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Published on: October 15, 2021
Surgical decompression for space-occupying cerebral infarction: outcomes at 3 years in the randomized HAMLET trial
Marjolein Geurts1, H Bart van der Worp, L Jaap Kappelle
1Department of Neurology and Neurosurgery, UMC Utrecht Stroke Center, Utrecht, The Netherlands. m.geurts-2@umcutrecht.nl
Insights
Surgical decompression for severe stroke patients showed sustained benefits in reducing death and improving quality of life at three years. However, it did not significantly improve functional outcomes compared to standard medical care.
Area of Science:
- Neurology
- Neurosurgery
- Critical Care Medicine
Background:
- Space-occupying hemispheric infarction is a severe stroke type.
- Decompressive surgery is a potential treatment option.
Purpose of the Study:
- To assess if the 1-year benefits of surgical decompression for hemispheric infarction are sustained at 3 years.
Main Methods:
- A randomized trial (Hemicraniectomy After Middle cerebral artery infarction with Life-threatening Edema Trial) followed 64 patients.
- Patients received either decompressive surgery or best medical treatment.
- Outcomes measured at 3 years included functional status (modified Rankin Scale), mortality, quality of life, and living situation.
Main Results:
- Surgery did not significantly improve functional outcomes at 3 years (absolute risk reduction 1%).
- Decompressive surgery significantly reduced case fatality (absolute risk reduction 37%).
- More surgically treated patients lived at home (absolute risk reduction 27%), and their quality of life improved between 1 and 3 years.
Conclusions:
- The positive effects of decompressive surgery on reducing mortality and improving quality of life in hemispheric infarction are sustained at 3 years.
- Surgical decompression did not improve functional outcomes 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:
In patients with space-occupying hemispheric infarction, the effects of decompressive surgery on case fatality and functional outcome observed at 1 year are sustained at 3 years.
Clinical Trial Registration Url:
http://www.controlled-trials.com. Unique identifier: ISRCTN94237756.