Dear Editors,
We read with special interest the article Decompressive craniotomy for the treatment of malignant infarction of the middle cerebral
artery: mortality and outcome by Bongiorni et al. in the last issue of Arquivos de Neuro-Psiquiatria[1]. The authors’ contribution to decompressive craniotomy (DC) for malignant middle
cerebral artery stroke is significant and should be congratulated; however, important
questions arise in the minds of those engaged in current stroke practice. The following
points should be considered, to clarify findings and strengthen current and future
evidences.
The main concern about this study is that the functional outcome assessment was limited
due to the selected methodology. Since the modified Rankin Scale is a categorical/ordinal
scale, measures of central tendency are seldom informative. The authors are encouraged
to present their data in stacked bar chart distributions – which would provide greater
power to detect the treatment effect along the whole scale range and could suggest
shifts of classes[2]. Also, a month is hardly enough to fully appraise the functional benefits of DC.
Therefore, they should also look for long-term assessments (i.e. 6–12 months) to facilitate
comparisons with other published works.
Another puzzling question to the reader is: why so few patients in their institution
received DC? The authors report on 20 procedures - which may be appropriate once local
epidemiology is acknowledged. However, a quick inquiry in the TABNET database system
disclosed that, from January 2008 to December 2014, a total of 3,753 acute stroke
patients were admitted at that institution[3]. If those numbers hold true, they suggest that Brazilian patients might be less
than half as likely to receive DC than their counterparts in the HeADDFIRST trial,
a significant difference (eligibility rate 0.53% vs 1.35%; OR 0.39, 95%CI 0.23-0.64;
p = 0.0002)[4]. Key to understanding this conundrum – and definitely more important than statistics
- is why patients are being declined surgery. Only a dedicated prospective registry
would disclose the reasons that are hampering many patients from benefiting from that
well-established therapeutic option.
