Role of decompressive hemicraniectomy in extensive middle cerebral artery strokes: a meta-analysis of randomised trials

• Published in: Internal medicine journal Vol. 45; no. 7; pp. 711 - 717
• Main Authors: Back, L., Nagaraja, V., Kapur, A., Eslick, G. D.
• Format: Journal Article
• Language: English
• Published: Australia Blackwell Publishing Ltd 01.07.2015
• Subjects: Adolescent; Adult; Age Factors; Aged; Aged, 80 and over; Child; Decompressive Craniectomy; hemicraniectomy; Humans; MCA infarction; medical management; meta-analysis; Middle Aged; Middle Cerebral Artery - pathology; Middle Cerebral Artery - surgery; Quality of Life; randomised trial; Randomized Controlled Trials as Topic; Stroke - mortality; Stroke - pathology; Stroke - surgery; surgical decompression; Young Adult; meta-analysis; hemicraniectomy; randomised trial; MCA infarction; medical management; surgical decompression
• ISSN: 1444-0903; 1445-5994
• DOI: 10.1111/imj.12724

Background Prognosis for patients with ‘malignant’ or space‐occupying oedema post middle cerebral artery infarct remains poor despite maximal medical therapy delivered in the intensive care setting. Aim We performed a meta‐analysis to evaluate the value of surgical decompression versus medical management alone in patients suffering from malignant middle cerebral artery infarct. Methods A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct and Web of Science. Original data was ed from each study and used to calculate a pooled odds ratio (OR) and 95% confidence interval (95% CI). Results The overall OR for mRS 6 (death) at 6 months for decompressive surgery as compared with standard medical management revealed a statistically significant reduction with OR of 0.19 (95% CI: 0.10–0.37). The frequency of patients with mRS 2, 3 and 5 outcomes was higher in the decompressive surgery cohort; however, these outcomes did not reach statistical significance. On the other hand, the number of patients with a mRS score of 4 was significantly higher in the decompressive surgery cohort with an OR of 3.29 (95% CI: 1.76–6.13). The overall OR for mRS 6 (death) at 12 months for decompressive surgery as compared with standard medical management revealed a statistically significant reduction with OR of 0.17 (95% CI: 0.10–0.29). The frequency of patients with mRS 3 and 5 outcomes was higher in the decompressive surgery cohort; however, these outcomes did not reach statistical significance. On the other hand, the number of patients with a mRS score of 4 was significantly higher in the decompressive surgery cohort with an OR of 4.43 (95% CI: 2.27–8.66). In the long run it was also observed that the number of patients with a mRS score of 2 was significantly higher in the decompressive surgery cohort an OR of 4.51 (95% CI: 1.06–19.24). Conclusions Our results imply that surgical intervention decreased mortality of patients with fatal middle cerebral artery infarct at the expense of increasing the proportion suffering from substantial disability at the conclusion of follow up.