To Decompress or Not? An Expected Utility Inspired Approach To Shared decision-making For Supratentorial Ischemic...

Patients with large territorial supratentorial infarctions are at high risk of cerebral edema, increased intracranial pressure, tissue herniation and death. There is strong evidence supporting prompt decompressive craniectomy after large hemispheric ischemic stroke as a means to reduce mortality. Nevertheless, functional outcomes can vary significantly. Clinical trials have traditionally judged these outcomes by a priori dichotomization without taking into account individual patient and caregiver preferences. If these are not incorporated into shared decision-making, there are significant risks in both directions, i.e. producing outcomes that may be judged as unacceptable to survivors, or not offering life-saving treatments to patients that according to their own values could be beneficial. In the absence of decision aids, we explore insights from decision theory and propose an expected utility-inspired approach as a supplementary navigating tool in the decision-making process. Four patient case scenarios are discussed as a demonstration of using individualized rankings of outcome preferences, and deriving expected utilities for interventions such as decompressive craniectomy versus medical therapy. The ultimate aim of the suggested approach is to assure that patient values are elicited and incorporated, and possible range and nature of outcomes are discussed, and by attempting to connect best available means to patient individualized ends.