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Surgery for Malignant Middle Cerebral Artery Infarction

A pooled analysis of three randomized trials provides the first controlled evidence of a benefit.

Researchers report a preplanned pooled analysis of three European randomized controlled trials (the French DECIMAL, German DESTINY, and Dutch HAMLET trials) that compared early decompressive surgery with conservative treatment for malignant middle cerebral artery (MCA) infarction. A total of 93 patients fulfilled the inclusion criteria for the pooled analysis: age 18 through 60, NIH Stroke Scale (NIHSS) score greater than 15, decrease in the level of consciousness to a 1 or greater on item 1a on the NIHSS, at least 50% of the MCA territory infarct seen on CT or infarct volume >145 cm³ on diffusion-weighted MRI, and treatment within 48 hours after onset of symptoms. The primary outcome was modified Rankin Scale (mRS) score at 1 year; favorable and unfavorable outcomes were defined as scores of 0–4 and 5–death, respectively.

At 1 year, significantly more patients in the surgery group than in the control group had mRS scores of 0–4 (75% vs. 24%), and scores of 0–3 (43% vs. 21%). Survival was much higher in the surgery group (78% vs. 29%). The proportion of patients with an mRS score of 5 did not differ significantly between the two groups (surgical group, 4%; controls, 5%). The effect of surgery was consistent across the three trials. The authors conclude that decompressive surgery within 48 hours of stroke onset increases the number of patients who survive with a favorable outcome.

Comment: Both the DECIMAL and DESTINY trials stopped recruitment early due to significant between-group differences in mortality, favoring surgery. HAMLET is ongoing. The findings of the pooled analysis are remarkable in that the survival rate dramatically increased, from 29% to 79%, and the number of patients with favorable outcome (mRS score 0–3) more than doubled after surgery. The decision to perform surgery, however, must be individualized. Although the surgery may improve the rates of survival and of less-than-severe functional outcome, patients and families must be advised that moderate to moderately severe disability is virtually inevitable after surviving such a serious injury.

— Kiwon Lee, MD

Dr. Lee is Director, Neurointensive Care Unit, Jefferson Hospital for Neuroscience; Director, Neurocritical Care Fellowship, and Assistant Professor, Neurology and Neurosurgery, Jefferson Medical College, Thomas Jefferson University, Philadelphia.

Published in Journal Watch Neurology May 8, 2007

Citation(s):

Vahedi K et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: A pooled analysis of three randomised controlled trials. Lancet Neurol 2007 Mar; 6:215-22.

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