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Surgical Decompression for Space-Occupying Hemispheric Infarction: A Systematic Review and Individual Patient
Hendrik Reinink1, Eric Jüttler2, Werner Hacke2
1Department of Neurology and Neurosurgery, Brain Center, University Medical Center, Utrecht University, Utrecht, the Netherlands.
Insights
Surgical decompression for space-occupying hemispheric infarction significantly reduces death and improves outcomes. This benefit appears consistent across most patient groups, though timing and elderly patient outcomes require further study.
Area of Science:
- Neurosurgery
- Neurology
- Clinical Trials
Background:
- Space-occupying hemispheric infarction poses a significant risk of mortality and poor functional outcomes.
- Surgical decompression is a potential intervention, but its efficacy across diverse patient populations remains under investigation.
Purpose of the Study:
- To evaluate the effectiveness of surgical decompression in reducing mortality and improving functional outcomes in patients with space-occupying hemispheric infarction.
- To determine if patient characteristics modify the treatment effect of surgical decompression.
Main Methods:
- A systematic review and meta-analysis of randomized clinical trials comparing surgical decompression with conservative treatment.
- Data from 7 trials involving 488 patients were analyzed using mixed-effect logistic regression, adhering to PRISMA guidelines.
Main Results:
- Surgical decompression was associated with a significantly decreased risk of death (aOR, 0.16; 95% CI, 0.10-0.24) and an increased likelihood of favorable outcomes (aOR, 2.95; 95% CI, 1.55-5.60).
- Treatment effects were consistent across most prespecified subgroups, including age, sex, stroke severity, and vascular territory.
Conclusions:
- Surgical decompression offers consistent benefits for patients with space-occupying hemispheric infarction.
- Further research is needed to clarify the benefits of surgery for patients treated more than 48 hours after stroke onset and for elderly individuals.
Importance:
In patients with space-occupying hemispheric infarction, surgical decompression reduces the risk of death and increases the chance of a favorable outcome. Uncertainties, however, still remain about the benefit of this treatment for specific patient groups.
Objective:
To assess whether surgical decompression for space-occupying hemispheric infarction is associated with a reduced risk of death and an increased chance of favorable outcomes, as well as whether this association is modified by patient characteristics.
Data Sources:
MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Stroke Trials Registry were searched from database inception to October 9, 2019, for English-language articles that reported on the results of randomized clinical trials of surgical decompression vs conservative treatment in patients with space-occupying hemispheric infarction.
Study Selection:
Published and unpublished randomized clinical trials comparing surgical decompression with medical treatment alone were selected.
Data Extraction And Synthesis:
Patient-level data were extracted from the trial databases according to a predefined protocol and statistical analysis plan. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and the Cochrane Collaboration's tool for assessing risk of bias were used. One-stage, mixed-effect logistic regression modeling was used for all analyses.
Main Outcomes And Measures:
The primary outcome was a favorable outcome (modified Rankin Scale [mRS] score ≤3) at 1 year after stroke. Secondary outcomes included death, reasonable (mRS score ≤4) and excellent (mRS score ≤2) outcomes at 6 months and 1 year, and an ordinal shift analysis across all levels of the mRS. Variables for subgroup analyses were age, sex, presence of aphasia, stroke severity, time to randomization, and involved vascular territories.
Results:
Data from 488 patients from 7 trials from 6 countries were available for analysis. The risk of bias was considered low to moderate for 6 studies. Surgical decompression was associated with a decreased chance of death (adjusted odds ratio, 0.16; 95% CI, 0.10-0.24) and increased chance of a favorable outcome (adjusted odds ratio, 2.95; 95% CI, 1.55-5.60), without evidence of heterogeneity of treatment effect across any of the prespecified subgroups. Too few patients were treated later than 48 hours after stroke onset to allow reliable conclusions in this subgroup, and the reported proportions of elderly patients reaching a favorable outcome differed considerably among studies.
Conclusions And Relevance:
The results suggest that the benefit of surgical decompression for space-occupying hemispheric infarction is consistent across a wide range of patients. The benefit of surgery after day 2 and in elderly patients remains uncertain.
