Schwab_EU Neurology 08/03/2010 15:53 Page 114
Surgery
Figure 2: Functional Outcome After Conservative Treatment (A) and After Hemicraniectomy (B) in
Patients with Malignant Middle Cerebral Artery Infarction
A. Functional outcome after 12 months – conservative treatment (mRS) B. Functional outcome after 12 months – hemicraniectomy (mRS)
6.7 20 6.7 13.3 53.3 23.5 23.5 29.4 5.9 17.6
Destiny Destiny
22.2 77.8 15 35 25 25
Decimal Decimal
2.5 19 2.5 5 71 14 29 31 4 22
Pooled Pooled
analysis analysis
0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%
2 3 4 5 6 2 3 4 5 6
was chosen based on interim analyses after every four patients. necessarily result in fatal brain oedema. It seems important to identify
Secondary end-points included survival and the score on the mRS at those patients who are at risk of developing a malignant clinical course
six and 12 months. Between December 2000 and November 2005, 38 as soon as possible. Magnetic resonance imaging (MRI) features are
patients were enrolled. Survival was significantly different between likely to contribute to rapid diagnosis and prediction of fatal oedema
both groups: the mortality rate was five of 20 patients (25%) in the formation; however, further studies and a more systematic evaluation
surgical treatment group and 14 of 18 patients (77.8%) in the are needed.
31,32
From our clinical experience we know that there are
conservative treatment group (p<0.0001). Functional outcome data patients with large brain infarctions who rapidly develop fatal brain
after 12 months are summarised in Figure 2: 40.0% of patients in the swelling. In these patients early decompressive surgery is probably the
surgical arm versus 22.2% of patients in the conservative arm only life-saving procedure. On the other hand there are patients with
reached an mRS of 0–3 (p=0.08).
27
massive infarctions but only mild brain swelling over a long period of
time. Many of these patients never develop signs of herniation, and
In 2007 the results of a prospectively planned pooled analysis of hemicraniectomy may not necessarily be mandatory. It is unclear
the three European randomised trials including all patients from which factors promote early and rapid brain swelling and which
DESTINY and DECIMAL and 23 patients from HAMLET receiving factors are protective. Experimental studies have suggested that free
early hemicraniectomy within 48 hours was published.
27–30
For the radicals, prostaglandins, arachidonic acid and leukotrienes may play a
pooled analysis, a maximum time window from stroke onset to role, and reperfusion of already irreversibly damaged brain tissue may
randomisation of 45 hours and of 48 hours to treatment start was enhance oedema formation.
7,33
adopted. Outcome measures were the score on the mRS at one year,
dichotomised into 0–4 and 5+6, as well as 0–3 and 4–6, and the case Data from the literature are contradictory: Mori et al. retrospectively
fatality rate at one year. All patients randomised in DECIMAL and compared patients who had been treated before the onset of brain
DESTINY and 23 patients from HAMLET were eligible for the pooled herniation with those who showed clinical and radiological signs of
analysis. Thus, a total of 93 patients were included, of whom 51 were herniation. Mortality was markedly reduced from 17.2 to 4.8% after
randomised to decompressive surgery and 42 to conservative one month and from 27.6 to 19.1% after six months. Outcome at six
treatment. Results demonstrated that after decompressive surgery, months was also significantly improved by early intervention.
15
more patients had an mRS ≤4 (75 versus 24%; p<0.0001), with a Another retrospective study by Woertgen and colleges investigated
pooled absolute risk reduction (ARR) of 51% (95% confidence interval 48 patients and showed comparable results for mortality (early versus
[CI] 34–69). In addition, more patients had an mRS ≤3 (43 versus 21%; delayed surgery: 16 versus 39%), but not for outcome.
34
p=0.014), with a pooled ARR of 23% (95% CI 5–41). The case fatality
rate in the surgical group was 78% versus 29% in the conservative These results were confirmed in two prospective studies: Schwab
treatment group (p<0.0001) indicating a pooled ARR of 50% (95% CI et al. demonstrated markedly decreased mortality in patients
33–67) (see Figure 2). The resulting numbers needed to treat are two treated within 24 hours after symptom onset compared with 48
for survival with an mRS ≤4, four for survival with an mRS ≤3 and hours or later (16 versus 34%), as well as a significantly decreased
two for survival irrespective of outcome.
30
duration of treatment in the ICU (7.4 versus 13.3 days) and a trend
for improved clinical outcome after three months in favour of early
Open Questions hemicraniectomy.
19
These results were not supported by other case
Timing of Surgery – Early or Delayed series: in a review by Gupta et al., including all individual patient data
Debate remains with regard to the optimal time-point for from the literature until 2004, neither the presence of brainstem
decompressive hemicraniectomy. It has still not been clarified whether signs nor the time from symptom onset to operation was associated
to operate as soon as possible, when the diagnosis of malignant MCA with poor outcome or increased mortality rates.
14
Because of the
infarction has been made, or to wait for development of clinical results from DESTINY and DECIMAL, early hemicraniectomy is
deterioration, midline shift on brain imaging, increased intracranial recommended as soon as the diagnosis of a malignant MCA
pressure or signs of herniation. Malignant MCA infarction does not infarction has been made.
114 EUROPEAN NEUROLOGICAL REVIEW
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