Treatment of space-occupying cerebral infarction.
OBJECTIVE
Patients with a hemispheric infarct accompanied by massive edema have a poor prognosis; the case fatality rate may be as high as 80%, and most survivors are left severely disabled. Various treatment strategies have been proposed to limit brain tissue shifts and to reduce intracranial pressure, but their use is controversial. We performed a systematic search of the literature to review the evidence of efficacy of these therapeutic modalities.


METHODS
Literature searches were carried out on MEDLINE and PubMed.


METHODS
Studies were included if they were published in English between 1966 and February 2002 and addressed the effect of osmotherapy, hyperventilation, barbiturates, steroids, hypothermia, or decompressive surgery in supratentorial infarction with edema in animals or humans.


RESULTS
Animal studies of medical treatment strategies in focal cerebral ischemia produced conflicting results. If any, experimental support for these strategies is derived from studies with animal models of moderately severe focal ischemia instead of severe space-occupying infarction. None of the treatment options have improved outcome in randomized clinical trials. Two large nonrandomized studies of decompressive surgery yielded promising results in terms of reduction of mortality and improvement of functional outcome.


CONCLUSIONS
There is no treatment modality of proven efficacy for patients with space-occupying hemispheric infarction. Decompressive surgery might be the most promising therapeutic option. For decisive answers, randomized, controlled clinical trials are needed.
Hofmeijer
Jeannette
J
Department of Neurology, University Medical Center Utrecht, The Netherlands. j.hofmeijer@neuro.azu.nl
van der Worp
H Bart
HB
Kappelle
L Jaap
LJ
D001463:Barbiturates / Q000627:therapeutic use; D002544:Cerebral Infarction / Q000150:complications / Q000473:pathology* / Q000628:therapy*; D019299:Decompression, Surgical; D006801:Humans; D006985:Hyperventilation / Q000150:complications; D007036:Hypothermia, Induced; D008353:Mannitol / Q000627:therapeutic use; D013256:Steroids / Q000627:therapeutic use
D001463:Barbiturates; D013256:Steroids; D008353:Mannitol