title: Early decompressive craniectomy for malignant cerebral infarction: Meta-analysis and clinical decision algorithm.
abstract: BACKGROUND
  Decompressive craniectomy (DC) is an aggressive life-saving surgical intervention for patients with malignant cerebral infarction (MCI). However, DC remains inconsistently and infrequently utilized, primarily due to enduring concern that increased survival occurs only at the cost of poor functional outcome. Our aim was to clarify the role of DC performed within 48 hours (early DC) for patients with MCI, including patients aged >60 years.
  
  
  METHODS
  We performed a meta-analysis of all available randomized controlled trials comparing early DC to best medical care for MCI. Studies were identified through literature searches of electronic databases including PubMed, EMBASE, and Scopus. We employed a Mantel-Haenszel fixed effects model to assess treatment effect on dichotomized modified Rankin Scale (mRS) outcomes at 12 months.
  
  
  RESULTS
  A total of 289 patients from 6 randomized controlled trials comparing early DC to best medical care were included. Early DC resulted in an increased rate of excellent outcomes, defined as mRS ≤2 (relative risk [RR] 2.81, 95% confidence interval [CI] 1.01-7.82,p= 0.047), and favorable outcomes, defined as mRS ≤3 (RR 2.06, 95% CI 1.25-3.40,p= 0.005). Early DC also increased the rate of survival with unfavorable outcomes, defined as mRS 4-5 (RR 3.03, 95% CI 1.98-4.65,p< 0.001).
  
  
  CONCLUSIONS
  Early DC increases the rate of excellent outcomes, i.e., functional independence, in addition to favorable and unfavorable outcomes; however, these findings must be interpreted within the context of patients' goals of care. We have developed a clinical decision algorithm that incorporates goals of care, which may guide consideration of early DC for MCI in clinical practice.
authors.affiliation: Department of Neurology and UPMC Stroke Institute (CDS, BJM), Health Sciences Library System (LMH), and Department of Critical Care Medicine (BJM), University of Pittsburgh, PA. Dr. Streib is currently affiliated with the University of Minnesota, Minneapolis.
authors.forename: Christopher D
authors.initials: CD
authors.lastname: Streib
authors.affiliation: Department of Neurology and UPMC Stroke Institute (CDS, BJM), Health Sciences Library System (LMH), and Department of Critical Care Medicine (BJM), University of Pittsburgh, PA. Dr. Streib is currently affiliated with the University of Minnesota, Minneapolis.
authors.forename: Linda M
authors.initials: LM
authors.lastname: Hartman
authors.affiliation: Department of Neurology and UPMC Stroke Institute (CDS, BJM), Health Sciences Library System (LMH), and Department of Critical Care Medicine (BJM), University of Pittsburgh, PA. Dr. Streib is currently affiliated with the University of Minnesota, Minneapolis.
authors.forename: Bradley J
authors.initials: BJ
authors.lastname: Molyneaux