Decompressive craniectomy for the treatment of malignant infarction of the middle cerebral artery

XiaoCheng Lu, BaoSheng Huang, JinYu Zheng, Yi Tao, Wan Yu, LinJun Tang, RongLan Zhu, Shuai Li, LiXin Li, XiaoCheng Lu, BaoSheng Huang, JinYu Zheng, Yi Tao, Wan Yu, LinJun Tang, RongLan Zhu, Shuai Li, LiXin Li

Abstract

Early decompressive craniectomy (DC) has been shown to reduce mortality in malignant middle cerebral artery (MCA) infarction, whereas efficacy of DC on functional outcome is inconclusive. Here, we performed a meta-analysis to estimate the effects of DC on malignant MCA infarction and investigated whether age of patients and timing of surgery influenced the efficacy. We systematically searched PubMed, Medline, Embase, Cochrane library, Web of Science update to June 2014. Finally, A total of 14 studies involved 747 patients were included, of which 8 were RCTs (341 patients). The results demonstrated that early DC (within 48 h after stroke onset) decreased mortality (OR = 0.14, 95%CI = 0.08, 0.25, p<0.0001) and number of patients with poor functional outcome (modified Rankin scale (mRS)>3) (OR = 0.38, 95%CI = 0.20, 0.73, p = 0.004) for 12 months follow-up. In the subgroup analysis stratified by age, early DC improved outcome both in younger and older patients. However, later DC (after 48h after stroke onset) might not have a benefit effect on lowering mortality or improving outcome in patients with malignant infarction. Together, this study suggested that decompressive surgery undertaken within 48 h reduced mortality and increased the number of patients with a favourable outcome in patients with malignant MCA infarction.

Figures

Figure 1. Flow chart of the literature…
Figure 1. Flow chart of the literature search.
Figure 2. Risk of bias assessment for…
Figure 2. Risk of bias assessment for randomized controlled trials.
‘+': low risk of bias, ‘−': high risk of bias, and ‘?': Indicates unclear risk of bias.
Figure 3. Forest plot with OR estimating…
Figure 3. Forest plot with OR estimating with the corresponding 95% CI for unfavourable outcome (defined as mRS>3) associated with early DC versus medical treatment for individual trials and the pooled population at 3 months, 6 months, 12 months and 36 months follow-up (patients in all ages) CI, confidence interval; DC: decompressive craniectomy; OR, odds ratio; mRS: modified Rankin scale.
Figure 4. Forest plot with OR estimating…
Figure 4. Forest plot with OR estimating with the corresponding 95% CI for (A) unfavourable outcome (defined as mRS>3) or (B) the proportion of survivors with moderately severe or severe disability (defined as mRS = 4 or 5) associated with early DC versus medical treatment for individual trials and the subgroup population stratified by age at 6 months follow-up.
CI, confidence interval; DC: decompressive craniectomy; OR, odds ratio; mRS: modified Rankin scale.
Figure 5. Forest plot with OR estimating…
Figure 5. Forest plot with OR estimating with the corresponding 95% CI for the proportion of survivors with moderately severe or severe disability (defined as mRS = 4 or 5) associated with early DC versus medical treatment for individual trials and the pooled population at 3 months, 6 months, 12 months and 36 months follow-up (patients in all ages) CI, confidence interval; DC: decompressive craniectomy; OR, odds ratio; mRS: modified Rankin scale.
Figure 6. Funnel plot to detect publication…
Figure 6. Funnel plot to detect publication bias.
No significant funnel asymmetry was observed which could indicate publication bias. (P value for Egger test was 0.38) logor Natural logarithm of the OR, s.e. of logor standard error of the logOR.

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