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Decompressive craniectomy in malignant MCA infarction in times of mechanical thrombectomy
Jennifer Göttsche1, Fabian Flottmann2, Larissa Jank2
1Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany. j.goettsche@uke.de.
Background:
Mechanical thrombectomies (MT) in stroke have changed the standard treatment regimen with a continuous increase of MTs during the last years. A subsequent reduction in the rates of decompressive craniectomies (DC) as well as a change in clinical characteristics of patients undergoing an additional DC after MT may be assumed. Therefore, objective of this study was to investigate the influence of nowadays regularly performed MT on patients undergoing DC.
Methods:
Patients with DC due to cerebral infarctions between January 2009 and January 2018 were included. Patients' clinical presentation and surgical parameters were collected retrospectively. Initial GCS and NIHSS, extent of the stroke, time interval from symptom onset to DC, and neurological outcome were compared between patients with and without thrombectomy.
Results:
A total of 5469 ischemic strokes were treated in the investigated period, leading to DC in 119 cases (2.2%). A decrease in the rate of performed DCs was recorded: in 2009, 2.8% of ischemic stroke patients underwent surgery compared to 1.9% in 2017. In the meantime, the number of MTs in our center has increased from 84 in 2014 to 160 in 2017. MT was performed in 32 patients prior to DC. No significant differences could be seen between the groups regarding age, initial NIHSS (median 18 in both groups, p = 0.81), extent of the infarctions prior to DC (median ASPECTS 0 in both groups, p = 0.87), time interval from symptom onset to DC, and neurological outcome.
Conclusions:
The introduction of routinely performed MT as part of the standard treatment regimen for ischemic stroke has led to a decrease in DCs. However, DC patients with and without MT showed no differences regarding their initial clinical criteria and outcome. These results suggest that earlier DC studies in patients with MCA infarction also apply for the collective of thrombectomized patients.
Insights
Mechanical thrombectomies (MT) have decreased the need for decompressive craniectomies (DC) in stroke patients. However, outcomes and patient characteristics remain similar between those who did and did not receive MT before DC.
Area of Science:
- Neurology
- Neurosurgery
- Stroke Medicine
Background:
- Mechanical thrombectomy (MT) is increasingly standard for stroke treatment.
- This trend may reduce the necessity for decompressive craniectomy (DC) and alter patient profiles undergoing DC.
- Investigating the impact of routine MT on DC patients is crucial.
Purpose of the Study:
- To assess the influence of current mechanical thrombectomy practices on patients undergoing decompressive craniectomy.
- To compare clinical and surgical parameters of DC patients with and without prior MT.
Main Methods:
- Retrospective analysis of 119 patients undergoing DC for cerebral infarctions (2009-2018).
- Collected data included initial Glasgow Coma Scale (GCS), National Institutes of Health Stroke Scale (NIHSS), stroke extent, and time intervals.
- Compared outcomes between patients who received MT before DC and those who did not.
Main Results:
- Decompressive craniectomy rates decreased from 2.8% in 2009 to 1.9% in 2017, coinciding with increased MT procedures.
- 32 patients underwent MT prior to DC; no significant differences were found in age, initial NIHSS, stroke extent (ASPECTS), time to DC, or neurological outcome between groups.
- The rate of DC decreased, while MT procedures increased during the study period.
Conclusions:
- Routine mechanical thrombectomy has led to a reduction in decompressive craniectomies.
- Decompressive craniectomy patients with and without prior MT showed comparable initial clinical features and outcomes.
- Findings suggest that previous DC studies are applicable to thrombectomized patient cohorts.
