A systematic review and meta-analysis of the effectiveness of surgical decompression in treating patients with malignant middle cerebral artery infarction

Abstract

Background
Malignant infarction of the middle-cerebral-artery (MCI) is life threatening. It is associated with a mortality as high as 80% and survival often at the expense of serious disability. Limited success of medical therapies has resulted in decompressive craniectomy (DC) being increasingly used as a treatment for MCI, though evidence of its efficacy is inconclusive. In this study, the efficacy of DC in improving survival, or survival free of severe disability, was assessed.

Methods
A meta-analysis was performed to approximate the efficacy of DC for treating MCI, considering age and time-to-surgery. A systematic literature review was conducted on Medline, Embase and Cochrane library databases to 01 August 2018. Death and severe
disability at 3, 6, 12 and 36 months follow-up were assessed, comparing best medical therapy with DC.

Results
18 studies were eligible for inclusion and represented 987 individuals who received DC. Nine of these were RCTs (n=374 DC). Early DC (<48h from onset of stroke) reduced mortality (OR=0.18, 95%CI=0.11, 0.29; P<0.00001) but not unfavourable outcome
(modified Rankin Scale (mRS)>4) (OR=1.38, 95%CI=0.47, 4.11; P=0.56) at 12 months follow-up. This survival benefit was maintained regardless of age.

Conclusion
Early DC reduces mortality but does not appear to improve favourable outcomes in patients aged younger or older than 60 years following MCI. RCTs incorporating quality of life assessments are warranted for MCI patients, in addition to defining the optimal timing and benefits of DC in older patients.