Clinical review: Therapy for refractory intracranial hypertension in ischaemic stroke

Jüttler, Eric; Schellinger, Peter D; Aschoff, Alfred; Zweckberger, Klaus; Unterberg, Andreas; Hacke, Werner

doi:10.1186/cc6087

Critical Care

Table 4 Mortality data in patients with malignant middle cerebral artery infarction: studies with comparative data on conservative treatment versus decompressive surgery

From: Clinical review: Therapy for refractory intracranial hypertension in ischaemic stroke

Authors	Patients treated with conservative treatment	Patients treated with decompressive surgery	Mean age (years)	Mortality in hospital	Mortality up to 3 months	Mortality up to 6 months	Mortality up to 12 months
Delashaw et al., 1990 [118]^a	4	9	NA vs. 57	100% vs. 0%	100% vs. 11%	100% vs. NA	100% vs. NA
Steiger 1991 [119]^b	7	8	NA	100% vs. 25%	100% vs. 25%	100% vs. 25%	NA
Rieke et al., 1995 [77], Hacke et al., 1996 [3], Wirtz et al., 1997 [104], Schwab et al., 1998 [109]^c	55	63	56 vs. 50	78% vs. 25%	NA vs. 25%	NA	NA
Holtkamp et al., 2001 [114]^d	12	12	73 vs. 65	83% vs. 17%	83% vs. 25%	83% vs. 25%	83% vs. 33%
Mori et al., 2001 [120]	15	19	72 vs. 63	60% vs. 11%	67% vs. 16%	NA	NA
Mori et al., 2004 [111]^e	15	19	72 vs. 65	62% vs. 12%	NA	71% vs. 24%	NA
Kuroki et al., 2001 [121]^f	7	8	80 vs. 72	86% vs. 13%	NA	NA	NA
Cho et al., 2003 [115]^g	10	42	64 vs. 63	80% vs. 29%	NA	NA	NA
Maramattom et al., 2004 [116]^h	10	14	63 vs. 55	60% vs. 0%	NA	NA	NA
Yang et al., 2005 [122]ⁱ	14	10	66 vs. 59	64% vs. 10%	64% vs. 10%	NA	NA
Wang et al., 2006 [117]^j	41	21	67 vs. 62	NA	NA	22% vs. 29%	NA
Authors	Patients treated with hypothermia	Patients treated with decompressive surgery	Mean age (years)	Mortality in hospital	Mortality up to 3 months	Mortality up to 6 months	Mortality up to 12 months
Georgiadis et al., 2002 [124]	19	17	56 vs. 52	47% vs. 12%	NA	NA	NA
Authors	Patients treated with decompressive surgery + hypothermia	Patients treated with decompressive surgery	Mean age (years)	Mortality in hospital	Mortality up to 3 months	Mortality up to 6 months	Mortality up to 12 months
Els et al., 2006 [125]^k	12	13	49 vs. 49	8% vs. 15%	8% vs. 15%	8% vs. 15%	NA

^aNot randomised. All four patients in the nonintervention group had a dominant MCA infarction, and all nine patients in the intervention group had a nondominant MCA infarction.
^bNot randomised. All patients were younger than 60 years. There is a selection bias because conservatively treated patients were not regarded as being suitable for surgery.
^cNot randomised. These studies represent the largest case series in the literature using the case series of Hacke and colleagues (1996) [3] as historical control group. Mortality rates of early versus delayed surgery were 16% versus 34%.
^dNot randomised. There is a selection bias by advanced age and more comorbidity in conservatively treated patients. All patients were older than 55 and younger than 75 years.
^eNot randomised. There is a selection bias because treatment decision was based primarily on the consent by the patient's relatives. Some patients received internal decompression. Mortality rates of early versus late surgery were 19% versus 28%. The case series of 2004 included the patients of the case series of 2001.
^fNot randomised. The study used historical controls.
^gNot randomised. Mortality rates of ultra-early (<6 hours) versus delayed surgery were 8% versus 37%.
^hNot randomised. Hemicraniectomy was performed only in patients, who deteriorated clinically.
ⁱNot randomised.
^jNot randomised. There was no difference between late and early hemicraniectomies.
^kRandomised. Twelve patients received mild hypothermia (35°C) in addition to hemicraniectomy. In the group treated by hemicraniectomy alone more patients had a right-sided infarction and additional infarction of the ACA or PCA.
ACA, anterior cerebral artery; NA, not available; PCA, posterior cerebral artery.

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