Decompressive hemicraniectomy as a salvage therapy in the Neuro-ICU: a meta-analysis of neurologic outcomes for malignant middle cerebral artery infarction.

BACKGROUND: Malignant middle cerebral artery infarction is a devastating condition associated with high mortality and poor functional outcomes despite maximal medical management. Decompressive hemicraniectomy has emerged as a salvage therapy to reduce intracranial pressure and prevent cerebral herniation, but uncertainty remains regarding functional outcomes across different follow-up periods and patient populations.

METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials evaluating decompressive hemicraniectomy versus medical management in patients with malignant middle cerebral artery infarction. A comprehensive search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials was performed from inception through 18th February 2026. The primary outcomes were mortality and favorable functional outcome, defined as modified Rankin Scale score of 0 to 4. Secondary outcomes included survival with severe disability, National Institutes of Health Stroke Scale scores, and Barthel Index scores. Pooled effect estimates were calculated using random-effects models. Heterogeneity was assessed using the I2 statistic.

RESULTS: Fourteen randomized controlled trials comprising 1,003 patients were included. Decompressive hemicraniectomy significantly reduced mortality at 30 days (risk ratio: 0.26, 95% confidence interval: 0.16 to 0.50), 6 months (risk ratio: 0.43, 95% confidence interval: 0.12 to 0.57), and 12 months (risk ratio: 0.46, 95% confidence interval: 0.13 to 0.59), with sustained benefit at 36 months. Favorable functional outcome was significantly improved at 3 months (risk ratio: 1.86, 95% confidence interval: 1.31 to 2.63) and 6 months (risk ratio: 1.58, 95% confidence interval: 0.94 to 2.67), but not at 12 months. Survival with severe disability did not differ significantly between groups at either 6 or 12 months. Barthel Index scores showed significant improvement favoring surgery at 3 and 6 months, though substantial heterogeneity was observed. Long-term follow-up demonstrated significant improvements in National Institutes of Health Stroke Scale and Barthel Index scores favoring the surgical group.

CONCLUSION: This updated meta-analysis of 14 RCTs (1,003 patients) provides three novel insights beyond prior syntheses. First, the mortality benefit of decompressive hemicraniectomy is sustained across all ages and time points, consistent with prior reports. Second, age-stratified analysis reveals that older patients (≥60 years) derive similar survival benefits but significantly poorer functional outcomes compared with younger patients. Third, time-dependent analysis demonstrates that functional benefits are significant at 3 and 6 months but not at 12 months, a trajectory not previously characterized. These findings refine the risk-benefit calculus for shared decision-making in the Neuro-ICU, particularly for older patients and for expectations regarding long-term functional independence.