Timing of Decompressive Hemicraniectomy for Stroke

The original randomized, controlled clinical trials that established the efficacy of decompressive hemicraniectomy after space-occupying, malignant cerebral artery infarction were neither designed nor powered to evaluate the optimal timing of intervention. Because of the time frame used as enrollment criteria in these clinical trials, the initial pooled analysis was restricted to patients treated within 48 hours; therefore, subsequent guidelines recommended intervention be pursued within 2 days of the onset of stroke symptoms. However, few patients in these randomized controlled trials underwent surgery after 48 hours, limiting assessment of outcomes based on the timing of surgery. Several factors influence the timing of decompressive hemicraniectomy, including the severity of infarction, antithrombotic medications, and the tempo of developing malignant cerebral edema. Previous publications have found that the progression of cerebral edema after acute infarction ranges between 2 and 5 days: while 68% of patients exhibit clinical deterioration within 48 hours of symptom onset, almost one third of patients experience worsening of sensorium after 48 hours. In such cases, clinicians are faced with a dilemma of pursuing a hemicraniectomy before significant neurological deterioration from mass effect has transpired, or performing surgery outside of the recommended interval. In addition, inappropriate patient selection and overutilization of surgery is suboptimal, as decompressive craniectomy carries a risk of additional perioperative complications, including infection and reoperation. The utilization of decompressive craniectomy in the setting of stroke is increasing, and authors have highlighted the need Background and Purpose—Previous clinical trials were not designed to discern the optimal timing of decompressive craniectomy for stroke, and the ideal surgical timing in patients with space-occupying infarction who do not exhibit deterioration within 48 hours is debated. Methods—Patients undergoing decompressive craniectomy for stroke were extracted from the Nationwide Inpatient Sample (2002–2011). Multivariable logistic regression evaluated the association of surgical timing with mortality, discharge to institutional care, and poor outcome (a composite end point including death, tracheostomy and gastrostomy, or discharge to institutional care). Covariates included patient demographics, comorbidities, year of admission, and hospital characteristics. However, standard stroke severity scales and infarct volume were not available. Results—Among 1301 admissions, 55.8% (n=726) underwent surgery within 48 hours. Teaching hospital admission was associated with earlier surgery (P=0.02). The timing of intervention was not associated with in-hospital mortality. However, when evaluated continuously, later surgery was associated with increased odds of discharge to institutional care (odds ratio, 1.17; 95% confidence interval, 1.05–1.31, P=0.005) and of a poor outcome (odds ratio, 1.12; 95% confidence interval, 1.02–1.23; P=0.02). When evaluated dichotomously, the odds of discharge to institutional care and of a poor outcome did not differ at 48 hours after hospital admission, but increased when surgery was pursued after 72 hours. Subgroup analyses found no association of surgical timing with outcomes among patients who had not sustained herniation. Conclusions—In this nationwide analysis, early decompressive craniectomy was associated with superior outcomes. However, performing decompression before herniation may be the most important temporal consideration. (Stroke. 2017;48:704-711. DOI: 10.1161/STROKEAHA.116.014727.)