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Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: A systematic review and
Ming-Hao Yang1, Hong-Yu Lin2, Jun Fu3
1Department of Neurosurgery, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China.
Insights
Decompressive hemicraniectomy (DHC) significantly reduces mortality for malignant middle cerebral artery infarctions (mMCAI). While DHC improves outcomes, it may slightly increase major disability among survivors, regardless of age.
Area of Science:
- Neurology
- Neurosurgery
- Critical Care Medicine
Background:
- Malignant middle cerebral artery infarctions (mMCAI) carry a high mortality rate, especially without surgical intervention.
- Decompressive hemicraniectomy (DHC) is recommended for younger patients (≤ 60 years) with mMCAI based on prior trials.
- Recent trials in older patients (> 60 years) necessitate an updated evaluation of DHC efficacy.
Purpose of the Study:
- To re-evaluate the effects of decompressive hemicraniectomy (DHC) in patients with malignant middle cerebral artery infarctions (mMCAI).
- To update previous meta-analyses with recent randomized controlled trials (RCTs) data.
Main Methods:
- Systematic literature search of PubMed, EMBASE, and Cochrane Library for relevant RCTs.
- Meta-analysis of six studies involving 314 patients.
- Primary outcomes: mortality and major disability (modified Rankin Scale [mRS] 4-5). Secondary outcomes: death or major disability (mRS > 3) and death or severe disability (mRS > 4).
Main Results:
- Decompressive hemicraniectomy (DHC) significantly decreased mortality risk.
- DHC reduced the risk of death or major disability (mRS > 3) and death or severe disability (mRS > 4).
- A non-significant increase in major disability (mRS 4-5) among survivors was observed, with no significant age-related differences.
Conclusions:
- Decompressive hemicraniectomy (DHC) significantly improves survival and functional outcomes compared to conservative treatment for mMCAI.
- DHC is associated with a slightly higher proportion of survivors experiencing major disability.
- Further research is needed for a comprehensive assessment of DHC in mMCAI management.
Background & Purpose:
Malignant middle cerebral artery infarctions (mMCAI) are one of the most devastating ischemic strokes, with up to 80% mortality in non-surgically treated patients. With the publication of three European randomized controlled trials (RCTs), decompressive hemicraniectomy (DHC) was recommended in patients with mMCAI who are aged ≤ 60 years. Recently, three other RCTs enrolling patients aged > 60 years were published; thus, it is necessary to update the previous meta-analysis to re-evaluate the effects of DHC in mMCAI.
Methods:
A systematic literature search of PubMed, EMBASE, and the Cochrane Library was conducted for published RCTs investigating the effects of DHC in mMCAI. Primary outcomes were mortality and major disability (modified Rankin Scale score: 4-5) among survivors. Secondary outcomes were death or major disability (mRS score > 3), and death or severe disability (mRS score > 4). Effect sizes were expressed in Peto odds ratio (Peto OR) with 95% confidence intervals.
Results:
Six studies with 314 patients were subjected to meta-analysis. Data showed that DHC, significantly decreased mortality risk, death or major disability (mRS score > 3), and death or severe disability (mRS score > 4); but was associated with a slightly higher proportion of major disability (mRS score: 4-5) among survivors. There were no statistically significant age differences.
Conclusions:
Compared to conservative treatment, DHC significantly decreased mortality and improved functional outcome, with a non-significant increase in the proportion of survivors with major disability. Further studies are required for multidimensional evaluation of DHC for mMCAI.
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