Decompressive hemicraniectomy for Malignant MCA infarction

by Chris Nickson, Last updated October 18, 2016

Reviewed and revised 30 March 2015
OVERVIEW
 Decompressive craniectomy is a controversial therapy for malignant middle cerebral artery
(MCA) stroke
 Malignant MCA stroke is indicated by:
 MCA territory stroke of >50% on CT
 Perfusion deficit of >66% on CT
 Infarct volume >82 mL within 6 hours of onset (on MRI)
 Infarct volume of >145mL within 14 hours of onset (on MRI)
RATIONALE
 Malignant MCA infarction is a devastating event with substantial morbidity and mortality,
due to:
 involvement of a large amount of brain tissue, resulting in cerebral edema and
increased intracranial pressure
 risk of haemorrhagic transformation
 midline shift resulting in compression of medial cerebral structures
 potential for transtentorial herniation, with compression of the posterior cerebral
artery
 Poor perfusion of the contralateral cerebral hemisphere due to increased ICP
 Decompressive craniectomy may have the following effects, which could lead to improved
morbidity and mortality:
 can decrease intracranial pressure by increasing cranial compliance
 prevent transtentorial herniation
 improving perfusion in the penumbra of the stroke

PROS AND CONS

Advantages

 face validity based on theoretical rationale

 decreased mortality in age <60 years with <48h onset of malignant MCA stroke
 Well tolerated even after thrombolysis (though apparently antiplatelet drugs tend to
increase the risk of bleeding)
 Craniectomy and evacuation of clot may be required for haemorrhagic transformation
anyway

Disadvantages

 Highly invasive procedure

 Resource intensive (monetary cost, neurosurgeons, OT, ICU care)
 Craniectomy has to be large enough to extend past the margins of the infarct
  Evidence base is limited by small trials and potential for systematic bias (e.g. due to lack
of allocation concealment)
 Should only be considered if age <60 years and <48h since stroke onset

EVIDENCE
There are 3 important trials that have studied decompressive hemicraniectomy for malignant
MCA strokes in patients <60 years of age

DESTINY trial (2007)

 Prospective, MC RCT from Germany

 n=32 (projected sample size calculated to be n-188)
 steering committee terminated the trial early as a statistically significant mortality
reduction was found at this stage in comibnation with the results of the other European
decompressive craniectomy trials
 Outcome: 88% vs 47% survival in favour of decompressive craniectomy

DECIMAL trial (2007)

 Prospective, MC RCT from France

 n=38
 data safety monitoring committee terminated the trial because of slow recruitment
 Outcome: ARR 52.8% in mortality favouring the decompressive craniectomy group (75%
vs 22% survival)

HAMLET trial (2009)

 Prospective, MC RCT from the Netherlands

 n=64
 Outcome: ARR 38% in mortality favouring the decompressive craniectomy group
Pooled analysis of DESTINY, DECIMAL and HAMLET (Vahedi et al, 2007)

 n=93
 Patients aged <60y with supratentorial infarctions treated with decompressive
craniectomy, usually within 48 hours of stroke onset
 With hemicraniectomy compared with medical management:
 Reduced mortality (22% versus 71% – pooled analysis; NNT=2)
 No individual study showed an improvement in the percentage of survivors with
good outcomes (mRS score, 0–3)
 Only shown in a pooled analysis (43% versus 21%).
 Only 14% of surgical survivors could look after their own affairs without
assistance (mRS score, 2)
  no difference in outcome whether dominant or non-dominant hemispheres are
involved

Subsequently, the DESTINY II Trial (2014) studied patients aged >60 years:

 n = 112 patients >60 years of age (median age was 70)

 Primary outcome measure was survival without severe disability
 38% in the hemicraniectomy group vs 18% in the control group
 Secondary outcomes:
 Overall mortality was lower in the surgery group (33% vs 70%)
 Almost none of the survivors has an outcome as good as an mRS score of 3; almost
all post-operative survivors were severely disabled

AN APPROACH
Decompressive hemicraniectomy

 can be considered in patients <60 years of age, within 48 hours of stroke onset,
although outcomes are still likely to be poor
 should not be performed in malignant MCA stroke patients aged >60 years as survivors
will be severely disabled

References and Links

Journal articles
 Back L, Nagaraja V, Kapur A, Eslick GD. The role of decompressive hemicraniectomy in
extensive middle cerebral artery strokes: a meta-analysis of randomized trials. Intern Med
J. 2015 Feb 13. doi: 10.1111/imj.12724. [Epub ahead of print] PubMed PMID: 25684396.
 Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp HB; HAMLET
investigators. Surgical decompression for space-occupying cerebral infarction (the
Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema
Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol. 2009
Apr;8(4):326-33. doi: 10.1016/S1474-4422(09)70047-X. Epub 2009 Mar 5. PubMed
PMID: 19269254.
 Jüttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, Witte S,
Jenetzky E, Hacke W; DESTINY Study Group. Decompressive Surgery for the Treatment
of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized,
controlled trial. Stroke. 2007 Sep;38(9):2518-25. Epub 2007 Aug 9. PubMed PMID:
17690310. [Free Full Text]
 Jüttler E, Unterberg A, Woitzik J, Bösel J, Amiri H, Sakowitz OW, Gondan M, Schiller P,
Limprecht R, Luntz S, Schneider H, Pinzer T, Hobohm C, Meixensberger J, Hacke W;
DESTINY II Investigators. Hemicraniectomy in older patients with extensive middle-
cerebral-artery stroke. N Engl J Med. 2014 Mar 20;370(12):1091-100. doi:
10.1056/NEJMoa1311367. PubMed PMID: 24645942. [Free Full Text]
 Rahme R, Zuccarello M, Kleindorfer D, Adeoye OM, Ringer AJ. Decompressive
hemicraniectomy for malignant middle cerebral artery territory infarction: is life worth
living? J Neurosurg. 2012 Oct;117(4):749-54. doi: 10.3171/2012.6.JNS111140. Epub 2012
Aug 24. Review. PubMed PMID: 22920962.
 Taylor B, Lopresti M, Appelboom G, Sander Connolly E Jr. Hemicraniectomy
for malignant middle cerebral artery territory infarction: an updated review. J Neurosurg
Sci. 2015 Mar;59(1):73-8. Epub 2014 Nov 25. PubMed PMID: 25423133.
 Torbey MT, Bösel J, Rhoney DH, Rincon F, Staykov D, Amar AP, Varelas PN, Jüttler E,
Olson D, Huttner HB, Zweckberger K, Sheth KN, Dohmen C, Brambrink AM, Mayer SA,
Zaidat OO, Hacke W, Schwab S. Evidence-Based Guidelines for the Management of
Large Hemispheric Infarction : A Statement for Health Care Professionals from the
Neurocritical Care Society and the German Society for Neuro-Intensive Care and
Emergency Medicine. Neurocrit Care. 2015 Jan 21. [Epub ahead of print] PubMed PMID:
25605626.
 Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, Boutron C, Couvreur G,
Rouanet F, Touzé E, Guillon B, Carpentier A, Yelnik A, George B, Payen D, Bousser MG;
DECIMAL Investigators. Sequential-design, multicenter, randomized, controlled trial of
early decompressive craniectomy in malignant middle cerebral artery infarction
(DECIMAL Trial). Stroke. 2007 Sep;38(9):2506-17. Epub 2007 Aug 9. PubMed PMID:
17690311.
 Vahedi K, Hofmeijer J, Juettler E, et al. Early decompressive surgery in malignant
infarction of the middle cerebral artery: a pooled analysis of three randomised controlled
trials. The Lancet Neurology 2007;6:215-22. PMID: 17303527.
 Yang MH, Lin HY, Fu J, Roodrajeetsing G, Shi SL, Xiao SW. Decompressive
hemicraniectomy in patients with malignant middle cerebral artery infarction: A
systematic review and meta-analysis. Surgeon. 2015;13:(4)230-40. [pubmed]