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Published on: June 22, 2022
Hemicraniectomy versus medical treatment with large MCA infarct: a review and meta-analysis
Paul Alexander1, Diane Heels-Ansdell2, Reed Siemieniuk2,3
1Department of Clinical Epidemiology and Biostatistics, Health Research Methods, McMaster University, Hamilton, Ontario, Canada.
Insights
Decompressive hemicraniectomy (DHC) significantly reduces mortality in large middle cerebral artery strokes (SO-MCAi). However, survivors often face severe disability, with evidence quality varying for functional outcomes.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Large space-occupying middle cerebral artery infarction (SO-MCAi) is associated with high mortality and severe disability.
- Decompressive hemicraniectomy (DHC) is a surgical intervention aimed at reducing intracranial pressure and improving outcomes in such cases.
- The efficacy of DHC in improving functional outcomes for survivors of SO-MCAi remains a subject of debate.
Purpose of the Study:
- To systematically evaluate the impact of DHC on survival and functional outcomes in patients with large SO-MCAi.
- To address the controversy surrounding the functional level of survivors after DHC for SO-MCAi.
- To pool data from randomized controlled trials (RCTs) to provide robust evidence.
Main Methods:
- A comprehensive search of MEDLINE, EMBASE, and Cochrane library databases was conducted for relevant RCTs.
- Studies comparing conservative management with DHC within 96 hours of stroke onset were included.
- Meta-analysis with random effects, subgroup analyses (time to treatment, age), and GRADE methodology were employed to assess outcomes (death, modified Rankin Scale) and evidence certainty.
Main Results:
- Seven RCTs involving 338 patients were analyzed.
- DHC significantly reduced mortality (from 69% to 30%).
- DHC increased the proportion of patients with moderate (mRS 2-3) to very severe disability (mRS 5), with significant increases in mRS 2-3 (14% to 27%) and mRS 4 (10% to 32%).
Conclusions:
- Decompressive hemicraniectomy substantially lowers mortality rates in patients with space-occupying middle cerebral artery infarction.
- While DHC improves survival, a significant proportion of survivors experience severe to very severe functional disability.
- The quality of evidence for functional outcomes is low to moderate, highlighting the need for cautious interpretation and further research.
Objective:
Large middle cerebral artery stroke (space-occupying middle-cerebral-artery (MCA) infarction (SO-MCAi)) results in a very high incidence of death and severe disability. Decompressive hemicraniectomy (DHC) for SO-MCAi results in large reductions in mortality; the level of function in the survivors, and implications, remain controversial. To address the controversy, we pooled available randomised controlled trials (RCTs) that examined the impact of DHC on survival and functional ability in patients with large SO-MCAi and cerebral oedema.
Methods:
We searched MEDLINE, EMBASE and Cochrane library databases for randomised controlled trials (RCTs) enrolling patients suffering SO-MCAi comparing conservative management to DHC administered within 96 hours after stroke symptom onset. Outcomes were death and disability measured by the modified Rankin Scale (mRS). We used a random effects meta-analytical approach with subgroup analyses (time to treatment and age). We applied GRADE methods to rate quality/confidence/certainty of evidence.
Results:
7 RCTs were eligible (n=338 patients). We found DHC reduced death (69-30% in medical vs surgical groups, 39% fewer), and increased the number of patients with mRS of 2-3 (slight to moderate disability: 14-27%, increase of 13%), those with mRS 4 (severe disability: 10-32%, increase of 22%) and those with mRS 5 (very severe disability 7-11%: increase of 4%) (all differences p<0.0001). We judged quality/confidence/certainty of evidence high for death, low for functional outcome mRS 0-3, and moderate for mRS 0-4 (wide CIs and problems in concealment, blinding of outcome assessors and stopping early).
Conclusions:
DHC in SO-MCAi results in large reductions in mortality. Most of those who would otherwise have died are left with severe or very severe disability: for example, inability to walk and a requirement for help with bodily needs, though uncertainty about the proportion with very severe, severe and moderate disability remains (low to moderate quality/confidence/certainty evidence).
