Related Experiment Video
Updated: May 26, 2026
Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation
Published on: October 15, 2021
Craniectomy for malignant cerebral infarction: prevalence and outcomes in US hospitals
Brian P Walcott1, Elena V Kuklina, Brian V Nahed
1Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America. walcott.brian@mgh.harvard.edu
Insights
Craniectomy for malignant cerebral edema after ischemic stroke is increasing. While outcomes are similar with thrombolysis, in-hospital mortality remains high for all patients undergoing this procedure.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Randomized trials confirm craniectomy's efficacy for malignant cerebral edema post-ischemic stroke.
- Understanding the national prevalence and outcomes of this procedure is crucial.
Purpose of the Study:
- To determine the national prevalence of craniectomy for ischemic stroke-related malignant cerebral edema.
- To analyze in-hospital mortality and discharge outcomes for patients undergoing craniectomy.
Main Methods:
- Analysis of the US Nationwide Inpatient Sample (1999-2008) for ischemic stroke patients undergoing craniectomy.
- Logistic regression models used to calculate adjusted prevalence and estimate in-hospital mortality.
- Outcomes compared between patients who received thrombolysis and those who did not.
Main Results:
- Craniectomy rates per 10,000 ischemic stroke hospitalizations rose significantly from 3.9 to 14.46 between 1999-2008.
- In-hospital mortality was 44% for patients aged 60+ and 24% for those aged 18-59.
- Outcomes were similar for patients treated with recombinant tissue plasminogen activator (rt-PA).
Conclusions:
- Craniectomy is increasingly utilized for malignant cerebral edema following large-territory ischemic strokes.
- The rising incidence correlates with growing evidence of the procedure's efficacy.
- High in-hospital mortality underscores the critical nature of this intervention.
Object:
Randomized trials have demonstrated the efficacy of craniectomy for the treatment of malignant cerebral edema following ischemic stroke. We sought to determine the prevalence and outcomes related to this by using a national database.
Methods:
Patient discharges with ischemic stroke as the primary diagnosis undergoing craniectomy were queried from the US Nationwide Inpatient Sample from 1999 to 2008. A subpopulation of patients was identified that underwent thrombolysis. Two primary end points were examined: in-hospital mortality and discharge to home/routine care. To facilitate interpretations, adjusted prevalence was calculated from the overall prevalence and two age-specific logistic regression models. The predictive margin was then generated using a multivariate logistic regression model to estimate the probability of in-hospital mortality after adjustment for admission type, admission source, length of stay, total hospital charges, chronic comorbidities, and medical complications.
Results:
After excluding 71,996 patients with the diagnosis of intracranial hemorrhage and posterior intracranial circulation occlusion, we identified 4,248,955 adult hospitalizations with ischemic stroke as a primary diagnosis. The estimated rates of hospitalizations in craniectomy per 10,000 hospitalizations with ischemic stroke increased from 3.9 in 1999-2000 to 14.46 in 2007-2008 (p for linear trend<0.001). Patients 60+ years of age had in-hospital mortality of 44% while the 18-59 year old group was found to be 24% (p = 0.14). Outcomes were comparable if recombinant tissue plasminogen activator had been administered.
Conclusions:
Craniectomy is being increasingly performed for malignant cerebral edema following large territory cerebral ischemia. We suspect that the increase in the annual incidence of DC for malignant cerebral edema is directly related to the expanding collection of evidence in randomized trials that the operation is efficacious when performed in the correct patient population. In hospital mortality is high for all patients undergoing this procedure.
