Decompressive craniectomy for the treatment of malignant infarction of the middle cerebral artery

Abstract

Early decompressive craniectomy (DC) has been shown to reduce mortality in malignant middle cerebral artery (MCA) infarction, whereas efficacy of DC on functional outcome is inconclusive. Here, we performed a meta-analysis to estimate the effects of DC on malignant MCA infarction and investigated whether age of patients and timing of surgery influenced the efficacy. We systematically searched PubMed, Medline, Embase, Cochrane library, Web of Science update to June 2014. Finally, A total of 14 studies involved 747 patients were included, of which 8 were RCTs (341 patients). The results demonstrated that early DC (within 48 h after stroke onset) decreased mortality (OR = 0.14, 95%CI = 0.08, 0.25, p<0.0001) and number of patients with poor functional outcome (modified Rankin scale (mRS)>3) (OR = 0.38, 95%CI = 0.20, 0.73, p = 0.004) for 12 months follow-up. In the subgroup analysis stratified by age, early DC improved outcome both in younger and older patients. However, later DC (after 48h after stroke onset) might not have a benefit effect on lowering mortality or improving outcome in patients with malignant infarction. Together, this study suggested that decompressive surgery undertaken within 48 h reduced mortality and increased the number of patients with a favourable outcome in patients with malignant MCA infarction.

Decompressive craniotomy for the treatment of malignant infarction of the middle cerebral artery: mortality and outcome

“…Individuals affected by a malignant ischemic event are seldom discharged without severe clinical deficits; this data is in accordance with a recent study of meta-analysis carried out in China, involving more than 700 patients, that considered an mRS of 4 a good functional result 10 .…”

“…In order to clearly define the indication for the surgical treatment and to decrease complications derived from DC in a university hospital in southern Brazil, a specific protocol for DC in the treatment of intracranial hypertension derived from ischemia of the MCA region has been implemented since 2007, in conjunction with the neurology department. Even though studies have demonstrated the efficacy of DC in patients presenting with malignant MCA infarction 5,6,7,8,9,10 , some resistance to its application still exists, particularly regarding the functionality of the patients who survive the acute event.The goals of the present study were to assess the mortality rates from the use of DC in the treatment of patients …”

Malignant MCA Infarction: Pathophysiology and Imaging for Early Diagnosis and Management Decisions

“…It was shown repeatedly that early DHC performed within 24 h after onset of symptoms significantly reduced mortality and improved outcome 6 and 12 months after stroke [44,45] . DHC performed 48 h after stroke onset might not have a beneficial effect on mortality or clinical outcome [51] . Additionally, the size of the hemicraniectomy is important and a diameter of DHC of at least 12 cm is recommended in most studies.…”

Treatment and Outcome of Hemorrhagic Transformation After Intravenous Alteplase in Acute Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

“…48 Although this finding may be a result of selection bias, this effect may be similar to that in patients with large hemispheric ischemic strokes with malignant edema, such that neurosurgical treatment may reduce mortality by preventing herniation but still leave the patient with substantially disabling neurological deficits. 129 Furthermore, although isolated subdural hemorrhage is a very rare manifestation of sICH, certain patients with isolated subdural hemorrhage may possibly benefit from neurosurgical evacuation. When neurosurgical treatments are considered, they should be performed after coagulopathy reversal, and decisions should be balanced against the risk of hemorrhagic complications in the setting of alteplaserelated coagulopathy.…”