Can a hemicraniectomy improve outcomes in elderly patients with middle-cerebral-artery stroke?

The authors aimed to assess the benefits of hemicraniectomy in elderly patients with middle-cerebral-artery stroke.

Middle-cerebral-artery stroke is the sudden onset of functional abnormality of the brain resulting from infarction (obstruction of blood supply) or ischemia (inadequate blood supply) to the territory supplied by the middle cerebral artery, the largest blood vessel that supplies the brain. It can lead to the development of massive brain edema (when the water content of the brain rises, causing massive pressure in the skull), which may lead to herniation (part of the brain is squeezed across structures in the skull) and early death.

Decompressive hemicraniectomy (temporary removal of a large part of the skull) combined with duraplasty (reconstructive surgery) allows water-swollen tissue to expand outside the skull, thereby preventing fatal internal moving and squeezing of brain tissue and subsequent herniation. In previous studies, hemicraniectomy within 48 hours of stroke increased 1-year survival from 29% to 78%. However, the upper age limit in previous studies has been 60 years and therefore the benefit in older patients is uncertain.

This study aimed to assess the benefit of early hemicraniectomy in patients over 60 years of age.

112 patients aged 61 years or older with malignant middle-cerebral-artery infarction were randomly assigned to either conservative treatment in the intensive care unit (control group) or hemicraniectomy within 48 hours of the onset of symptoms of stroke. Data was typically collected at 6 and 12 months.

At 6 months the proportion of patients who survived without severe disability was 38% in the hemicraniectomy group compared to 18% in the control group. Those in the hemicraniectomy group were almost 3 times more likely to survive without severe disability. Mortality rates (the percentage people who died during follow-up) were 33% for the hemicraniectomy group and 70% for the control group.

The modified Rankin scale is an assessment of stroke outcomes where 0 indicates no symptoms, 1 indicates no significant disability despite symptoms, 2 indicates slight disability, 3 indicates moderate disability, 4 indicates moderately severe disability and 5 indicates severe disability. No patients had a modified Rankin scale of 0-2. 7% of hemicraniectomy and 3% of the control group had a score of 3. 32% of the hemicraniectomy group and 15% of the control group had a score of 4. 28% of the hemicraniectomy group and 13% of the control group had a score of 5.

The 12-month survival rate was 57% in the hemicraniectomy group and 24% in the control group.

The authors stated that hemicraniectomy increased survival without severe disability among patients 61 years of age or older with a malignant middle-cerebral-artery infarction. However, the majority of survivors required assistance with most bodily needs.