Decompressive Hemicraniectomy in the Treatment of Malignant Middle Cerebral Artery Infarction: A Meta-Analysis

Background: Malignant middle cerebral artery infarctions are large space-occupying infarctions involving massive edema, herniation, and frequently death. Survivors are disabled. Management involves medical treatment, with or without decompressive hemicraniectomy and later duraplasty. This meta-analysis aimed to determine whether surgery is worthwhile with particular regard to views on quality of life of professionals and patients.

Methods: A Medline search was performed with the search terms "decompressive surgery," "craniectomy," "hemicraniectomy," "decompressive hemicraniectomy," and "middle cerebral artery," "MCA," "infarct,*" "stroke,*" "embolus," "emboli," "thrombosis," "occlusion," "infarction," and "middle cerebral artery stroke," A second search was also done for views on postoperative quality of life. Studies retrieved were randomized controlled trials, observational studies, and reviews. We compared patients who received only medical treatment with those who had decompressive surgery. Participants were adult patients presenting with malignant middle cerebral artery infarction.

Results: 270 abstracts were reviewed. 40 articles were identified: 8 randomized controlled trials and 4 observational studies. There were a total of 692 patients: 268 surgical and 424 medical. The 2 groups were comparable, with similar demographics. In most trials, mortality was lower with surgery. However, morbidity tended to be higher, particularly in the elderly population. Morbidity was lower with medical treatment. Twelve articles on postoperative quality of life were reviewed; views differed between professionals, and survivors and caregivers. A patient-level comparison could not be made between all studies.

Conclusions: Surgical decompression results in lowered mortality but high morbidity, especially in the elderly. There is an increase in Quality Adjusted Life Years but at high costs. Professionals think that surgery is not worth the high disability rate. However, patients and caregivers are satisfied with their postoperative quality of life. Survey data from healthy study participants who are not professionals in stroke care were not available. The decision to treat surgically needs to be decided on an individual basis.