Elsevier

The Surgeon

Volume 13, Issue 4, August 2015, Pages 230-240
The Surgeon

Review
Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: A systematic review and meta-analysis

https://doi.org/10.1016/j.surge.2014.12.002Get rights and content

Abstract

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.

Introduction

Malignant middle cerebral artery infarction (mMCAI), which accounts for up to 8% of all hospitalized ischemic stroke, is associated with a high fatality of 80%, despite intensive care-based treatment.1 Most patients experience neurological deterioration and transtentorial herniation within 72–96 h.2 For the therapy strategies, conservative medical treatment consisted of hyperventilation, mannitol, and sedation has not been supported by sufficient evidence of efficacy from clinical trials.3, 4 Decompressive hemicraniectomy (DHC), which aims at relieving refractory intracranial hypertension and brainstem compression by removing a part of skull and opening the dura to accommodate the swelling cerebral tissue, has been studied since 19565 and has become an attractive option for patients with mMCAI.

A previous meta-analysis, completed by Cruz-Flores et al.,6 confirmed the beneficial effects of DHC in decreasing the mortality and improving functional outcome in patients with mMCAI aged ≤60 years, as reported in three European randomized controlled trials (RCTs).7, 8, 9 Subsequently, guidelines from the American Heart Association/American Stroke Association (AHA/ASA) recommended DHC for mMCAI patients aged <60 years with a level of evidence of I.1 However, restricted to the limited RCTs, the efficacy of DHC in patients aged >60 years remained unclear. Recently, three more RCTs with additional 187 patients with an age limit of up to 80 years were published.10, 11, 12 Whether these reports change the previous conclusions and whether patients with mMCAI aged >60 years benefit from DHC are unclear. To address these issues, we conducted an updated meta-analysis to evaluate the effect of DHC in patients with mMCAI.

Section snippets

Literature search and inclusion criteria

A systematic literature search of PubMed, EMBASE, and the Cochrane Library Central Register of Control Trials, was conducted by two reviewers (M−H Y and H–Y L) to identify all the relevant articles published up to June 15, 2014. The search used key terms including hemicraniectomy, decompressive craniectomy, surgical decompression, middle cerebral artery, and stroke. No language and human subject restrictions were imposed. Subsequently, we also searched and evaluated the reference lists of

Study identification and selection

The initial search strategy identified 1426 articles. Of these, 1414 articles were removed because of duplicate studies and various other reasons (reviews/commentaries/letters, non-randomized control studies, or irrelevant to our analysis) based on the titles and abstracts. The remaining 12 were retrieved for full text review. Of these, six were excluded because two were duplicated data,16, 17 one was a non-randomized trial,18 one was terminated,19 one was awaiting assessment,20 and one

Discussion

This is an updated meta-analysis of six RCTs comprising of 314 patients to evaluate the efficacy of DHC in adult patients with mMCAI. The results of the present meta-analysis confirm the beneficial role of DHC in reducing mortality, death or major disability (mRS score >3) and death or severe disability (mRS score >4) in patients aged 18–80 years, although with a non-significant increase in the proportion of survivors with major disability (mRS score: 4–5). Specifically, a subgroup analysis

Acknowledgment

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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