A Meta-analysis Of The Effectiveness Of Decompressive Hemicraniectomy And Conservative Treatment In Treating Patients With Malignant Middle Cerebral Artery Infarction

Background Malignant middle cerebral artery infarction(m MCAI)is one of the most devastating ischemic strokes,with a mortality rate of up to 80% in patients without surgery.The purpose of this study was to compare the effectiveness of Decompressive hemicraniectomy(DHC)and conservative treatment(CT)in patients with m MCAI,and to evaluate the efficacy of DHC in improving survival or survival without severe disability.To explore the effects of age and surgical timing on mortality and functional outcomes.Methods Pub Med/Medline,Embase,The Cochrane Library,China Biology Medicine disc(CBM),China National Knowledge Infrastructure(CNKI),and Wanfang database were searched.The randomized controlled trials(RCT)or observational studies(OS)published before February 2020 were searched,to compare the effect of DHC and CT in patients with m MCAI.After strictly following the inclusion and exclusion criterion to conduct literature screening,extract data and evaluate the quality of the literature,using Rev Man5.3 software to analyze the relevant data.The primary outcome included mortality at different follow-up periods(1 month to 3 years),and the incidence of survival without severe or moderately severe disability(modified Rankin scale score:0-3points).The secondary outcome included the incidence of death and survival with moderately severe or severe disability(modified Rankin scale score> 3 points)and the incidence of death and survival with severe disability(modified Rankin scale score>4points).The combined effect amount is expressed as odds ratio(OR)and its 95%confidence interval(CI).Results This meta-analysis included a total of 24 studies(1424 patients).Decompressive hemicraniectomy significantly reduced mortality in patients with m MCAI at different follow-up times(OR=0.21,95%CI=0.16,0.27;P<0.001),but failed to improve the incidence of survival without severe or moderately severe disability(OR=0.80,95%CI=0.56,1.16;P=0.24).There are significant differences of the incidence of death and survival with moderately severe or severe disability(P<0.001)and the incidence of death and survival with severe disability(P<0.001)between the DHC group and the CT group.In the subgroup analysis of different age groups and timing of surgery,early surgical treatment(operation within 48 hours after stroke onset)can significantly reduce mortality(OR=0.13,95% CI=0.07,0.24;P<0.001),regardless of age≤60 years old or>60 years old,surgery reduced mortality,but the functional outcomes are different.Conclusions This meta-analysis showed that compared with conservative treatment,Decompressive hemicraniectomy reduced the mortality of patients with malignant middle cerebral artery infarction and reduced the occurrence of poor functional outcomes,however,the disability ratio of survivors cannot be reduced,and age and timing of surgery are important factors that affect the survival and fuctional outcome of patients.The final decision to deal with malignant middle cerebral artery infarction should be based on the patient’s specific factors(economic,values,etc.)and the joint decision of doctors and patients.