Early decompressive craniectomy for malignant cerebral infarction

Abstract

Background: Decompressive craniectomy (DC) is an aggressive life-saving surgical intervention for patients with malignant cerebral infarction (MCI). However, DC remains inconsistently and infrequently utilized, primarily due to enduring concern that increased survival occurs only at the cost of poor functional outcome. Our aim was to clarify the role of DC performed within 48 hours (early DC) for patients with MCI, including patients aged .60 years. Methods: We performed a meta-analysis of all available randomized controlled trials comparing early DC to best medical care for MCI. Studies were identified through literature searches of electronic databases including PubMed, EMBASE, and Scopus. We employed a Mantel-Haenszel fixed effects model to assess treatment effect on dichotomized modified Rankin Scale (mRS) outcomes at 12 months. Results: A total of 289 patients from 6 randomized controlled trials comparing early DC to best medical care were included. Early DC resulted in an increased rate of excellent outcomes, defined as mRS #2 (relative risk [RR] 2.81, 95% confidence interval [CI] 1.01-7.82, p 5 0.047), and favorable outcomes, defined as mRS #3 (RR 2.06, 95% CI 1.25-3.40, p 5 0.005). Early DC also increased the rate of survival with unfavorable outcomes, defined as mRS 4-5 (RR 3.03, 95% CI 1.98-4.65, p , 0.001). Conclusions: Early DC increases the rate of excellent outcomes, i.e., functional independence, in addition to favorable and unfavorable outcomes; however, these findings must be interpreted within the context of patients' goals of care. We have developed a clinical decision algorithm that incorporates goals of care, which may guide consideration of early DC for MCI in clinical practice. Neurol Clin Pract 2016;6:433-443 M alignant cerebral infarction (MCI) refers to large-volume ischemic strokes involving the middle cerebral artery territory, which are complicated by lifethreatening cerebral edema. 1 Managed medically, MCI carries a mortality rate of 80%. 1,2 Decompressive craniectomy (DC), the surgical removal of a portion Editorial, page 381

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

“…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.…”

Malignant middle cerebral artery infarct: A clinical case report

“…However, three recent RCTs in which patients >60 years were included reported worse outcomes for early DC for MCI. None of the older patients achieved an excellent functional outcome (mRS 0-2) and very few patients reached mRS 3 (Streib, Hartman, & Molyneaux, 2016). An Absolute Reduction Incidence (ARI) of 4% and numbers needed to treat 25 indicates favourable outcomes and for unfavourable outcomes, the ARI was 32.5% and numbers needed to treat was 3.1 (Streib et al, 2016).…”

“…None of the older patients achieved an excellent functional outcome (mRS 0-2) and very few patients reached mRS 3 (Streib, Hartman, & Molyneaux, 2016). An Absolute Reduction Incidence (ARI) of 4% and numbers needed to treat 25 indicates favourable outcomes and for unfavourable outcomes, the ARI was 32.5% and numbers needed to treat was 3.1 (Streib et al, 2016). The decision to proceed with DC in Mary's case was based on the knowledge that it would likely improve her chances of survival but not necessarily her functional recovery together with information provided by the family.…”

Relationship between normalized distributional pattern and functional outcome in patients with acute cardiogenic cerebral embolism

“…As mentioned earlier, mean ischemic volume was greater in the left hemisphere than in the right, which might have contributed to the different propensity compared with previous reports. Cerebral herniation signifies large ischemic stroke involving the middle cerebral artery area [26–28]. Many studies have reported defining 145 mL of acute ischemic volume as the cutoff value for malignant middle cerebral artery occlusion [25,27,28].…”