Temperature management in malignant infarction requiring decompressive craniectomy: real-world experience and...

Targeted temperature management (TTM) is commonly used in patients with acute brain injury for multiple indications, including control of cerebral edema, intracranial pressure, and fever. However, its use in patients with malignant infarction requiring decompressive craniectomy remains controversial due to concerns regarding hemorrhagic complications. We aimed to evaluate real-world patterns of TTM and its association with hemorrhagic outcomes in this high-risk population.

We conducted a retrospective observational study of consecutive patients with anterior circulation infarction who underwent decompressive craniectomy at a single tertiary referral center between 2011 and 2025. Patients were divided into TTM and non-TTM groups. The primary outcome was the occurrence of parenchymal hematoma type 2 (PH2). Secondary outcomes included any hemorrhagic transformation (HT) and in-hospital mortality. Temporal relationships between HT, decompressive craniectomy, and TTM were also assessed.

A total of 50 patients were included, of whom 16 (32.0 %) received TTM. Preoperative HT was more frequent in the TTM group (68.8 % vs. 38.2 %, p = 0.044), whereas antiplatelet use was more common in the non-TTM group (44.1 % vs. 0 %, p < 0.001). There were no significant differences between groups in overall HT (75.0 % vs. 73.5 %, p = 0.912), PH2 (12.5 % vs. 8.8 %, p = 0.686), or in-hospital mortality (25.0 % vs. 32.4 %, p = 0.597). Among PH2 cases, 4 of 5 events occurred after mechanical thrombectomy, suggesting a contribution of reperfusion-related injury. Temporal patterns between HT and TTM were heterogeneous, with a substantial proportion of HT occurring prior to TTM initiation.

In this high-risk cohort of patients with malignant infarction undergoing decompressive craniectomy, TTM was applied across heterogeneous clinical contexts without a clear signal of increased risk for severe hemorrhagic complications. Severe hemorrhagic transformation appeared to be more closely related to reperfusion-related mechanisms and edema progression than to TTM. These findings provide clinically relevant reassurance regarding the use of TTM in high-risk neurocritical care settings.