Middle cerebral artery occlusion

Malignant MCA strokes

Meta-analysis (DECIMAL, DESTINY, HAMLET) summary:

• Hemicraniectomy ≤48 hrs: ↓ mortality, ↑ favorable fnx outcomes.
• Rx w/ meds alone: ↑ morbidity & mortality risk.
• Intra-arterial tPA: can be given up to 6 hrs post-stroke onset.
• Pt presented 24 hrs post-Sx onset: not a candidate for IA tPA.
• EVD placement & mechanical thrombectomy: no current evidence of ↓ mortality risk in malignant MCA strokes.

Trial	Treatment Groups	Baseline Differences	Primary Outcome Measures	Secondary Outcome Measures
DECIMAL	DC Qx (n=?)	Surgically treated group had lower mean systolic blood pressure compared to the conservatively treated group.	↓ Mortality (Absolute reduction: 52.8%) in surgical group compared to conservative treatment group.	↑ mRS scores of 3 or less (non-significant), ↑ mRS scores of ≥4 (non-significant).
DESTINY	DC Qx (n=?)	Conservatively treated group had a higher NIHSS score than the surgically treated group.	↓ Mortality at 12 months (Relative reduction: X%) in surgical group compared to conservative treatment group.	Non-significant ↑ survival with mRS score of 3 or less. No significant ↑ in comatose survivors.
HAMLET	DC Qx (n=?)	Baseline differences: Longer time to randomization. NIHSS scores higher. Higher body temperature. History of TIA/stroke and history of ischemic heart disease differed.	↓ Mortality (Absolute risk reduction: 38%) in surgical group compared to conservative treatment group.	No significant ↓ in poor functional outcomes in survivors.