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Thursday, March 20, 2014

Should Hemicraniectomy Be Considered in Older Patients with Middle-Cerebral-Artery Stroke?

For elderly patients who experience middle-cerebral-artery infarction, should hemicraniectomy (a neurosurgical procedure in which part of the skull is removed) be considered? A new study published in this week's New England Journal of Medicine set out to answer this question, but found conflicting results.  

Eric Jüttler, MD, PhD, of the University of Heidelberg in Germany, and colleagues conducted a prospective, randomized, controlled, open, multicenter trial of 112 patients 61 years of age or older (median of 70 years). These patients with malignant middle-cerebral-artery infarction were randomly assigned within 48 hours of symptom onset to either conservative treatment in the intensive care unit (the control group) or hemicraniectomy. The primary end point was survival without severe disability (defined by a score of 0 to 4 on the modified Rankin scale, with 0 meaning asymptomatic) six months after randomization. 

Dr. Jüttler and colleagues reported a statistically significant improvement in the primary outcome: 38 percent of patients in the hemicraniectomy group survived without severe disability, as compared with 18 percent in the control group (P = 0.04). There was a lower mortality in the surgery group (33% vs. 70%). Although none of the patients reported a score of 0 to 2 on the modified Rankin scale, 7 percent of patients in the surgery group had a score of 3, compared with 3 percent in the control group; 32 percent and 15 percent, respectively, had a score of 4; and 28 percent and 13 percent, respectively, had a score of 5 (severe disability). There were more reported infections in the hemicraniectomy group, but herniation was more frequent in the control group.

Overall, the authors wrote, despite the observed efficacy of the surgical procedure in older patients, the treatment decision remains difficult. Although the survival of these older patients increased with hemicraniectomy, many had “substantial disability. Important questions such as the long-term effect of chronic disability and patient characteristics associated with a greater or lesser benefit from hemicraniectomy require further research.”

     In an editorial published in the same issue of the NEJM, Allan H. Ropper, MD, of Brigham and Women’s Hospital in Boston, said the study provided additional information for these difficult scenarios, but was ultimately inconclusive. He wrote: “In many ways, hemicraniectomy tests the fortitude of patients and their families who, in the moment, must make a decision about survival. Numerical values for the likelihood of severe disability have now been provided by the trial and may be discussed with the patient or a surrogate decision maker.
    "However, the choice must be made early and quickly, just as the brain begins to swell, and advance directives typically do not cover these specific circumstances.”

Stay tuned for a full discussion of these findings from the authors and outside experts in an upcoming issue of Neurology Today. For now, see our previous coverage of hemicraniectomy: