title: Surgical decompression improves mortality and morbidity after large territory acute cerebral infarction: a critically appraised topic.
abstract: 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.
authors.affiliation: Department of Neurology, Mayo Clinic, Scottsdale, Mayo Clinic, Phoenix, AZ, USA.
authors.forename: Amaal J
authors.initials: AJ
authors.lastname: Starling
authors.forename: Kay E
authors.initials: KE
authors.lastname: Wellik
authors.forename: Charlene R
authors.initials: CR
authors.lastname: Hoffman Snyder
authors.forename: Maria I
authors.initials: MI
authors.lastname: Aguilar
authors.forename: Bart M
authors.initials: BM
authors.lastname: Demaerschalk
authors.forename: Richard S
authors.initials: RS
authors.lastname: Zimmerman
authors.forename: Dean M
authors.initials: DM
authors.lastname: Wingerchuk
mesh_terms: D002544:Cerebral Infarction / Q000401:mortality* / Q000473:pathology* / Q000601:surgery*; D019299:Decompression, Surgical; D003937:Diagnosis, Differential; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000401:mortality / Q000473:pathology / Q000601:surgery; D016239:MEDLINE; D008297:Male; D015201:Meta-Analysis as Topic; D008875:Middle Aged; D015337:Multicenter Studies as Topic; D011379:Prognosis; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome