Decision making for decompressive craniectomy (DC) in patients with malignant middle cerebral artery infarction (mMCAI) based on inclusion criteria of clinical studies: A systematic review

Abstract

The introduction of DC as therapy for mMCAI reduced the mortality rate. We aimed to summarise the inclusion criteria in studies of DC to provide a guidance of patients selection.

We searched 7 databases from inception till 31st December 2021 with an updated search on 25th June 2024. We included studies if they compared patients with mMCAI who underwent DC in addition to medical treatment and patients managed with medical care alone.

32 studies were published between 1995 and 2022. All studies stated that infarction of at least >50 % of MCA territory was the main inclusion criterion. The mean age of patients was 53 but varied from 18 to 89. Most studies (n = 27) included patients >60 years. Clinical inclusion criteria were NIHSS>15, used by 15 studies, and GCS ≥ 6, used by 9 studies. Radiological criteria were MLS ≥ 5 mm (n = 6), and signs of brain herniation (n = 8). The stroke duration was an inclusion criterion in 17 studies; it varied from 6 h to 96 h, with 10 studies limiting the time window to <48 h since the infarct onset. Lastly, 23 studies excluded patients with previous disabilities measured as mRS > 1 or patients with signs of brain death.

Inclusion criteria for mMCAI to undergo DC varied among studies; however, there were many similarities, namely a large volume of infarction, wide age range without exclusion of older patients, less severe neurological status as assessed with NIHSS or GCS, no previous physical disability, clear midline shift on imaging and the first two days since the onset of stroke.