A Systematic Review and Meta-Analysis of the Effectiveness of Surgical Decompression in Treating Patients with Malignant Middle Cerebral Artery Infarction

Gul, Wisha; Fuller, Heidi R.; Wright, Helen; Sen, Jon

doi:10.1016/j.wneu.2018.08.189

Cited by 15 publications

(23 citation statements)

References 40 publications

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“…The condition leads to space-occupying brain edema, resulting in raised ICP, with subsequent ischemic cell death and brain herniation. [ 2 ] The prognosis is poor, with mortality as high as 70% to 80%, and the survivors being left with severe disabilities. [ 17 19 ] Patients receive ICP-lowering therapies similar to that in TBI, with DC being reserved for those with RICH.…”

Section: Discussionmentioning

confidence: 99%

“…Acute brain injury (ABI) is a leading cause of death and disability worldwide. [ 1 2 ] The major causes of ABI include traumatic brain injury (TBI), malignant cerebral infarction (MCI), and intracranial hemorrhage (ICH). Intracranial pressure (ICP)-lowering therapies which prevent secondary brain injury are usually administered in a step-wise manner, starting with safer first-line interventions (head elevation, osmotic agents, controlled hyperventilation, hypothermia, and sedation), while reserving high-risk options for patients with refractory intracranial hypertension (RICH).…”

Section: Introductionmentioning

confidence: 99%

“…Intracranial pressure (ICP)-lowering therapies which prevent secondary brain injury are usually administered in a step-wise manner, starting with safer first-line interventions (head elevation, osmotic agents, controlled hyperventilation, hypothermia, and sedation), while reserving high-risk options for patients with refractory intracranial hypertension (RICH). [ 2 3 4 ] Decompressive craniectomy (DC) is one such high-risk surgical procedure in which part of the skull is removed and the underlying dura is expanded to reduce raised ICP and ensure normal cerebral perfusion. [ 5 ] Although DC is effective in reducing ICP and mortality, it is accompanied by a myriad of nontrivial complications, and there is a concern that survivors will experience permanent severe disability.…”

Section: Introductionmentioning

confidence: 99%

“…DC has been evaluated in a few randomized controlled trials (RCTs) for TBI and acute ischemic stroke, which has further widened the controversy. [ 2 3 4 6 ] The role of DC in countries with low neurocritical care and neurosurgical resources is under scanner. [ 7 8 9 ] Low- and middle-income countries (LMICs) cannot afford the higher costs associated with protocol-based ICP monitoring as a requisite for diagnosing RICH for all ABI patients.…”

Section: Introductionmentioning

confidence: 99%

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Protocol-based early decompressive craniectomy in a resource-constrained environment: A tertiary care hospital experience

Pattankar

Misra

2020

Asian J Neurosurg

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Objectives: Decompressive craniectomy (DC) is an emergency life-saving procedure used to treat refractory intracranial hypertension (RICH). The authors aim to analyze their experience with protocol-based early DC (<24 h) in RICH cases diagnosed based on clinical and radiological evidence, without preoperative intracranial pressure monitoring done over 10 years. Materials and Methods: This is a retrospective, observational study which includes 58 consecutive patients who underwent protocol-based early DC by the senior author at a single institution between 2007 and 2017. Background variables and outcome in the form of Glasgow Outcome Score-Extended (GOS-E) at 6 months and 1 year were analyzed. Results: Fourteen patients had traumatic brain injury (TBI), 17 had intracranial hemorrhage (ICH), 14 had malignant cerebral infarcts (MCI), and the reminder 13 patients had other causes. At 6 months, the mortality rate was 22.4%. Good recovery, moderate disability, and severe disability were seen in 13.8%, 17.2%, and 43.1% of patients, respectively. Two patients were in vegetative state. The cutoff for favorable/unfavorable outcome was defined as GOS-E 4–8/1–3. By this application, 63.8% of patients had favorable outcome at 6 months. The favorable outcome in patients of TBI, ICH, and MCI was 57.1%, 58.8%, and 85.7%, respectively. Conclusions: DC helps in obtaining a favorable outcome in selected patients with a defined pathology. The diagnosis of RICH based on clinical and radiological parameters, and protocol-based early DC, is reasonably justified as the way forward for resource-constrained environments. The risk of vegetative state is small.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Protocol-based early decompressive craniectomy in a resource-constrained environment: A tertiary care hospital experience

Pattankar

Misra

2020

Asian J Neurosurg

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“…However, in some studies showed nonsignificant benefit with DC in these patients (17). Several factors such as patient age and timing of surgery were studied to if affect the success/outcome of the surgery or not (18).…”

Section: Introductionmentioning

confidence: 99%

What is the optimum time to decompressive surgery in the patients with malignant middle cerebral artery infarction?

Yücetaş¹,

Üçler²,

Kafadar³

et al. 2019

Ann Med Res

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In the patients with malignant middle cerebral artery (MCA) infarctions, the mortality was as high as 70% with conservative treatment. Decompressive craniectomy (DC) was shown to decrease mortality especially in 48 hours. We aimed to investigate both the effect of decompression time and the size of craniectomy on the mortality in this patient group. Material and Methods: 45 adult patients underwent to DC due to malignant MCA infarction were evaluated in this study. The demographic and clinical features were recorded retrospectively. The patients were splitted into three groups: Group 1, DC in the first 24 hours; group 2, in 24-48th hours; group3, in 48-96th hours of the admission. The size of craniectomy was the same as the infarct (standard), or it was two centimeters larger than the size of infarct (larger). Results: Of all patients, 53.3% (n=24) was female; and mean age of the sample was 67.38±4.76. 66.7% (n=30) of the patients died due to malign MCA infarction. The size of craniectomy was larger in 26.7% (n=12), and was standard in the others. Mean time to surgery was 43.07±29.87 hours. Mortality rate was minimum in group 2 (p=0.01). The patients undergoing to larger craniectomy survived longer than the others, but the difference was non-significant (p=0.06). Conclusion: We suggested that not the approach of "surgery as soon as possible" but the surgery between 24-48th hours of the admission would be the optimal approach. This issue is especially important, because earlier or later interventions not only have a less benefit on the outcome but also may lead several unnecessary complications.

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Surgical decompression for malignant cerebral oedema after ischaemic stroke

Dower

Mulcahy

Maharaj

et al. 2022

Cochrane Database of Systematic Reviews

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A Systematic Review and Meta-Analysis of the Effectiveness of Surgical Decompression in Treating Patients with Malignant Middle Cerebral Artery Infarction

Cited by 15 publications

References 40 publications

Protocol-based early decompressive craniectomy in a resource-constrained environment: A tertiary care hospital experience

Protocol-based early decompressive craniectomy in a resource-constrained environment: A tertiary care hospital experience

What is the optimum time to decompressive surgery in the patients with malignant middle cerebral artery infarction?

Surgical decompression for malignant cerebral oedema after ischaemic stroke

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