Surgery in stroke patients may improve survival, but not quality of life

Patients with extensive middle-cerebral-artery stroke may benefit somewhat from hemicraniectomy, based on research published March 20 in the New England Journal of Medicine. The study found the procedure improved survival, but left many patients with considerable disability.

The Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery II (DESTINY II) trial compared early hemicraniectomy with conservative treatment in the intensive care unit (control group) among patients 61 years of age and older with malignant middle-cerebral-artery infarction at 13 German sites. In the trial, Eric Juttler, MD, PhD, of the University of Heidelberg in Heidelberg, Germany, and colleagues randomly assigned 112 patients to either group.

Treatment was started within 48 hours of symptom onset and not later than six hours after randomization. Conservative treatment consisted of standard therapy, including osmotherapy, sedation, intubation, mechanical ventilation, hyperventilation and buffer solutions. Surgery involved a hemicraniectomy with a diameter of at least 12 centimeters and duroplasty.

The primary outcome was a modified Rankin scale score of 0 to 4 at six months, indicative of survival without severe disability. Survival was among the secondary endpoints evaluated at 12 months.

The proportion of patients who met the primary outcome was higher in the surgical group (38 percent vs. 18 percent), a result of lower mortality in the surgical group (33 percent vs. 70 percent). There were no patients with a modified Rankin scale score of 0 to 2, indicating survival with no disability or slight disability.

Severe disability (modified Rankin score of 5), however, occurred in a higher proportion of the surgical group (29 percent vs. 13 percent), as was moderately severe disability, or a modified Rankin score of 4 (32 percent vs. 15 percent). A score of 4, the authors noted, renders patients in need of assistance with most bodily needs.

The investigators argued that their findings highlight the need to consider whether these outcomes are acceptable to patients before undergoing the procedure. “Our trial provides helpful information for health professionals, patients, and their caregivers who must decide whether or not to pursue hemicraniectomy,” they wrote.