="elsevierStylePara elsevierViewall">Our review includes 21 patients treated in our centre by decompressive hemicraniectomy for a malignant infarction over the last 13 years &#40;2004&#8211;2017&#41;&#46; The clinical pathway of our stroke centre was followed&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Participants&#8217; age was restricted to those over 18&#44; with a diagnosis of malignant infarction originating in the middle cerebral artery and valid medical history and available imaging tests&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Questionnaires</span><p id="par0045" class="elsevierStylePara elsevierViewall">Specific questionnaires were addressed to family members of the patients and interviews were carried out by telephone&#44; using the DESTINY-S<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and other study surveys as a model&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Information was collected on the current situation&#44; home autonomy and opinion of family members&#46; We interviewed family members of survivors and of the deceased&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The modified Rankin scale &#40;mRS&#41; was chosen as it is a validated and specific scale within the scope of stroke&#44; in addition to being the most used by other working groups&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The mRS score was calculated at different points after surgery&#58; discharge&#44; 3 months&#44; 12 months and current &#40;at the time of the survey&#41;&#46; In the vast majority of cases it was possible to obtain the discharge and 3-month mRS scores using those reported in the discharge reports and at outpatient check-ups&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Epidemiological data and surgical technique</span><p id="par0060" class="elsevierStylePara elsevierViewall">The mean age at the time of the intervention was 54&#46;76<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;67 years&#44; 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and over 80&#37; had been operated on within the first 72<span class="elsevierStyleHsp" style=""></span>h of the onset of stroke&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Mean NIHSS on admission was 17&#46;87 &#40;&#177;4&#46;27&#41;&#46; Glasgow Coma Scale &#40;GCS&#41; score prior to surgery was 7&#46;81<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;23 and there was a mid-line shift on the CT of 8&#46;975<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;06<span class="elsevierStyleHsp" style=""></span>mm&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Complications</span><p id="par0085" class="elsevierStylePara elsevierViewall">The main complications are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; Mechanical ventilation was required in 100&#37; of cases and 42&#46;85&#37; required tracheostomy&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Hydrocephalus&#44; which is relatively common after decompressive craniectomy &#40;30&#8211;48&#46;7&#37;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a>&#41;&#44; occurred in 16&#46;66&#37; of cases in our series and was treated by ventriculoperitoneal shunt&#59; one patient also required a temporary external ventricular drain&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Among the survivors at 12 months post-intervention &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#41; the bone flap was replaced in 81&#46;25&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#41;&#46; The bone flap was not replaced in two patients in a minimally conscious state and waking coma&#44; or in a third who refused the surgery&#46; There was one case of aesthetic defect of the autologous cranioplasty which meant it had to be replaced by a synthetic one&#44; and one case of infection of the flap by <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#44; for which it had to be removed&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In 28&#46;57&#37; of our patients&#44; there was haemorrhagic transformation of the infarction&#44; in all cases occurring before surgery&#44; with 75&#37; being intraparenchymal &#40;PH&#41; and 25&#37; petechial &#40;IH&#41;&#46; The functional outcomes in this group were no worse than in those who did not suffer bleeding events&#44; and their mRS was 3 at 12 months&#59; in the group without transformation&#44; mRS was 3&#46;5&#46; It has been suggested that type II &#40;PH-2&#41; may lead to worse outcomes in functional terms&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Al-Jehani et al&#46; showed that the presence of different forms of haemorrhagic transformation did not affect the functional prognosis if they survived the hemicraniectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> In these patients there were more thrombectomies and thrombectomies combined with fibrinolysis&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Functional outcomes</span><p id="par0105" class="elsevierStylePara elsevierViewall">In the analysis of the functional outcomes we excluded the deceased patients &#40;mRS 6&#41; as their functional recovery could not be assessed&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">At discharge&#44; the mean mRS was 4&#46;53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;51&#59; at three months post-intervention&#44; 4&#46;12<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;02&#59; and at 12 months&#44; 3&#46;57<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;01&#46; The &#8220;current&#8221; moment means the mRS on the date of the telephone interview &#40;2017&#41; and includes patients with very different recovery times since surgery &#40;from a few months to 13 years&#41;&#44; in addition to different ages at presentation&#46; Here we measured a mean mRS of 3&#46;46<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;06&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">There is a clear tendency &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; towards a worse functional prognosis &#40;higher mRS&#41; in older patients &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;56&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;035&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">To classify the functional outcomes as good or poor&#44; there are a number of ethical&#44; individual and socio-cultural considerations which do not represent the reason for this study&#46; In DESTINY-S<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> this was considered as one of the main objectives of the study and the international consensus states that a result can be classified as acceptable when the mRS is less than or equal to 3 &#40;Moderate disability&#58; requiring some help but able to walk without assistance&#44; with the aid of a walking stick&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">At 12 months&#44; half of our patients had poor outcomes &#40;mRS 4 or 5&#41;&#44; 12&#46;5&#37; had died and 37&#46;5&#37; had good outcomes&#46; Virtually none of the patients recovered the same functional autonomy as prior to the stroke&#44; and only one case had an mRS of 1&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In the age analysis we obtained differences which&#44; due to the sample size&#44; did not reach statistically significant levels&#44; but which are consistent with the literature in this regard&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">We divided our patients into three groups&#58; aged &#60;50&#44; aged 50&#8211;60 and aged &#62;60 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">The best outcomes were among the youngest patients&#44; where three out of four evolved favourably&#44; and we found no cases of death in the postoperative period or during follow-up&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Most of the cases were in the 50&#8211;60-year-old age range &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#41;&#46; In this subgroup&#44; one in three had good outcomes and the mortality rate was 12&#46;5&#37; at 12 months&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The worst outcomes were among the over-60<span class="elsevierStyleHsp" style=""></span>s&#59; only 20&#37; had an mRS &#8804;3 at one year and the mortality rate was double that of the 50&#8211;60-year-olds&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">One year after surgery&#44; the young patients &#40;&#60;50&#41; had improved 1&#46;85 points on average in the mRS compared to discharge&#44; while amongst the over-60<span class="elsevierStyleHsp" style=""></span>s any improvement was much less noticeable&#44; with only 0&#46;75 points of recovery on average&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">There is an instantaneous decrease &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> in the first section of the survival function&#44; corresponding to postoperative deaths among our patients &#40;9&#46;53&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#44; which is sustained for the first 12 months&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">Over 75&#37; of our patients lived beyond eight years&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Autonomy and language</span><p id="par0170" class="elsevierStylePara elsevierViewall">Mobility is fundamental in the assessment of functional outcomes and carries a great weight in the mRS&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Among those who survive more than 12 months&#44; 55&#37; are able to walk&#44; 30&#46;76&#37; usually use a wheelchair&#59; either alone or assisted&#59; almost 40&#37; use an orthotic device&#44; the most common being a walking stick and an anti-equine splint&#46; Only 15&#37; mobilise unaided &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">Another 15&#37; of our series &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41; remain permanently bedridden due to their severe neurological sequelae&#59; 50&#37; of the patients were discharged from a rehabilitation centre and 36&#37; were referred to other hospitals or other medical departments for rehabilitation purposes&#59; and 14&#37; returned to their homes with an outpatient rehabilitation programme&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">In left middle cerebral artery infarctions mixed aphasia was the most common type &#40;80&#37;&#41;&#46; At the &#8220;current&#8221; point&#44; 28&#46;6&#37; of global aphasia was reported&#44; with 57&#46;1&#37; incomplete motor aphasia in varying degrees and 14&#46;3&#37; pure complete motor&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Almost a quarter of our patients failed to achieve adequate communication skills&#58; vegetative state &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#59; minimally conscious state &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#59; global aphasia &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">A total of 55&#46;5&#37; of patients with their language abilities affected &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#41; achieved at least partial recovery of their ability to communicate &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#41;&#46; We have included in this group the cases of pure complete &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41; and incomplete &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41; motor aphasia&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Of the respondents&#44; 42&#46;85&#37; have been diagnosed at some point with depression which required treatment&#44; two thirds being females&#44; while in the first degree relatives&#44; there was an incidence of 27&#46;2&#37;&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0205" class="elsevierStylePara elsevierViewall">The results of our review can help neurosurgeons in deciding when to indicate hemicraniectomy&#44; and provide family members and other medical staff with a realistic idea of the prognosis&#46; The novelty of this study is the use of the family as the connecting thread&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">The ideal age established by the international community in which hemicraniectomy is indicated is 60 or under<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5&#44;14&#44;20</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a> &#40;level of evidence Ia&#44; grade of recommendation A&#41;&#46; For patients over the age of 60&#44; the established evidence for good outcomes is Ib&#44; with grade of recommendation A&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">The current mRS in relation to the current age &#40;2017&#41; maintained a statistically significant relationship &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;035&#41; which reflects the importance of age in the recovery prognosis&#46; It was the only prognostic factor found in this review directly related to the functional outcomes &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;56&#41;&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Some 75&#37; of young patients &#40;&#60;50 years&#41; were able to achieve good outcomes&#44; while only 20&#37; of those over 60 did so&#46; The post-intervention mortality rate among the older patients was double that of the younger patients&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">In DESTINY II<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and others<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> hemicraniectomy was assessed in people over 60&#44; and although it can improve survival&#44; it did not produce the same good functional outcomes as seen in young patients&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">In our series&#44; a good correlation was found between the functional outcomes at 12 months and the current situation&#44; so we recommend an Outpatient assessment at this point of the recovery process as a prognostic marker of the functional benefit provided&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Neither being male&#44; nor the midline shift&#44; GCS score or the affected side were related to the functional outcomes in our patients&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">A patient&#8217;s ability to communicate&#44; which will usually be more damaged when the dominant hemisphere is affected&#44; can influence the neurosurgeon&#8217;s decision in terms of the indication for surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;20</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">Authors such as&#44; Benejam et al reviewed the outpatient situation using Sickness Impact Profile scores&#44; they found no relationship between the affected hemisphere&#44; different clinical parameters&#44; except in the communication section &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> We also found the infarcted hemisphere not todecisive in our group of patients&#44; as the measuring instrument used &#40;mRS&#41; does not cover the aspect of language in particular&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">As our review showed&#44; studies conducted on this subject claim that aphasia is not necessarily permanent in the dominant hemisphere&#46; Moreover&#44; if the surgery is early and the patient is young&#44; they will have a better chance of recovering language&#44; although probably not in full&#46; Therefore&#44; hemicraniectomy should not be rejected in patients with infarctions of the dominant hemisphere for that reason alone&#46; Other studies in this area<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> sustain that two out of three patients will have aphasia 12 months after decompressive craniectomy in the dominant hemisphere&#44; and up to 62&#37; of aphasic patients will meet DSM criteria for depression &#40;11&#8211;33&#37; for non-aphasics&#41;&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Among those who survive longer than 12 months&#44; 64&#46;28&#37; return to their homes&#44; while 28&#46;57&#37; are permanently institutionalised in some type of centre&#46; This point is of great importance as&#44; with our indication for decompression craniectomy&#44; potentially almost a third of patients will not be able to return to their homes and&#44; despite having good initial family support&#44; their families will not be able to cope with the burden&#46; In our series&#44; 35&#46;7&#37; of survivors at one year said they could remain alone at home without assistance for a variable period of time&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">One of our main objectives was to find out whether or not patients and family members were satisfied with the surgery&#46; This issue can be difficult to measure&#44; as there is a significant bias due to the ethical and socioeconomic individualities of each family&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">They were asked the question&#44; &#8220;Would you make the same decision &#40;decompressive hemicraniectomy&#41; again with your family member&#63;&#8221;&#59; 78&#46;94&#37; answered that they would&#44; which correlates quite well with the data obtained by previous studies in this area<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;9&#44;15&#44;28</span></a>&#59; 15&#46;7&#37; said they would not and 5&#46;2&#37; did not answer&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Among those not satisfied&#44; we found the presence of very severe sequelae&#44; such as waking coma&#44; blindness and complete aphasia&#44; and the fact that this group of patients was older than the satisfied group &#40;age 61 vs 52&#46;7&#41;&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">The resignation in terms of the sequelae of a malignant infarction which was noted during the telephone conversations does not prevent family members from singing the praises of the life-saving nature of the hemicraniectomy&#44; and the role of the neurosurgeon&#44; previously non-existent&#44; is seen to be greatly reinforced and supported&#44; including at the family level&#46; In light of the data&#44; the families express complete approval of hemicraniectomy&#44; showing us how important it is that we mediate more when it comes to making decisions for others&#46; We must not fall into the so-called disability paradox&#44; which tends to underestimate a person&#8217;s ability to adapt to a new disability situation&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Many interviewees seemed hesitant before answering the question&#44; while others were even offended to be asked whether performing life-saving surgery on their family member had been the right thing to do&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">The moral aspect that constantly permeates our work can cause our interviewees not to answer freely or not to be as honest as we might hope&#44; camouflaging what they are really thinking&#46; These rates of acceptance must therefore be contextualised to give us a holistic view of what the prognosis of decompressed malignant infarction really involves through more objective data&#44; as we provide in this review&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">In the indication for decompression surgery&#44; the decision about which ultimately falls to the neurosurgeon&#44; the family must take an active part&#44; and we must not ignore the patient&#8217;s own wishes in life&#46; It is the duty of the neurosurgeon to concisely inform about the prognosis of a malignant infarction before performing decompression surgery on a patient&#44; and in this study we have added further data on a standard Spanish population&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusions</span><p id="par0295" class="elsevierStylePara elsevierViewall">Among the parameters analysed to assess our outcomes&#44; it seems to be only age that worsens the prognosis&#46; The midline shift&#44; the level of consciousness measured by the Glasgow Coma Scale and the infarction in the left &#40;dominant&#41; hemisphere had no negative prognostic significance with our measurement tools&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">The functional status at discharge of older patients &#40;aged &#62;60&#41; will be more similar to their final outcome after 12 months&#44; while in younger patients &#40;especially aged &#60;50&#41; in our series the margin of improvement is far superior&#46; We consider one year post-intervention as a good time to assess the functional outcome after decompressive craniectomy at the Neurosurgery Outpatient Clinic&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">In our study we used the family as a connecting thread&#44; and we want to highlight their role as active participants in decision making&#44; since they will be the cornerstone of the future of these patients&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">The high satisfaction rate with surgery is a faithful reflection that despite the severe neurological damage suffered&#44; this is a disability that families are willing to tolerate&#46; This family satisfaction should not camouflage the prognosis&#44; so we must contextualise the results with the real outpatient situation of the patients&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0315" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The prognosis of one hemisphere malignant infarction creates doubt among neurosurgeons about decompressive hemicraniectomy indication&#46; What results are achieved in the short to medium term&#63; Are families satisfied with the surgery once the patient is at home&#63; In the present study&#44; we analyze our experience in this matter during the last thirteen years&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">In our review&#44; twenty-one patients were included from 2004 to 2017&#44; according to the protocol for the management of ischaemic stroke that is implemented in our institution&#46; The relatives were interviewed by telephone&#46; The functional outcome at discharge&#44; 3 months&#44; 1<span class="elsevierStyleHsp" style=""></span>year&#44; and at present was measured using the modified Rankin scale &#40;mRS&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Patient age was shown to be directly related to the mRS &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;56&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;035&#41; and 37&#46;5&#37; achieved a good outcome &#40;mRS&#8804;3&#41;&#46; 78&#46;9&#37; of the interviewed relatives would repeat the surgical decision&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">We present a 21 patients group where the best outcome was achieved in patients &#8804;60 years old&#46; The severe neurological sequelae in patients with malignant infarction subjected to decompressive hemicraniectomy are tolerated and accepted by most families to the benefit of survival&#46; We must not let this family satisfaction hide the prognosis&#44; having to contextualize it within the real ambulatory situation of the patients&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">El pron&#243;stico en los infartos malignos de un hemisferio siembra dudas entre los neurocirujanos a la hora de indicar una hemicraniectom&#237;a descompresiva&#46; &#191;Qu&#233; resultados a corto y medio plazo se obtienen&#63; &#191;est&#225;n las familias satisfechas con la cirug&#237;a una vez con el enfermo en su domicilio&#63;&#46; En el presente trabajo analizamos nuestra experiencia en esta materia en los &#250;ltimos 13 a&#241;os&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Incluimos en nuestra revisi&#243;n a 21 pacientes intervenidos entre 2004 y 2017 siguiendo la v&#237;a cl&#237;nica de nuestro centro para el ictus&#46; Se entrevist&#243; a los familiares v&#237;a telef&#243;nica&#46; Se midi&#243; el resultado funcional al alta&#44; 3 meses&#44; 1 a&#241;o y actual con la escala modificada de Rankin &#40;mRS&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La edad demostr&#243; estar directamente relacionada con la mRS &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;56&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;035&#41; y en el 37&#46;5&#37; se obtuvo un buen resultado &#40;mRS&#8804;3&#41;&#46; El 78&#46;9&#37; de los familiares entrevistados repetir&#237;a la decisi&#243;n quir&#250;rgica tomada&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Aportamos un grupo de 21 pacientes sometidos a craniectom&#237;a descompresiva por infarto maligno donde los mejores resultados funcionales se han dado entre los &#60;60 a&#241;os&#46; Las graves secuelas neurol&#243;gicas en pacientes con infarto maligno sometidos a hemicraniectom&#237;a descompresiva fueron toleradas y aceptadas por la mayor&#237;a de familias a favor de su supervivencia&#46; No debemos dejar que esta satisfacci&#243;n familiar camufle el pron&#243;stico&#44; teniendo que contextualizarla dentro de la situaci&#243;n real ambulatoria de los pacientes&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#237;a-Feijoo P&#44; Isla A&#44; D&#237;ez-Tejedor E&#44; Mansilla B&#44; Palpan Flores A&#44; S&#225;ez-Alegre M&#44; et al&#46; Craniectom&#237;a descompresiva en el infarto malignode arteria cerebral media&#58; percepci&#243;n familiar&#44; resultados y factores pron&#243;sticos&#46; Neurocirug&#237;a&#46; 2020&#59;31&#58;7&#8211;13&#46;</p>"
      ]
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        "etiqueta" => "Fig&#46; 1"
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        "mostrarFloat" => true
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        "figura" => array:1 [
          0 => array:4 [
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Relationship between current age and current mRS&#46; The mRS at 12 months after surgery in relation to age was also shown to be related&#44; and despite the small sample size&#44; it was almost statistically significant&#46; mRS&#58; modified Rankin Scale&#46;</p>"
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        "identificador" => "fig0010"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Analysis of functional prognosis by age subgroups&#46; mRS&#58; modified Rankin Scale&#46;</p>"
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        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
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        "mostrarFloat" => true
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        "figura" => array:1 [
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Survival function after decompressive craniectomy&#46;</p>"
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      3 => array:8 [
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        "etiqueta" => "Fig&#46; 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
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        "detalles" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Outpatient situation&#58; includes patients who survived the stroke and have at least one year of follow-up since surgery&#59; 35&#46;7&#37; managed to return home to the extent that they could be alone at home for long periods of time&#59; 22&#46;22&#37; of the families needed to hire a home care assistant&#44; although in the surveys carried out up to 85&#46;71&#37; of the patients need help for activities of daily living&#44; and in most cases this is provided by the relatives themselves&#59;42&#46;85&#37; are able to manage their own medication&#46;</p>"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">MCA&#58; middle cerebral artery&#59; mRS&#58; modified Rankin Scale&#46; An even number of male and female patients were included and all were right-handed&#44; assuming left brain dominance&#46; Two thirds of those operated on were aged 60 or younger&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">Gender</span></th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">11 &#40;52&#46;38&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;47&#46;62&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Location</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Left MCA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;47&#46;62&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Right MCA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;52&#46;38&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Dominance</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Right-handed&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">21 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Left-handed&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Age</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8804;60 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;66&#46;66&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;60 years&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7 &#40;33&#46;33&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>mRS &#8804;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">21 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>mRS &#62;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Pneumonia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">42&#46;85&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Urinary tract infections&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Pressure sores&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">21&#46;42&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Shunt-dependent hydrocephalus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">16&#46;66&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Surgical revision post-cranioplasty&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">15&#46;38&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Tracheobronchitis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">14&#46;28&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">External ventricular drain&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#46;14&#37;&nbsp;\t\t\t\t\t\t\n
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Clinical Research
Decompressive craniectomy in malignant middle cerebral artery infarction: family perception, outcome and prognostic factors
Craniectomía descompresiva en el infarto malignode arteria cerebral media: percepción familiar, resultados y factores pronósticos
Pablo García-Feijooa,
Corresponding author
g.feijoo.neurosurgery@gmail.com

Corresponding author.
, Alberto Islaa, Exuperio Díez-Tejedorb, Beatriz Mansillaa, Alexis Palpan Floresa, Miguel Sáez-Alegrea, Catalina Vivancosa
a Servicio de Neurocirugía, Hospital Universitario La Paz, Madrid, Spain
b Servicio de Neurología, Hospital Universitario La Paz, Madrid, Spain

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