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Published on: October 20, 2017
Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three
Katayoun Vahedi1, Jeannette Hofmeijer, Eric Juettler
1Department of Neurology, Assistance Publique, Hôpitaux de Paris, Lariboisière Hospital, Paris, France.
Background:
Malignant infarction of the middle cerebral artery (MCA) is associated with an 80% mortality rate. Non-randomised studies have suggested that decompressive surgery reduces this mortality without increasing the number of severely disabled survivors. To obtain sufficient data as soon as possible to reliably estimate the effects of decompressive surgery, results from three European randomised controlled trials (DECIMAL, DESTINY, HAMLET) were pooled. The trials were ongoing when the pooled analysis was planned.
Methods:
Individual data for patients aged between 18 years and 60 years, with space-occupying MCA infarction, included in one of the three trials, and treated within 48 h after stroke onset were pooled for analysis. The protocol was designed prospectively when the trials were still recruiting patients and outcomes were defined without knowledge of the results of the individual trials. The primary outcome measure was the score on the modified Rankin scale (mRS) at 1 year dichotomised between favourable (0-4) and unfavourable (5 and death) outcome. Secondary outcome measures included case fatality rate at 1 year and a dichotomisation of the mRS between 0-3 and 4 to death. Data analysis was done by an independent data monitoring committee.
Findings:
93 patients were included in the pooled analysis. More patients in the decompressive-surgery group than in the control group had an mRS
Interpretation:
In patients with malignant MCA infarction, decompressive surgery undertaken within 48 h of stroke onset reduces mortality and increases the number of patients with a favourable functional outcome. The decision to perform decompressive surgery should, however, be made on an individual basis in every patient.
Insights
Decompressive surgery for malignant middle cerebral artery (MCA) infarction significantly reduces mortality and improves functional outcomes. This life-saving stroke treatment is recommended for eligible patients within 48 hours of symptom onset.
Area of Science:
- Neurology
- Neurosurgery
- Critical Care Medicine
Background:
- Malignant middle cerebral artery (MCA) infarction carries an 80% mortality rate.
- Previous non-randomized studies suggested decompressive surgery may reduce mortality.
- Pooled data from three European randomized controlled trials (DECIMAL, DESTINY, HAMLET) were analyzed to confirm surgical benefits.
Purpose of the Study:
- To evaluate the efficacy of decompressive surgery in reducing mortality and improving functional outcomes in patients with malignant MCA infarction.
- To provide reliable estimates of the effects of decompressive surgery through pooled analysis of randomized controlled trials.
- To assess the impact of early decompressive surgery on patient survival and disability.
Main Methods:
- Individual patient data from 93 patients (aged 18-60) with space-occupying MCA infarction, treated within 48 hours of stroke onset, were pooled.
- Prospective protocol design with outcomes defined prior to data unblinding.
- Primary outcome: modified Rankin Scale (mRS) at 1 year (favorable 0-4 vs. unfavorable 5/death); Secondary outcomes: case fatality rate, mRS 0-3 vs. 4-death.
Main Results:
- Decompressive surgery significantly improved outcomes: 75% vs. 24% achieved mRS ≤ 4 (absolute risk reduction 51%).
- Surgery increased favorable functional outcome (mRS ≤ 3) to 43% from 21% (23% increase).
- Survival rates were markedly higher in the surgery group (78% vs. 29%), indicating a number needed to treat of two for survival.
Conclusions:
- Decompressive surgery within 48 hours of stroke onset is effective in reducing mortality for malignant MCA infarction.
- The procedure significantly increases the likelihood of favorable functional outcomes.
- Individual patient assessment is crucial for deciding on decompressive surgery.
