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Published on: August 11, 2015
Decompressive craniectomy in symptomatic intracerebral hemorrhage after ischemic stroke: a multicenter retrospective
Elliot Pressman1, Zachary C Gersey2, Soren B Jonzzon3
11Department of Neurosurgery & Brain Repair, University of South Florida, Tampa, Florida.
Insights
Decompressive craniectomy (DC) after symptomatic intracerebral hemorrhage (sICH) did not improve 90-day functional outcomes in multivariable analysis. Younger age and no history of cancer were linked to better outcomes in stroke patients.
Area of Science:
- Neurosurgery
- Neurology
- Stroke Medicine
Background:
- Symptomatic intracerebral hemorrhage (sICH) is a severe complication post-stroke.
- Decompressive craniectomy (DC) is considered for large supratentorial sICH with significant mass effect, but its benefit is debated.
Purpose of the Study:
- To evaluate the effectiveness of decompressive craniectomy (DC) in improving functional outcomes for patients with symptomatic intracerebral hemorrhage (sICH) after acute ischemic stroke (AIS).
Main Methods:
- Retrospective study across 8 stroke centers (January 2016 - December 2020) including patients with sICH post-AIS.
- Compared outcomes (modified Rankin Scale, Glasgow Outcome Scale-Extended) at 90 days between patients who underwent DC and those receiving standard medical treatment.
Main Results:
- DC patients were younger (58 vs 76 years) and had no history of cancer.
- DC was associated with longer ICU stays but did not significantly improve functional outcomes (mRS 0-3) at 90 days in multivariable analysis.
- Younger age and absence of cancer history correlated with better 90-day mRS scores.
Conclusions:
- Decompressive craniectomy (DC) did not demonstrate improved functional outcomes at 90 days post-symptomatic intracerebral hemorrhage (sICH) in multivariable analysis.
- Factors such as younger age and a lack of prior cancer history are associated with better functional recovery after sICH.
Objective:
Symptomatic intracerebral hemorrhage (sICH) after stroke is a devastating neurological complication. Current guidelines support a "possible benefit" of decompressive craniectomy (DC) for large supratentorial sICH with significant mass effect.
Methods:
The authors conducted a retrospective study of 8 comprehensive stroke centers. They included all patients who sustained an sICH after acute ischemic stroke (AIS), as defined by the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST), from January 2016 to December 2020. They compared patients who underwent DC to those who were treated with standard medical treatment to measure functional outcome at 90 days, primarily as defined by the modified Rankin Scale (mRS) and secondarily by the Glasgow Outcome Scale-Extended (GOS-E).
Results:
Eighty-five patients were identified, 26 of whom (30.5%) underwent DC. Patients who underwent DC were younger (58 years [DC] vs 76 years [no DC], p < 0.001). No patient with a previous history of cancer underwent DC (n = 14, p = 0.004). Twenty-five patients (96.2%) in the DC group underwent thrombectomy versus 54 (91.5%) in the non-DC group (p = 0.443). Patients who underwent DC had a longer ICU stay (median [IQR] 240 [38-408] hours vs 24 [5-96] hours in non-DC patients, p = 0.002). At 90 days, 3 patients (4.1%) had obtained an mRS score of 0-2 and 10 patients (11.7%) an mRS score of 0-3. Patients who had improved functional outcome were younger (mRS score, OR 1.06, 95% CI 1.01-1.10, p = 0.012). Patients with a history of cancer had worse 90-day mRS scores (OR 8.49, 95% CI 1.54-159, p = 0.046). The rate of in-hospital mortality or discharge to hospice was significantly higher in the non-DC cohort (10 [38.5%] patients in the DC cohort vs 38 [64.4%] in the non-DC cohort, p = 0.026). Ninety days later, patients who underwent DC were more likely to have improved outcome (mRS mean rank 30.0 vs 40.0, p = 0.027). In multivariable analysis, history of cancer (OR 12.2, 95% CI 1.26-118, p = 0.031) and older age (OR 1.07, 95% CI 1.02-1.13, p = 0.011) increased the odds of worse mRS outcomes while DC did not (OR 1.34, 95% CI 0.357-5.03, p = 0.665).
Conclusions:
DC after sICH did not improve functional outcome at 90 days according to multivariable analysis, although younger age and absence of previous cancer history were associated with improved outcomes.
