Hemicraniectomy versus Conservative Treatment in Large Hemispheric Ischemic Stroke Patients: A Meta-analysis of Randomized Controlled Trials.
BACKGROUND
Several small trials have inconclusively evaluated the effect of hemicraniectomy in reducing death and disability in acute ischemic stroke patients with large hemispheric infarctions. We compared the effects of hemicraniectomy on death and disability with conservative treatment in patients with large hemispheric infarctions.


METHODS
We calculated pooled odds ratios (ORs) and 95% confidence intervals (CIs) using random-effects models from 7 randomized trials that compared hemicraniectomy with conservative treatment in acute ischemic stroke patients. The primary end point was a favorable outcome defined by modified Rankin Scale grades of 0 (no symptoms), 1 (no significant disability), 2 (slight disability), and 3 (moderate disability) at 6-12 months post randomization.


RESULTS
Of the 341 total subjects randomized, the proportion of subjects who achieved a favorable outcome was significantly greater among those randomized to hemicraniectomy than among those randomized to conservative treatment (OR 2.04, 95% CI 1.03-4.03, P = .04). Survival was also significantly greater among those randomized to hemicraniectomy (OR 5.56, 95% CI 3.40-9.08, P < .001) than among those randomized to conservative treatment. There was a trend toward higher odds of favorable outcome among those randomized to hemicraniectomy than among those randomized to conservative treatment in trials that permitted recruitment of patients aged 60 years or older (303 subjects analyzed; OR 1.87, 95% CI .91-3.86, P = .09).


CONCLUSIONS
Compared with conservative treatment, the odds of achieving a favorable outcome at 6 months is approximately 2-folds higher with hemicraniectomy in patients with large hemispheric infarctions.
Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota. Electronic address: qureshai@gmail.com.
Adnan I
AI
Qureshi
Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota.
Muhammad F
MF
Ishfaq
Houston Methodist Hospital-Texas Medical Center, Houston, Texas.
Haseeb A
HA
Rahman
Houston Methodist Hospital-Texas Medical Center, Houston, Texas.
Abraham P
AP
Thomas
D002545:Brain Ischemia / Q000150:complications; D000072700:Conservative Treatment / Q000379:methods*; D003399:Craniotomy / Q000379:methods*; D016206:Databases, Bibliographic / Q000706:statistics & numerical data; D007839:Functional Laterality / Q000502:physiology*; D006801:Humans; D016017:Odds Ratio; D016032:Randomized Controlled Trials as Topic; D020521:Stroke / Q000209:etiology / Q000601:surgery*; D016896:Treatment Outcome
Hemicraniectomy; acute ischemic stroke; disability; meta-analysis; mortality; surgical decompression