Decompressive craniectomy can significantly improve survival following a massive stroke, new research suggests. Mortality rates after these 'malignant' middle cerebral artery (MCA) infarctions typically exceed 70.

No medical therapies have proven effective in preventing brain herniation or improving the outcomes of patients with malignant MCA infarction, Dr. Katayoun Vahedi, from Hopital Lariboisiere in Paris, and colleagues note. Surgical decompression remains a controversial treatment, as no randomized trials have established its efficacy, and it may cause residual disability.

In the DEcompressive Craniectomy In MALignant MCA Infarction (DECIMAL) trial, the French research team assessed the outcomes of 38 patients who were randomized to undergo decompressive craniectomy or to receive standard medical therapy.

Surgery was associated with improvements in disability, according to the report in the September issue of Stroke. After surgery, the proportion of patients with a modified Rankin score of three or less was 25 per cent at six months and 50 per cent at one year. The corresponding percentages in the control group were much lower: 5.6 and 22.2 per cent.

In addition, craniectomy was associated with a 52.8 per cent absolute reduction in mortality (p < 0.0001), the findings show.

The take-home message for clinicians "would be that any patient with a severe stroke (including those who will have a decompressive hemicraniectomy) needs long term multidisciplinary follow up (practicing physician, neurologist, rehabilitation physician and psychologist if necessary)," Dr. Vahedi told Reuters Health. "It is also important to follow and help the close relatives who will have a crucial role in the rehabilitation of the patient in normal life."

Further studies are needed to address "more specifically, the psychological impact of the hemicraniectomy, the long term outcome and the quality of life of these patients," Dr. Vahedi added.

In a similar study, entitled the Decompressive Surgery for the Treatment of Malignant Infarction of the MCA (DESTINY) trial, Dr. Werner Hacke, from the University of Heidelberg in Germany, and colleagues assessed the outcomes of 32 patients with massive strokes.

At 30 days, 15 of 17 (88 per cent) surgical patients were alive compared with seven of 15 (47 per cent) patients treated conservatively. On long-term follow-up, 47 per cent of surgical patients had a modified Rankin score of three or less compared with 27 per cent of those treated conservatively.

In an accompanying editorial, Dr. Stephan A. Mayer, from the Neurological Institute in New York, comments that "until now, massive MCA infarction has essentially been a guarantee of death or devastation....Hemicraniectomy combined with aggressive ICU support can give many patients with MCA infarction a second chance on life, compared with supportive care alone combined with a possibly more nihilistic approach.