Researchers at the University of Rochester Medical Center (URMC; NY, USA) used a medical decision analysis technique to evaluate the results of recent hemicraniectomy trials in terms of quality-adjusted life-years. Survival data and probability of various functional outcome states at one year after treatment were abstracted from clinical trial data, and utility scores for modified Rankin states were abstracted from literature sources. The researchers then conducted sensitivity analyses to study the results over a wide range of utility values.

The results showed that the hemicraniectomy treatment pathway was associated with more quality-adjusted life-years over the first year than the medical management pathway. Hemicraniectomy remained the preferred option, except when the utility associated with the possible outcome states dropped considerably, or when 1-week surgical mortality increased considerably (5% to 67%). However, while patients who did not have the surgery were about 3 times more likely to die within a year of their stroke, many of the surgery patients were left with significant functional disability. The study was published early online in the July 14, 2010, issue of Neurology.

"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,” said study coauthor Robert Holloway, M.D., M.P.H. "The question I had was at what point do you value QOL 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?”

To answer this question, the researchers constructed a decision-making model that suggested that 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 modified Rankin Scale is a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke, and it has become the most widely used clinical outcome measure for stroke clinical trials.

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