Decompressive craniectomy for the treatment of malignant middle cerebral artery infarction

Introduction: Malignant middle cerebral artery (MCA) infarction is associated with up to 80% mortality in the first week, despite maximal medical therapy. Decompressive craniectomy (DC) has been shown to improve survival rates in these patients. However, there are concerns that DC prolongs poor quality of life by increasing the number of survivors with major disability. This review will assess if DC in patients with malignant MCA infarction improves functional outcomes compared to maximal medical therapy. It will estimate the optimal time for surgery following stroke onset and ask if DC is effective in older patients (>60 years).Methods: A literature search was conducted using Medline, Embase, PubMed and the Cochrane Library. Randomised controlled trials and meta-analysis that fulfilled the inclusion criteria and answered the clinical question were evaluated.Results: Twelve papers were identified and considered appropriate to answer the clinical question. These included 8 prospective randomised controlled trials and 4 meta-analysis. A critical review of these papers was conducted.Conclusions: In patients 60 years of age or younger, DC within 48hours of stroke onset significantly reduced risk of death and major disability (mRS>3) compared to maximal medical therapy only. In older patients (>60 years) DC also significantly improved survival but the majority of survivors were left with major disability (mRS 4-5). DC performed more than 48hours after symptom onset does not appear to be superior to best medical management. The decision to perform decompressive surgery needs to be made on a case-by-case basis, taking into account the degree of disability patients and their carers are willing to accept.