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

Excerpt

Malignant middle cerebral infarction is defined as a clinical deterioration from hemispheric swelling and is named “malignant” because it is rapidly injurious to the patient. Recommendations for early decompressive hemicraniectomy (DHC) in malignant middle cerebral artery infarction (mMCAI) in the clinical routine are based on data from three European randomised controlled trials (DECIMAL, DEcompressive Craniectomy In MALignant middle cerebral artery infarcts [1]; DESTINY, DEcompressive Surgery for the Treatment of malignant Infarction of the middle cerebral artery [2]; and HAMLET, Hemicraniectomy After Middle cerebral artery infarction with Life-threatening Edema Trial [3]) and two pooled meta-analyses [3, 4]. The results clearly demonstrated that DHC is more than just an optional intervention in mMCAI as mortality was consistently significantly lower in patients who underwent surgery across all three trials, as compared with controls. None of the trials or meta-analyses were able to show significant improvement in functional outcome with DHC when the predefined dichotomization between a modified Rankin scale score (mRS) of 0–3 and 4–6 was used [3, 5]. However, a post hoc meta-analysis of the pooled data including totally 109 patients indicates that early surgery (<48 h after symptom onset) may also result in a higher proportion of patients with a mRS of 4 or lower, as compared to best medical treatment [3]. One of the unresolved and important questions after DECIMAL, DESTINY, and HAMLET is, if there is an age limit from which on the benefits of DHC are nullified. …