Should Age be Considered When Proposing Decompressive Hemicraniectomy in Malignant Stroke, and If so Where is the Limit?

Abstract

Malignant middle cerebral infarction is defined as a clinicaldeterioration from hemispheric swelling and is named‘‘malignant’’ because it is rapidly injurious to the patient.Recommendations for early decompressive hemicraniec-tomy (DHC) in malignant middle cerebral artery infarction(mMCAI)intheclinicalroutineare based ondata fromthreeEuropean randomised controlled trials (DECIMAL, DE-compressive Craniectomy In MALignant middle cerebralartery infarcts [1]; DESTINY, DEcompressive Surgery forthe Treatment of malignant Infarction of the middle cerebralartery [2]; and HAMLET, Hemicraniectomy After Middlecerebral artery infarction with Life-threatening Edema Trial[3]) and two pooled meta-analyses [3, 4]. The results clearlydemonstrated that DHC is more than just an optional inter-vention in mMCAI as mortality was consistentlysignificantlylowerinpatientswho underwentsurgery acrossall three trials, as compared with controls. None of the trialsormeta-analyses were abletoshow significant improvementin functional outcome with DHC when the predefineddichotomization between a modified Rankin scale score(mRS) of 0–3 and 4–6 was used [3, 5]. However, a post hocmeta-analysis of the pooled data including totally 109patients indicates that early surgery ( 4 (6 months: 31.2 vs. 92.3 %; 1 year: 37.5 vs.100 %). Based on those findings, the authors come to theoptimistic conclusion that DHC is beneficial for patientsaged 61–80 years although there seems to be an increasedlikelihood for those patients to survive with moderatelysevere disability (mRS 4).As Zhao et al. state in the discussion of their article,those results are ‘‘exciting,’’ providing the first outcome