• Neurosurgery · Mar 2020

    Meta Analysis

    Outcome After Decompressive Craniectomy for Middle Cerebral Artery Infarction: Timing of the Intervention.

    • Taco Goedemans, Dagmar Verbaan, Bert A Coert, Bertjan Kerklaan, René van den Berg, Jonathan M Coutinho, Tessa van Middelaar, Paul J Nederkoorn, W Peter Vandertop, and Pepijn van den Munckhof.
    • Neurosurgical Centre Amsterdam, Amsterdam Medical Centre, Amsterdam University Medical Centres (UMC), University of Amsterdam, Amsterdam, the Netherlands.
    • Neurosurgery. 2020 Mar 1; 86 (3): E318-E325.

    BackgroundBased on randomized controlled trials (RCTs), clinical guidelines for the treatment of space-occupying hemispheric infarct employ age (≤60 yr) and time elapsed since stroke onset (≤48 h) as decisive criteria whether to perform decompressive craniectomy (DC). However, only few patients in these RCTs underwent DC after 48 h.ObjectiveTo study the association between the timing of DC and (un)favorable outcome in patients with space-occupying middle cerebral artery (MCA) infarct undergoing DC.MethodsWe performed a single-center cohort study from 2007 to 2017. Unfavorable outcome at 1 yr was defined as a Glasgow outcome scale 1 to 3. Additionally, we systematically reviewed the literature up to November 2018, including studies reporting on the timing of DC and other predictors of outcome. We performed Firth penalized likelihood and random-effects meta-analysis with odds ratio (OR) on unfavorable outcome.ResultsA total of 66 patients were enrolled. A total of 26 (39%) patients achieved favorable and 40 (61%) unfavorable outcomes (13 [20%] died). DC after 48 h since stroke diagnosis did not significantly increase the risk of unfavorable outcome (OR 0.8, 95% CI 0.3-2.3). Also, in the meta-analysis, DC after 48 h of stroke onset was not associated with a higher risk of unfavorable outcome (OR 1.11; 95% CI 0.89-1.38).ConclusionThe outcome of DC performed after 48 h in patients with malignant MCA infarct was not worse than the outcome of DC performed within 48 h. Contrary to current guidelines, we, therefore, advocate not to set a restriction of ≤48 h on the time elapsed since stroke onset in the decision whether to perform DC.Copyright © 2020 by the Congress of Neurological Surgeons.

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