How often are patients with ischemic stroke eligible for decompressive hemicraniectomy?

Area of Science:

• Neurology
• Neurosurgery
• Stroke Medicine

Background:

• Malignant middle cerebral artery infarction occurs in 10% of ischemic strokes.
• Decompressive hemicraniectomy is an effective treatment, yet its application is limited.
• Patient selection criteria for hemicraniectomy have evolved with recent clinical trials.

Purpose of the Study:

• To determine the proportion of ischemic stroke patients with large middle cerebral artery infarction eligible for decompressive hemicraniectomy.
• To assess eligibility based on criteria used in recent major clinical trials.
• To evaluate the potential impact of hemicraniectomy in a pre-trial publication era.

Main Methods:

• Retrospective analysis of ischemic stroke cases from 2005 in the Greater Cincinnati/Northern Kentucky area.
• Inclusion criteria: baseline modified Rankin Scale score < 2, age ≥ 18, National Institutes of Health Stroke Scale score ≥ 10.
• Definition of large middle cerebral artery infarction: >50% territory or >145 mL on MRI; hemicraniectomy eligibility: age 18-60, NIHSS > 15.

Main Results:

• Of 2227 ischemic strokes, 39 (1.8%) had large middle cerebral artery infarction with minimal baseline disability.
• None of these patients underwent hemicraniectomy; 41% died within 30 days.
• Only 6 patients (0.3% of all ischemic strokes) met all eligibility criteria; one died within 30 days.

Conclusions:

• Clinical trial criteria identified only 0.3% of ischemic stroke patients as eligible for decompressive hemicraniectomy.
• The study highlights a potential gap in identifying patients who could benefit from this intervention.
• Further research is needed to explore eligibility in broader patient subgroups.