Surgical decompression improves mortality and morbidity after large territory acute cerebral infarction: A critically appraised topic

Background: Patients who suffer from large territory cerebral infarctions have poor prognosis. Whether adjunctive surgical therapy improves clinical outcomes has long been a controversial topic. Objective: 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. Methods: 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. Results: 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). CONCLUSIONS: 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.