Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial - 07/08/11
, L Jaap Kappelle, MD b, Ale Algra, MD b, c, G Johan Amelink, MD d, Jan van Gijn, FRCP b, H Bart van der Worp, MD bfor the HAMLET investigators‡
Summary |
Background |
Patients with space-occupying hemispheric infarctions have a poor prognosis, with case fatality rates of up to 80%. In a pooled analysis of randomised trials, surgical decompression within 48 h of stroke onset reduced case fatality and improved functional outcome; however, the effect of surgery after longer intervals is unknown. The aim of HAMLET was to assess the effect of decompressive surgery within 4 days of the onset of symptoms in patients with space-occupying hemispheric infarction.
Methods |
Patients with space-occupying hemispheric infarction were randomly assigned within 4 days of stroke onset to surgical decompression or best medical treatment. The primary outcome measure was the modified Rankin scale (mRS) score at 1 year, which was dichotomised between good (0–3) and poor (4–6) outcome. Other outcome measures were the dichotomy of mRS score between 4 and 5, case fatality, quality of life, and symptoms of depression. Analysis was by intention to treat. This trial is registered, ISRCTN94237756.
Findings |
Between November, 2002, and October, 2007, 64 patients were included; 32 were randomly assigned to surgical decompression and 32 to best medical treatment. Surgical decompression had no effect on the primary outcome measure (absolute risk reduction [ARR] 0%, 95% CI −21 to 21) but did reduce case fatality (ARR 38%, 15 to 60). In a meta-analysis of patients in DECIMAL (DEcompressive Craniectomy In MALignant middle cerebral artery infarction), DESTINY (DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY), and HAMLET who were randomised within 48 h of stroke onset, surgical decompression reduced poor outcome (ARR 16%, −0·1 to 33) and case fatality (ARR 50%, 34 to 66).
Interpretation |
Surgical decompression reduces case fatality and poor outcome in patients with space-occupying infarctions who are treated within 48 h of stroke onset. There is no evidence that this operation improves functional outcome when it is delayed for up to 96 h after stroke onset. The decision to perform the operation should depend on the emphasis patients and relatives attribute to survival and dependency.
Funding |
Netherlands Heart Foundation.
Le texte complet de cet article est disponible en PDF.Plan
Vol 8 - N° 4
P. 326-333 - avril 2009 Retour au numéro
Article précédent
- Caring for Aged Dementia Care Resident Study (CADRES) of person-centred care, dementia-care mapping, and usual care in dementia: a cluster-randomised trial
- Lynn Chenoweth, Madeleine T King, Yun-Hee Jeon, Henry Brodaty, Jane Stein-Parbury, Richard Norman, Marion Haas, Georgina Luscombe
- Safety and efficacy of quinacrine in human prion disease (PRION-1 study): a patient-preference trial
- John Collinge, Michele Gorham, Fleur Hudson, Angus Kennedy, Geraldine Keogh, Suvankar Pal, Martin Rossor, Peter Rudge, Durre Siddique, Moira Spyer, Dafydd Thomas, Sarah Walker, Tom Webb, Steve Wroe, Janet Darbyshire
Bienvenue sur EM-consulte, la référence des professionnels de santé.
L’accès au texte intégral de cet article nécessite un abonnement.
Déjà abonné à cette revue ?