Decompressive craniectomy after endovascular thrombectomy in acute ischemic stroke: a systematic review

Endovascular thrombectomy (EVT) is a safe and efficacious treatment of choice for acute ischemic stroke (AIS) patients due to large artery occlusion in the anterior circulation. Despite these achievements, some patients still require decompressive craniectomy (DC) even after undergoing a timely EVT. Identifying patients requiring post-EVT DC is crucial to improve the clinical outcome, even though signs and symptoms at that period may not be reliable. In this study, we aimed to investigate risk factors for DC after EVT.

A systematic review was conducted from inception to 24 August 2024 in PubMed, Scopus, and Web of Science databases following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Articles published in English investigating AIS patients undergoing DC after EVT were selected.

Our initial search resulted in 6776 articles. After removing duplicates, 141 articles were fully screened. Eleven studies with 2243 patients were included. Multiple risk factors were associated with DC after EVT, including higher baseline NIHSS score (OR 1.17, 95% CI 1.03-1.32; p < 0.001), heavier thrombus burden (OR 1.35, 95% CI 1.02-1.79; p < 0.001), baseline ASPECTS ≤ 8 (OR 7.41, 95% CI 2.43-22.66; p < 0.001), unsuccessful recanalization (OR 7.49, 95% CI 2.13-26.36; p < 0.001), larger diffusion-weighted imaging infarct volume, longer time to thrombectomy, higher admission blood glucose levels, poor collaterals on computed tomography angiography, higher number of EVT passes, and preadmission antiplatelet use.

DC is essential for some AIS patients undergoing EVT who have cerebral edema and/or hemorrhagic transformation caused by large ischemic infarction. Multiple risk factors, such as higher baseline NIHSS scores, heavier thrombus burden, baseline ASPECTS ≤ 8, and unsuccessful recanalization were found to be associated with DC after EVT.