A Cochrane review [Abstract] 1 included 3 studies with a total of 134 subjects. All the patients were 60 years of age or younger and they had a clinically and radiologically confirmed cerebral infarct complicated with cerebral oedema. Surgery was performed to remove some of the skull bone over the swollen area of brain to reduce the pressure. The time window for the surgical decompression was 30 hours from stroke onset in two studies and 96 hours in one study. The surgical intervention was compared with standard medical therapy. All trials were stopped early. Surgical decompression reduced the risk of death at the end of follow-up (OR 0.19, 95% CI 0.09 to 0.37) and the risk of death or disability defined as modified Rankin scale (mRS) >4 at 12 months (OR 0.26, 95% CI 0.13 to 0.51). Death or disability defined as mRS >3 at the end of follow-up was not different between the treatment arms (OR 0.56, 95% CI 0.27 to 1.15).
Comment: The quality of the evidence is downgraded by study quality (inadequate allocation concealment, lack of blinding, all trials stopped early) and imprecise results (limited study size for each comparison) and upgraded by large magnitude of effect.
Since survival may be at the expense of substantial disability, surgery should be the treatment of choice only when it can be assumed, based on their preferences, that it is in the best interest of patients.
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