Decompressive hemicraniectomy for large hemispheric infarction after endovascular therapy

Area of Science:

• Neurology
• Neurosurgery
• Critical Care Medicine

Background:

• Endovascular therapy (EVT) is a standard treatment for acute ischemic stroke.
• Large hemispheric infarction (LHI) following EVT can lead to severe outcomes.
• Decompressive hemicraniectomy (DHC) is a potential intervention for LHI, but its benefit in the context of EVT requires clarification.

Purpose of the Study:

• To evaluate the efficacy of DHC in patients with LHI after EVT.
• To identify patient subgroups most likely to benefit from DHC post-EVT.

Main Methods:

• Pooled analysis of RESCUE-RE and ANGEL-ASPECT trials.
• Inclusion criteria: LHI and severe neurological deficits post-EVT.
• Propensity score matching (PSM) to compare DHC versus conservative therapy groups.
• Primary outcome: 90-day mortality; secondary outcome: 90-day modified Rankin Scale (mRS) distribution.

Main Results:

• DHC significantly reduced 90-day mortality compared to conservative therapy (OR, 0.26; p=0.005).
• No significant improvement in 90-day mRS distribution was observed (common OR, 0.47; p=0.06).
• Patients with specific ranges of midline shift (10-17 mm) or infarct volume (250-330 mL) showed comprehensive clinical benefit.

Conclusions:

• DHC is associated with reduced mortality in LHI patients post-EVT when performed per guidelines.
• Patients with intermediate-to-high injury severity post-EVT may derive the most benefit from DHC.
• Further research may refine patient selection for DHC after EVT.