Surgical Decompression for Space-Occupying Cerebral Infarction

Abstract

A pooled analysis of 3 European randomized trials has shown that in patients with space-occupying hemispheric infarction, surgical decompression initiated within 48 hours of stroke onset strongly reduces the risk of death and increases the chance of a favorable functional outcome at 1 year. However, this large reduction in case fatality comes at the expense of an increased risk of moderately severe or severe disability at 1 year, 1 and the majority of survivors have global cognitive impairment.2 Some authors have therefore expressed concerns about the effect of decompressive surgery on long-term quality of life.3 It is unknown whether the effects of surgery at 1 year are sustained over a longer follow-up period. We assessed outcomes 3 years after inclusion in the randomized Hemicraniectomy After Middle cerebral artery infarction with Life-threatening Edema Trial (HAMLET). MethodsThe design of HAMLET (ISRCTN94237756) has been reported previously.1 In brief, adult patients ≤60 years of age with space-occupying hemispheric infarction were randomly assigned to surgical decompression or to best medical treatment. The trial was approved by institutional review boards, and written informed consent was obtained for each patient.The primary outcome measure was functional outcome as measured with the modified Rankin Scale at 1 year, dichotomized between good (modified Rankin Scale, 0-3) and poor (modified Rankin Scale, 4, 5, or death). Predefined secondary outcome measures included functional outcome at 3 years, and case fatality, functional dependence assessed with the Barthel Index, quality of life assessed with the Medical Outcomes Study 36-item short-form health survey and a visual analogue scale, symptoms of depression measured by the Montgomery and Åsberg Depression Rating Scale, and caregiver strain assessed with the caregiver strain index at 1 and at 3 years.Background and Purpose-We assessed whether the effects of surgical decompression for space-occupying hemispheric infarction, observed at 1 year, are sustained at 3 years. Methods-Patients with space-occupying hemispheric infarction, who were enrolled in the Hemicraniectomy After Middle cerebral artery infarction with Life-threatening Edema Trial within 4 days after stroke onset, were followed up at 3 years. Outcome measures included functional outcome (modified Rankin Scale), death, quality of life, and place of residence. Poor functional outcome was defined as modified Rankin Scale >3. Results-Of 64 included patients, 32 were randomized to decompressive surgery and 32 to best medical treatment. Just as at 1 year, surgery had no effect on the risk of poor functional outcome at 3 years (absolute risk reduction, 1%; 95% confidence interval, −21 to 22), but it reduced case fatality (absolute risk reduction, 37%; 95% confidence interval, 14-60). Sixteen surgically treated patients and 8 controls lived at home (absolute risk reduction, 27%; 95% confidence interval, 4-50). Quality of life improved between 1 and 3 years in patients treated with surgery. Conclusions-...

Improved Neurological Outcome With Mild Hypothermia in Surviving Patients With Massive Cerebral Hemispheric Infarction

“…Several randomized controlled trials (RCTs) have demonstrated that DC can reduce the ICP and reduce mortality to 17% to 36%. [2][3][4][5][6][7] Although DC is a lifesaving treatment, not all patients with MCHI can receive the surgery quickly enough. Additionally, patients who routinely take antiplatelet or anticoagulant drugs are at an increased risk of developing massive bleeding during or after DC, which limits its application.…”

Decompressive craniectomy for malignant middle cerebral artery infarctions: a meta-analysis

“…1). Fourteen of them were finally included to the meta-analysis, including eight RCT [14][15][16][17][18][19][20][21] and six retrospective cohort studies [22][23][24][25][26][27]. The 423 DC cases and 389 conservative managed cases were involved.…”

Early decompressive craniectomy for malignant cerebral infarction

“…Although existing data support the use of 12-month functional outcomes rather than earlier time points, it is recognized that some patients continue to regain function after 1 year, which could lead to an underestimation of treatment effect. 27,36 Only one RCT of DC has reported outcomes past 12 months. 27 …”

“…Hofmeijer et al 5 reported a post hoc analysis of 39 patients enrolled in HAMLET within 48 hours of stroke onset, but did not report baseline patient characteristics or whether their initial randomization stratification was maintained in this subgroup. 5,27 Secondary to these concerns, Slezins et al 23 and Hofmeijer et al 5 both received an unclear risk of bias rating. A full risk of bias rating table is included in figure e-1.…”