Hemicraniectomy After Massive Stroke Results in Better Quality of Life Than Medical Management

Fran Lowry

July 23, 2010

July 23, 2010 — In a specially constructed decision-making model, researchers show that under most circumstances, the quality of life gained is greater for hemicraniectomy than for medical management after malignant infarction of the middle cerebral artery.

This holds true except in cases where patients, or those who are making decisions for them, place a very low value on the health states that might ensue as a result of the aggressive surgery, or when surgical mortality is very high, write Adam G. Kelly, MD, and Robert G. Holloway, MD, MPH, from the University of Rochester Medical Center, New York.

The finding, published online July 14 in Neurology, provides further evidence that hemicraniectomy is the preferred treatment, Brett Kissela, MD, vice chairman of neurology at the University of Cincinnati, Ohio, told Medscape Medical News.

"Breakthrough studies showed that hemicraniectomy could be life saving and lead to better functional capability, according to the modified Rankin score, and it has become standard of care to offer this procedure to people with massive strokes," said Dr. Kissela, who was not part of the study.

"Now, the authors of this study are talking about quality of life. As a result, not only can we measure how much life and function we are able to save with this aggressive surgery, we can also put a value on that and say how much this would contribute to someone's quality of life."

In the study, Dr. Kelly and Dr. Holloway created a decision model to evaluate the results of recent hemicraniectomy trials, including DECIMAL, DESTINY, and HAMLET, in terms of quality-adjusted life-years.

The 3 trials compared outcomes of patients treated with medical management alone with those of patients treated with hemicraniectomy and found that patients who did not have the surgery were about 3 times more likely to die within a year of their stroke than patients who had the surgery. However, many of the surgery patients were left with significant functional disability.

"Surgery or medical management is a tough decision confronting patients and families, and of course it is usually the families who must make the decision, because patients are unable to do this for themselves," Dr. Holloway said in an interview.

"The question I had was: At what point do you value quality of life so much that you would choose medical management, or in other words, almost certain death, over surgical treatment, with the possibility of prolonged life, but in a health state that is considerably reduced?"

According to the decision model, it was only when patients or families valued the outcome after stroke extremely poorly — as a fate worse than death — that medical management became the preferred choice. A very high surgical mortality rate of 67% was also a reason for choosing medical management.

The authors state that surgery is not a good option for all patients. People with comorbidities or with slim chances of surviving the surgery, or those who have explicitly stated that they do not want such surgery, should not undergo hemicraniectomy.

Surgery Treatment of Choice

In an accompanying editorial, H. Bart van der Worp, MD, PhD, from University Medical Center Utrecht, the Netherlands, writes that the study provides "circumstantial but reassuring evidence that surgical decompression reduces the risk of a poor functional outcome, thereby resulting in more [quality-adjusted life-years]."

However, he asserts, how these results apply to individual patients remains in question.

He points out that treatment decisions will continue to rely on communication of the average risks and benefits of surgical decompression for space-occupying infarction and that conservative treatment may be most appropriate for patients with severe comorbidities or those who have made their wishes known in advance directives.

However, for most patients, Dr. van der Worp concludes, "all evidence points toward a benefit of surgical decompression in terms of case fatality, functional outcome, and quality of life gained; this should be the treatment of choice for the majority of patients."

Dr. Holloway said understanding how someone left with poor functional ability after a stroke can still value his or her life can be difficult for people who are healthy. It is something he sees almost every day in his work as a neurologist and in palliative care.

"We humans do a bad job — we always misimagine the unimaginable. Family members usually value those limited health states worse than patients themselves. For years, I've seen families wrestle with these decisions. You have to counsel families and also remind yourself that you may have a tendency to underestimate how well patients can acclimate to their new health state in a way that we, as healthy individuals, cannot imagine," he said.

Weighing in with her opinion, Helmi Lutsep, MD, from Oregon Health and Sciences Center, Oregon, admitted that although she does not use epidemiologic and statistical indices of outcomes and quality-adjusted life-years in her day-to-day practice as a neurologist, the point that the authors make in their study does have an effect on her practice.

"We do use hemicraniectomy, but there is always a bit of a concern on our part about this quality-of-life issue. I think the article does come across pretty clearly that unless there are certain situations in which patients will have bad outcomes, we should feel ok about going ahead with the surgery," she commented.

She added that, although some patients who rate their disability as being "not so bad" may not be fully aware of their condition, "on the other hand," she said, "it's not our job to try and place a value judgment on that. If they are not fully aware, maybe life isn't all that bad, because that is in fact, their perception. Still, I think it is a very complex area."

Dr. Kissela agrees: "The decision model is something you would only do for research. It is not a clinical tool, but it supports a clinical practice that is already underway," he said. "There may still be some lingering doubt for some people, and this would certainly help dispel that and show that we are on the right track with hemicraniectomy for these people."

Dr. Kelly, Dr. Kissela, and Dr. Lutsep have reported no relevant financial relationships. Dr. Holloway serves as an associate editor of Neurology Today and has financial relationships with Milliman Inc. Dr. van der Worp was the principal investigator of the Hemicraniectomy After Middle Cerebral infarction with Life-threatening Edema Trial and has reported financial relationships with Servier. He also receives research support from the Netherlands Organization for Health Care Research and Development.

Neurology. Published online July 14, 2010.