Several studies have evaluated the use of decompressive hemicraniectomy (DHC) in malignant middle cerebral artery infarction (MMCAI). In the United Kingdom (UK), the National Institute for Health and Care Excellence (NICE) has set criteria for selection of patients for DHC in MMCAI.

Basu et al. set out to survey the attitudes and practice of neurosurgeons and stroke physicians within the UK towards DHC in MMCAI.

An electronic survey of questions on management of MMCAI in various clinical scenarios was submitted to the academic committees of the Society of British Neurological Surgeons (SBNS) and the British Association of Stroke Physicians (BASP) for approval, prior to dissemination through the consultant members. Responses were collected over two months.

78 responses, from 51 neurosurgeons and 27 stroke physicians, were included in final analysis. 54% and 24% of all respondents would recommend DHC in patients aged 60-70 and 70-80 years, respectively. 60% would advocate surgery between 48-72 hours and 27% beyond 72 hours. 36% indicated DHC with pre-operative GCS 15/15. These findings do not conform to current NICE guidelines. Stroke physicians were statistically more likely to recommend DHC in patients over 60 years (p = 0.032) and in those with dominant multi-territorial infarcts (p = 0.042) and accept a higher post-operative modified Rankin Scale (mRS) (p = 0.034) compared to neurosurgeons.

In view of evidence from recent trials and differences in NICE guidelines and current clinical practice within the UK, based on our survey results, it is important to re-evaluate NICE guidelines ¹⁾.