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Intervention Review

Surgical decompression for cerebral oedema in acute ischaemic stroke

  1. Nicholas CD Morley1,*,
  2. Eivind Berge2,
  3. Salvador Cruz-Flores3,
  4. Ian R Whittle4

Editorial Group: Cochrane Stroke Group

Published Online: 21 JAN 2009

Assessed as up-to-date: 25 APR 2002

DOI: 10.1002/14651858.CD003435

Database Title

Additional Information

How to Cite

Morley NCD, Berge E, Cruz-Flores S, Whittle IR. Surgical decompression for cerebral oedema in acute ischaemic stroke. Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No.: CD003435. DOI: 10.1002/14651858.CD003435.

Author Information

  1. 1

    University of Edinburgh, Division of Clinical Neurosciences, Edinburgh, UK

  2. 2

    Ullevaal University Hospital, Department of Internal Medicine, NO-0407 Oslo, Norway

  3. 3

    Saint Louis University School of Medicine, Department of Neurology, St. Louis, Missouri, USA

  4. 4

    Western General Hospital, Division of Clinical Neurosciences, Edinburgh, UK

*Nicholas CD Morley, Division of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU, UK. csrg@skull.dcn.ed.ac.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 21 JAN 2009

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary

Background

The high mortality that follows a large cerebral infarction is in part due to brain oedema. Oedema causes mass-effect with raised intracranial pressure and herniation. Medical therapies are used to reduce intracranial pressure but outcome is poor in spite of treatment. Decompressive surgical techniques that attempt to relieve high intracranial pressure due to oedema have been described, but their efficacy in reducing case fatality and disability is uncertain.

Objectives

To compare medical therapy plus decompressive surgery with medical therapy alone on the outcomes death and 'death or dependency' in patients with an acute ischaemic stroke complicated by clinical and radiologically confirmed cerebral oedema.

Search methods

We searched the Cochrane Stroke Group Trials Register (4 October 2001), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 3, 2001), MEDLINE (1966 to April 2002), EMBASE (1980 to April 2002), and SCISEARCH (to April 2002). We also searched the reference lists of all relevant articles retrieved and contacted individual investigators and experts in the field.

Selection criteria

Randomised controlled studies comparing the outcome of treatment with decompressive surgical intervention with treatment not involving surgery. We aimed to include only those studies with low or moderate risk of bias.

Data collection and analysis

Titles retrieved by searching were assessed for relevance by one author. Data were extracted independently by two authors with discussion to resolve differences. Relevant sub-group analyses were planned and we planned to calculate Peto odds ratios with 95% confidence intervals.

Main results

Over 9000 citations were retrieved and inspected for relevance. We identified no randomised controlled trials to include in a meta-analysis. Five observational studies reporting comparative data were found along with a number of small series and single case reports. Two ongoing randomised controlled trials were identified.

Authors' conclusions

There is no evidence from randomised controlled trials to support the use of decompressive surgery for the treatment of cerebral oedema in acute ischaemic stroke. Evidence from randomised controlled trials is needed to accurately assess the effect of decompressive surgery.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary

Surgical decompression for cerebral oedema in acute ischaemic stroke

There is no evidence that surgery to relieve pressure on the brain improves outcome after massive stroke. About four-fifths of strokes are due to blockage of an artery in the brain. When the artery is blocked, part of the brain can be damaged, called a cerebral infarct. If a main artery is blocked the area of brain damage can be large. About 24 to 48 hours after a large infarct the brain can swell, causing a dangerous rise of pressure inside the head. Surgery to remove some of the skull bone over the swollen area of brain can help reduce the pressure and may reduce the risk of death or disability. However, operating on patients who are acutely ill after a stroke can carry significant risks. At present, there is not enough evidence to decide whether surgery does more good than harm. Randomised trials to compare surgery with conservative treatment are in progress.

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