Claude Nguyen, MD
Geurts M, van der Worp HB, Kappelle LJ, Amelink GJ, Algra A, and Hofmeijer J. Surgical Decompression for Space-Occupying Cerebral Infarction:Outcomes at 3 Years in the Randomized HAMLET Trial. Stroke. 2013
Collectively, several signature trials assessing the effectiveness of hemicraniectomy for malignant edema after stroke have indicated that the procedure reduces mortality, although survivors tend to have moderate-to-severe disability. To see if there was any change in this trend, Geurts et al. reviewed data at the three-year mark for patients from the Hemicraniectomy After Middle cerebral artery infarction with Life-threatening Edema Trial (HAMLET). Unfortunately, the group did not find much improvement in the functional outcomes of both surgical and non-surgical groups at three years. They also found no difference in the quality of life measures and depression scores between groups.
This study does not add much to the conundrum that hemicraniectomy may not help to improve quality of life despite reducing mortality. Although one would have hoped that such patients receiving hemicraniectomy would continue to recover over time, we know that recovery tends to plateau, and any improvement after six months, especially in the case of a large MCA stroke, would be negligible. We should continue to keep in mind that the inclusion criteria were conservative, with no one included above the age of 60 years. With our population living well beyond this cutoff, we will see more and more patients with malignant strokes who are much older than the patients in these trials, and therefore need revised trials to see whether hemicraniectomy should be used.
Personally, this study has not altered my philosophy when treating these patients. I remember seeing a patient for follow-up who was independent before her stroke, who had received a hemicraniectomy and was now a modified Rankin Scale of 5. Despite other practitioners questioning the true benefit of surgery, the patient later reported that she was glad to have lived despite her severe disability. As we know, evidence based medicine does not always translate to personalized medicine; in the end, we must help the patient and their family make the best decision possible.