Strokectomy for malignant middle cerebral artery infarction: experience and meta-analysis of current evidence
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REVIEW
Strokectomy for malignant middle cerebral artery infarction: experience and meta‑analysis of current evidence Saad Moughal1,4 · Sarah Trippier2 · Alaa AL‑Mousa3 · Atticus H. Hainsworth1,2 · Anthony C. Pereira2 · Pawanjit S Minhas4 · Anan Shtaya1,4 Received: 17 August 2020 / Revised: 25 November 2020 / Accepted: 4 December 2020 © The Author(s) 2020
Abstract Strokectomy means surgical excision of infarcted brain tissue post-stroke with preservation of skull integrity, distinguishing it from decompressive hemicraniectomy. Both can mitigate malignant middle cerebral artery (MCA) syndrome but evidence regarding strokectomy is sparse. Here, we report our data and meta-analysis of strokectomy compared to hemicraniectomy for malignant MCA infarction. All malignant MCA stroke cases requiring surgical intervention in a large tertiary centre (January 2012–December 2017, N = 24) were analysed for craniotomy diameter, complications, length of follow-up and outcome measured using the modified Rankin score (mRS). Good outcome was defined as mRS 0–3 at 12 months. In a meta-analysis, outcome from strokectomy (pooled from our cohort and published strokectomy studies) was compared with hemicraniectomy (our cohort pooled with published DECIMAL, DESTINY and HAMLET clinical trial data). In our series (N = 24, 12/12 F/M; mean age: 45.83 ± 8.91, range 29–63 years), 4 patients underwent strokectomy (SC) and 20 hemicraniectomy (HC). Among SC patients, craniotomy diameter was smaller, relative to HC patients (86 ± 13.10 mm, 120 ± 4.10 mm, respectively; p = 0.003), complications were less common (25%, 55%) and poor outcomes were less common (25%, 70%). In the pooled data (N = 41 SC, 71 HC), strokectomy tended towards good outcome more than hemicraniectomy (OR 2.2, 95% CI 0.99–4.7; p = 0.051). In conclusion, strokectomy may be non-inferior, lower risk and cost saving relative to hemicraniectomy sufficiently to be worthy of further investigation and maybe a randomised trial. Keywords Malignant MCA infarction · Decompressive craniectomy · Strokectomy
Introduction Malignant middle cerebral artery (MCA) infarction is a lifethreatening medical emergency that carries a poor prognosis with mortality of up to 80% in untreated patients [10, 15]. In malignant MCA syndrome expanding oedema causes mass effect, a substantial rise in intracranial pressure (ICP) * Anan Shtaya [email protected] 1
Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George’s, University of London, London SW17 0RE, UK
2
Neurology Department, St George’s University Hospitals NHS Foundation Trust, London, UK
3
Department of Surgery, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
4
Atkinson Morley Neurosurgery Centre, St George’s University Hospitals NHS Foundation Trust, London, UK
and reduction of cerebral blood flow (CBF) [11]. Malignant MCA syndrome can cause further infarction in other vascular territories especially the anterior cerebral artery [15]. Medical treatment alone to reduce the raised intr
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