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Indications, Timing, and Outcome of Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarction: A
Modar Alhamdan1, Alba Corell2, Klas Holmgren3
1Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden.
Background:
Malignant middle cerebral artery infarction (MMI) can cause life-threatening edema with high mortality rates. Randomized controlled trials (RCTs) have shown that decompressive hemicraniectomy (DC) can improve survival rate and functional outcome in selected MMI patients. However, real-world outcomes are less well described.
Objective:
To investigate DC indications, timing, and outcomes in MMI patients treated at 4 Swedish neurosurgical centers and the degree of alignment of real-world patient selection with eligibility criteria from 2 landmark RCTs-DESTINY I & II.
Methods:
This retrospective, Swedish multicenter (n = 4) cohort study included 335 MMI patients treated with DC between 2008 and 2022. Demographics, clinical and radiological status, surgical factors, and 6-month outcomes (modified Rankin Scale [mRS]) were collected and compared across centers and with DESTINY trials.
Results:
Median age was 55 (48-61) years, and 75% were male. Pre-DC, median Glasgow Coma Scale Motor score was 5 (5-6) and Charlson Comorbidity Index score was 3 (3-4). DC was performed at a median of 38 (25-56) hours from stroke onset. Median mRS at 6 months was 4 (4-5), 24% had mRS ≤ 3, and mortality was 17%. Only 19% and 12% of patients would have qualified for DESTINY I and II trials, respectively.
Conclusions:
Indication and timing of DC as a treatment of MMI demonstrated notable discrepancies in surgical practice across centers and compared to landmark RCTs. However, despite differences in timing and indications for DC, the outcome did not differ significantly across centers. Our findings provide insight into the outcome of DC performed for MMI outside the strict criteria supported by level 1 evidence.
Insights
Decompressive hemicraniectomy (DC) for malignant middle cerebral artery infarction (MMI) shows varied real-world application compared to clinical trials. Despite differing indications and timing, outcomes were consistent across Swedish centers.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Malignant middle cerebral artery infarction (MMI) presents a high mortality risk due to severe edema.
- Decompressive hemicraniectomy (DC) is a proven intervention in randomized controlled trials (RCTs) for selected MMI patients.
- Real-world data on DC for MMI is less comprehensively documented.
Purpose of the Study:
- To evaluate the indications, timing, and outcomes of DC in MMI patients across four Swedish neurosurgical centers.
- To assess the alignment of real-world patient selection for DC with criteria from landmark RCTs (DESTINY I & II).
Main Methods:
- A retrospective multi-center cohort study involving 335 MMI patients treated with DC (2008-2022).
- Data collected included demographics, clinical/radiological status, surgical factors, and 6-month outcomes (modified Rankin Scale [mRS]).
- Comparisons were made across centers and against DESTINY trial eligibility criteria.
Main Results:
- The study included 335 MMI patients; 75% were male, with a median age of 55.
- DC was performed at a median of 38 hours post-stroke onset.
- Median 6-month mRS was 4, with 24% achieving mRS ≤3 and a 17% mortality rate. Critically, only 19% and 12% met DESTINY I and II criteria, respectively.
Conclusions:
- Significant variations exist in DC indications and timing for MMI treatment across centers and compared to RCTs.
- Despite these practice variations, functional outcomes and mortality rates were comparable across the participating centers.
- This study offers valuable insights into the outcomes of DC for MMI when applied outside strict RCT eligibility criteria.
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