Surgical Decompression Improves Mortality and Morbidity After Large Territory Acute Cerebral Infarction

Abstract

patients who suffer from large territory cerebral infarctions have poor prognosis. Whether adjunctive surgical therapy improves clinical outcomes has long been a controversial topic. to determine whether surgical decompression, compared with best medical management, improves mortality and morbidity in the setting of a large territory acute middle cerebral artery infarction. the objective was addressed through the development of a structured critically appraised topic. This included development of a clinical scenario, structured clinical questions, search strategy and selection of an article, critical appraisal, evidence summary, clinical bottom lines, and expert commentary from vascular neurologists and a vascular neurosurgeon. the study selected for appraisal included data from both a multicenter randomized trial and an updated meta-analysis. Surgical decompression within 4 days of stroke onset did not reduce the risk of poor outcome [absolute risk reduction (ARR), 0%; 95% confidence interval (CI), -21% to 21%]; however, it did reduce case fatality (ARR, 38%; 95% CI, 15% to 60%). The updated meta-analysis showed that surgical decompression within 48 hours of stroke onset reduces both poor outcome [ARR, 42%; 95% CI, 23% to 56%; number needed to treat (NNT)=2; 95% CI, 2 to 4] and case fatality (ARR, 50%; 95% CI, 32% to 64%; NNT=2; 95% CI, 2 to 3). early surgical decompression (within 48 h of stroke onset) reduces the risks of death and poor clinical outcome at 1 year in patients with large territory cerebral infarction.