Mechanical thrombectomy and decompressive hemicraniectomy trends for acute ischemic stroke: A nationwide analysis

Indications for endovascular treatment for acute ischemic stroke (AIS) and the need for decompressive hemicraniectomy (DHC) have evolved. This study provides an updated, analysis of mechanical thrombectomy (MT) and DHC rate trends following publication of the MT extended-time trials.

Using International Classification of Diseases, Ninth and Tenth Edition codes, we conducted a retrospective analysis of the National Inpatient Sample database for United States adults (≥18 years old) from 2012 to 2020 with large-vessel, proximal anterior circulation AIS who underwent surgical intervention. Subgroups corresponded to the landmark MT trial eras: 2012-2014 (pre-thrombectomy), 2015-2017 (thrombectomy), 2018-2020 (expanded thrombectomy). Statistical analysis with frequency tables and multivariable logistic regression models were used.

A total of 1,036,738 patients (49.4% male) were analyzed. AIS hospitalizations increased from 329,398 to 359,242 over 2012-2020. The rate of MT increased from 0.94% (n = 3,104) in 2012-2014 to 3.2% (n = 11,495) in 2018-2020, while the rate of DHC decreased from 0.4% (n = 1,402) to 0.2% (n = 559), respectively. MT was more commonly performed at small and medium sized hospitals from 2018 to 2020 (27.5%; n = 3,196) compared to 2012-2014 (21.2%; n = 657). Fewer patients were transferred from their presenting hospital for MT in 2018-2020 (56.7%) compared to 2012-2014 (61.4%). Patients >81 years old and with extreme illness severity were more likely to undergo MT in 2018-2020 versus 2012-2014 (adjusted odds ratio, 4.47 and 2.67, respectively; p < 0.0001).

Since 2012 the nationwide incidence of MT has increased, while DHC has decreased. Expanded MT-eligibility trials had limited effect on these trends. Surgical stroke treatment has decentralized over time, with MT and DHC more frequently performed at small and medium sized hospitals and MT increasingly performed at rural hospitals. MT is expanding to older and sicker AIS patients.