Decompressive Hemicraniectomy in the Modern Era of Acute Ischemic Stroke: The Impact of Mechanical Thrombectomy. (16th November 2020)

• Record Type: Journal Article
• Authors: Mouchtouris, Nikolaos; Saiegh, Fadi Al; Baldassari, Michael; Hafazalla, Karim; Nauheim, David; Romo, Victor M; Herial, Nabeel; Gooch, M. Reid; Jabbour, Pascal; Tjoumakaris, Stavropoula I; Rosenwasser, Robert H; Rincon, Fred
• Is Part Of: Neurosurgery. Volume 67(2010)Supplement 1
• Publication Date: 2020-11-16
• Subjects: Nervous system -- Surgery -- Periodicals; 617.48005
• DOI: 10.1093/neuros/nyaa447_292
• Languages: English
• ISSNs: 0148-396X

Abstract

Abstract: INTRODUCTION: Mechanical thrombectomy (MT) has since revolutionized AIS prognosis and has transformed the epidemiological landscape of MCE and decompressive hemicraniectomy (DHC). As MT usage increases, rates of DHC diminish by up to 53%. Additional international studies have identified stroke severity and recanalization failure as independent predictors of DHC in the MT era. These findings confirm that successful recanalization is a protective factor against MCE and DHC, but the details of this relationship remain unclear. METHODS: We conducted a retrospective review of 561 patients with acute ischemic stroke who underwent mechanical thrombectomy at our institution between 2010 and 2019. We collected data on patient demographics, comorbidities and risk factors for stroke, clinical presentation, revascularization and functional outcomes. RESULTS: Of the 561 patients, 19 (3.4%) required a DHC at an average 2.32 ± 1.64 days from stroke onset. The DHC group was significantly younger than the non-DHC group ( P < . 001), had higher NIHSS on presentation ( P = . 112), lower successful reperfusion rates (73.7% vs. 85.1%, P = . 176), larger infarct size ( P < . 001) and higher rate of hemorrhagic conversion ( P = . 08) than the DHC group. Favorable functional outcome (mRS 0–2) was achieved by 28.8% of the non-DHC group, while only 5.3% in the DHC group ( P = . 025). Inpatient mortality was more frequent in the DHC group (15.8% vs. 9.6%; P = . 372). From 2010–2016, 221 patients underwent a MT, 14 of whom (6.3%) required a DHC, while 340 patients underwent MT from 2016–2019 and only 5 patients required a DHC (1.5%; P = . 002). Logistic regression analysis demonstrated age ( P = . 001), hemorrhagic conversion with mass effect ( P = . 007) and increasing infarct size ( P < . 001) to be significant predictors of requiring a DHC. When controlling for age, NIHSS on presentation, hemorrhagic conversion with mass effect, and t-PA administration, higher TICI score significantly reduced the need for DHC ( P = . 004) CONCLUSION: The widespread adoption of mechanical thrombectomy has significantly decreased the need for decompressive hemicraniectomy for patients with acute ischemic stroke. Our study represents one of the largest single-center experiences and our findings demonstrate that improved recanalization decreased the need for DHC without increasing the risk of hemorrhagic conversion.