Strokectomy for malignant middle cerebral artery infarction: experience and meta-analysis of current evidence
Saad Moughal1,2, Sarah Trippier3, Alaa Al-Mousa4
1Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, SW17 0RE, UK.
Abstract:
Strokectomy means surgical excision of infarcted brain tissue post-stroke with preservation of skull integrity, distinguishing it from decompressive hemicraniectomy. Both can mitigate malignant middle cerebral artery (MCA) syndrome but evidence regarding strokectomy is sparse. Here, we report our data and meta-analysis of strokectomy compared to hemicraniectomy for malignant MCA infarction. All malignant MCA stroke cases requiring surgical intervention in a large tertiary centre (January 2012-December 2017, N = 24) were analysed for craniotomy diameter, complications, length of follow-up and outcome measured using the modified Rankin score (mRS). Good outcome was defined as mRS 0-3 at 12 months. In a meta-analysis, outcome from strokectomy (pooled from our cohort and published strokectomy studies) was compared with hemicraniectomy (our cohort pooled with published DECIMAL, DESTINY and HAMLET clinical trial data). In our series (N = 24, 12/12 F/M; mean age: 45.83 ± 8.91, range 29-63 years), 4 patients underwent strokectomy (SC) and 20 hemicraniectomy (HC). Among SC patients, craniotomy diameter was smaller, relative to HC patients (86 ± 13.10 mm, 120 ± 4.10 mm, respectively; p = 0.003), complications were less common (25%, 55%) and poor outcomes were less common (25%, 70%). In the pooled data (N = 41 SC, 71 HC), strokectomy tended towards good outcome more than hemicraniectomy (OR 2.2, 95% CI 0.99-4.7; p = 0.051). In conclusion, strokectomy may be non-inferior, lower risk and cost saving relative to hemicraniectomy sufficiently to be worthy of further investigation and maybe a randomised trial.
Insights
Strokectomy, a surgical removal of infarcted brain tissue, shows promise for malignant middle cerebral artery (MCA) syndrome. This less invasive procedure may offer better outcomes than hemicraniectomy, warranting further clinical trials.
Area of Science:
- Neurosurgery
- Stroke Medicine
- Critical Care Neurology
Background:
- Malignant middle cerebral artery (MCA) syndrome poses a significant threat post-stroke, often necessitating surgical intervention.
- Decompressive hemicraniectomy (HC) is a standard surgical approach, but strokectomy (SC), involving infarctectomy with skull preservation, is less understood.
- Evidence comparing strokectomy to hemicraniectomy for malignant MCA infarction remains sparse.
Purpose of the Study:
- To compare the efficacy and safety of strokectomy versus hemicraniectomy in patients with malignant MCA infarction.
- To analyze surgical parameters, complications, and patient outcomes using the modified Rankin score (mRS).
- To conduct a meta-analysis pooling data from a single tertiary center and published studies.
Main Methods:
- Retrospective analysis of 24 malignant MCA stroke patients undergoing surgical intervention (2012-2017) at a tertiary center.
- Comparison of craniotomy diameter, complication rates, and mRS outcomes between strokectomy (SC) and hemicraniectomy (HC) groups.
- Meta-analysis combining data from the center's cohort with published strokectomy studies and major hemicraniectomy trial data (DECIMAL, DESTINY, HAMLET).
Main Results:
- In the center's cohort (4 SC, 20 HC), strokectomy patients had significantly smaller craniotomy diameters (86±13.10 mm vs. 120±4.10 mm, p=0.003).
- Strokectomy was associated with fewer complications (25% vs. 55%) and less frequent poor outcomes (25% vs. 70%) compared to hemicraniectomy.
- Pooled meta-analysis (41 SC, 71 HC) indicated a trend towards better outcomes with strokectomy (OR 2.2, 95% CI 0.99-4.7, p=0.051).
Conclusions:
- Strokectomy may be a viable alternative to hemicraniectomy for malignant MCA infarction, potentially offering non-inferior outcomes with reduced risk.
- The findings suggest strokectomy could be a lower-risk and cost-effective intervention.
- Further investigation, including randomized controlled trials, is warranted to definitively establish strokectomy's role in managing malignant MCA syndrome.
