Background: Decompressive craniectomy (DC) is an aggressive life-saving surgical intervention for patients with malignant cerebral infarction (MCI). However, DC remains inconsistently and infrequently utilized, primarily due to enduring concern that increased survival occurs only at the cost of poor functional outcome. Our aim was to clarify the role of DC performed within 48 hours (early DC) for patients with MCI, including patients aged >60 years. Methods: We performed a meta-analysis of all available randomized controlled trials comparing early DC to best medical care for MCI. Studies were identified through literature searches of electronic databases including PubMed, EMBASE, and Scopus. We employed a Mantel-Haenszel fixed effects model to assess treatment effect on dichotomized modified Rankin Scale (mRS) outcomes at 12 months. Results: A total of 289 patients from 6 randomized controlled trials comparing early DC to best medical care were included. Early DC resulted in an increased rate of excellent outcomes, defined as mRS ≤2 (relative risk [RR] 2.81, 95% confidence interval [CI] 1.01-7.82, p 0.047), and favorable outcomes, defined as mRS ≤3 (RR 2.06, 95% CI 1.25-3.40, p 0.005). Early DC also increased the rate of survival with unfavorable outcomes, defined as mRS 4-5 (RR 3.03, 95% CI 1.98-4.65, p < 0.001). Conclusions: Early DC increases the rate of excellent outcomes, i.e., functional independence, in addition to favorable and unfavorable outcomes; however, these findings must be interpreted within the context of patients' goals of care. We have developed a clinical decision algorithm that incorporates goals of care, which may guide consideration of early DC for MCI in clinical practice.
Bibliographical noteFunding Information:
C. Streib was an NIH StrokeNET fellow supported by 1U01NS086489-02 (P.I. Tudor Jovin and Lawrence Wechsler). This project was supported by the NIH through UL1-TR-000005 and UL1-RR-024153.