Hemicraniectomy versus Conservative Treatment in Large Hemispheric Ischemic Stroke Patients: A Meta-analysis of Randomized Controlled Trials

Qureshi, Adnan I.; Ishfaq, Muhammad F; Rahman, Haseeb; Thomas, Abraham

doi:10.1016/j.jstrokecerebrovasdis.2016.03.053

Cited by 11 publications

(8 citation statements)

References 30 publications

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“…The results of these trials when pooled in a Cochrane review 61 indicated that hemicraniectomy was associated with a significantly reduced risk of death at the end of follow-up (OR ¼ 0.19, 95% CI 0.09-0.37) and in the risk of death or severe disability (mRS > 4) at 12 months (OR ¼ 0.26, 95% CI 0.13-0.51). A more recent systematic review, which included the results from seven trials, 62 documented that the odds of a favorable outcome (mRS 0-3) and survival at 6-12 months were significantly increased for patients in the hemicraniectomy group with odds ratios of 2.04 (95% CI 1.03-4.02, p ¼ 0.04) and 5.56 (95% CI 3.40-9.08, p < 0.001), respectively. The benefit of surgery in older patients is less certain.…”

Section: Section 6: Acute Antiplatelet Therapymentioning

confidence: 99%

Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018

Boulanger

Lindsay

Gubitz

et al. 2018

International Journal of Stroke

306

292

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The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider's recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

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Section: Section 6: Acute Antiplatelet Therapymentioning

confidence: 99%

Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018

Boulanger

Lindsay

Gubitz

et al. 2018

International Journal of Stroke

306

292

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“…5,6 Surgical decompression, consisting of a large hemicraniectomy and duraplasty, consistently reduced the risk of death in randomized clinical trials and increased the chance of a favorable outcome in some meta-analyses of these trials. [7][8][9][10][11][12][13][14] However, because of the small size of the individual trials and of pooled analyses of these trials, uncertainties still remain about the benefit of surgical decompression for specific patient groups, 15,16 including those with aphasia or involvement of an additional vascular territory next to that of the middle cerebral artery (MCA) and those presenting later than 48 hours after stroke onset. Data pooling may provide more precise estimates of treatment effects.…”

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confidence: 99%

Surgical Decompression for Space-Occupying Hemispheric Infarction

et al. 2021

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IMPORTANCEIn patients with space-occupying hemispheric infarction, surgical decompression reduces the risk of death and increases the chance of a favorable outcome. Uncertainties, however, still remain about the benefit of this treatment for specific patient groups.OBJECTIVE To assess whether surgical decompression for space-occupying hemispheric infarction is associated with a reduced risk of death and an increased chance of favorable outcomes, as well as whether this association is modified by patient characteristics.DATA SOURCES MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Stroke Trials Registry were searched from database inception to October 9, 2019, for English-language articles that reported on the results of randomized clinical trials of surgical decompression vs conservative treatment in patients with space-occupying hemispheric infarction.STUDY SELECTION Published and unpublished randomized clinical trials comparing surgical decompression with medical treatment alone were selected.DATA EXTRACTION AND SYNTHESIS Patient-level data were extracted from the trial databases according to a predefined protocol and statistical analysis plan. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and the Cochrane Collaboration's tool for assessing risk of bias were used. One-stage, mixed-effect logistic regression modeling was used for all analyses. MAIN OUTCOMES AND MEASURESThe primary outcome was a favorable outcome (modified Rankin Scale [mRS] score Յ3) at 1 year after stroke. Secondary outcomes included death, reasonable (mRS score Յ4) and excellent (mRS score Յ2) outcomes at 6 months and 1 year, and an ordinal shift analysis across all levels of the mRS. Variables for subgroup analyses were age, sex, presence of aphasia, stroke severity, time to randomization, and involved vascular territories.RESULTS Data from 488 patients from 7 trials from 6 countries were available for analysis. The risk of bias was considered low to moderate for 6 studies. Surgical decompression was associated with a decreased chance of death (adjusted odds ratio, 0.16; 95% CI, 0.10-0.24) and increased chance of a favorable outcome (adjusted odds ratio, 2.95; 95% CI, 1.55-5.60), without evidence of heterogeneity of treatment effect across any of the prespecified subgroups. Too few patients were treated later than 48 hours after stroke onset to allow reliable conclusions in this subgroup, and the reported proportions of elderly patients reaching a favorable outcome differed considerably among studies. CONCLUSIONS AND RELEVANCEThe results suggest that the benefit of surgical decompression for space-occupying hemispheric infarction is consistent across a wide range of patients. The benefit of surgery after day 2 and in elderly patients remains uncertain.

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“…The literature search identified eight RCTs comparing surgical decompression with no surgical decompression, [4][5][6][7][8][9][10][11] one additional RCT published in the supplement of an individual patient data meta-analysis 3 but later published separately 12 (Supplemental Figure 1), one earlier and smaller individual patient data meta-analysis, 13 and 10 systematic reviews and meta-analyses. [17][18][19][20][21][22][23][24][25][26][27] One RCT 8 could not be included in the quantitative metaanalyses because no information was available on effects in patients in the two different age groups. 7,8,[10][11][12] In DECIMAL, DESTINY, Zhao et al, Slezins et al, and DEMITUR patients had to be treated up to 48 hours after symptom onset.…”

Section: Resultsmentioning

confidence: 99%

“…The literature search identified eight RCTs comparing surgical decompression with no surgical decompression, [4][5][6][7][8][9][10][11] one additional RCT published in the supplement of an individual patient data meta-analysis 3 but later published separately 12 (Supplemental Figure 1), one earlier and smaller individual patient data meta-analysis, 13 and 10 systematic reviews and meta-analyses. [17][18][19][20][21][22][23][24][25][26][27] One RCT 8 could not be included in the quantitative metaanalyses because no information was available on effects in patients in the two different age groups. Three early RCTs included adult patients 60 years: DEcompressive Craniectomy In MALignant middle cerebral artery infarct (DECIMAL), DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY (DESTINY), and Hemicraniectomy After Middle cerebral artery infarction with Lifethreatening Edema Trial (HAMLET).…”

Section: Resultsmentioning

confidence: 99%

European Stroke Organisation (ESO) guidelines on the management of space-occupying brain infarction

Worp

Hofmeijer

Jüttler

et al. 2021

European Stroke Journal

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Space-occupying brain oedema is a potentially life-threatening complication in the first days after large hemispheric or cerebellar infarction. Several treatment strategies for this complication are available, but the size and quality of the scientific evidence on which these strategies are based vary considerably. The aim of this Guideline document is to assist physicians in their management decisions when treating patients with space-occupying hemispheric or cerebellar infarction. These Guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. A working group identified 13 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence-based recommendations. An expert consensus statement was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high-quality evidence to recommend surgical decompression to reduce the risk of death and to increase the chance of a favourable outcome in adult patients aged up to and including 60 years with space-occupying hemispheric infarction who can be treated within 48 hours of stroke onset, and low-quality evidence to support this treatment in older patients. There is continued uncertainty about the benefit and risks of surgical decompression in patients with space-occupying hemispheric infarction if this is done after the first 48 hours. There is also continued uncertainty about the selection of patients with space-occupying cerebellar infarction for surgical decompression or drainage of cerebrospinal fluid. These Guidelines further provide details on the management of specific subgroups of patients with space-occupying hemispheric infarction, on the value of monitoring of intracranial pressure, and on the benefits and risks of medical treatment options. We encourage new high-quality studies assessing the risks and benefits of different treatment strategies for patients with space-occupying brain infarction.

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Hemicraniectomy versus Conservative Treatment in Large Hemispheric Ischemic Stroke Patients: A Meta-analysis of Randomized Controlled Trials

Cited by 11 publications

References 30 publications

Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018

Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018

Surgical Decompression for Space-Occupying Hemispheric Infarction

European Stroke Organisation (ESO) guidelines on the management of space-occupying brain infarction

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