Decompressive craniectomy in malignant MCA infarction in times of mechanical thrombectomy

Göttsche, Jennifer; Flottmann, Fabian; Jank, Larissa; Thomalla, Götz; Rimmele, David Leander; Czorlich, Patrick; Westphal, Manfred; Regelsberger, Jan

doi:10.1007/s00701-019-04180-0

Cited by 21 publications

(17 citation statements)

References 26 publications

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“…Prior TL in patients receiving mechanical thrombectomy (MT) may enhance survival without additional risk of symptomatic hemorrhagic transformation [26]. The use of MT in acute stroke patients continuously increased during the last years, which has led to a decrease in the rates of decompressive hemicraniectomy (DHC) [27][28][29]. We documented sixteen patients with thrombectomy prior to DHC, of which seven patients were treated with both, MT and TL in the absence of antiplatelet treatment.…”

Section: Discussionmentioning

confidence: 99%

Risk profile of decompressive hemicraniectomy for malignant stroke after revascularization treatment

Alzayiani

Schmidt

Veldeman

et al. 2021

Journal of the Neurological Sciences

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Revascularization by pharmacological and/or endovascular treatment is an effective therapy for acute ischemic stroke caused by artery occlusion. In the context of malignant middle cerebral artery infarction (MMI), decompressive hemicraniectomy (DHC) can be life-saving. However, its effectiveness and safety after revascularization have not been thoroughly assessed. This retrospective study aimed to determine the risk profile of presurgical revascularization treatment (RT) for subsequent DHC. Methods: A total of 152 consecutive patients treated by DHC after MMI were identified between 2012 and 2015. After elimination of cases with previous stroke and cases pre-treated with antiplatelets or anticoagulants (increased postoperative bleeding), twenty-four out of fifty patients (n = 24/50, 48%) received pre-surgical revascularization treatment by intravenous thrombolysis (TL), mechanical thrombectomy (MT) or a combination of both. Demographic data was compared alongside perioperative, postoperative complications (intra− / extracerebral hemorrhage, revision surgery due to hemorrhage or infection, and overall mortality) and economic parameters.Results: Comparing patients with and without prior RT, there was no statistically significant difference in duration of surgery min vs. no-RT: 96 [69-119] min, p = 0.308), intraoperative blood loss (RT: 300 [225-375] ml vs. no-RT: 300 [250-400] ml, p = 0.763), intraoperative transfusion requirement (RT: 12.5% vs. no-RT: 26.9%, p = 0.294), or need for volume substitution (RT: 1300 [1200-1400] ml vs. no-RT: 1200 [1100-1400] ml, p = 0.359). The rate of postoperative complications was also comparable in both groups, including intra− /extracerebral hemorrhage, revision due to hemorrhage or infections, and mortality (p = 0.814, p = 0.520, p = 0.697, and p = 0.769). Health economic parameters were not affected (ventilation time: hrs.,

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Section: Discussionmentioning

confidence: 99%

Risk profile of decompressive hemicraniectomy for malignant stroke after revascularization treatment

Alzayiani

Schmidt

Veldeman

et al. 2021

Journal of the Neurological Sciences

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“…This observation is in contradistinction to recent studies using data from the Nationwide Inpatient Sample (NIS), as well as data from a single center in Germany. [19][20][21] Analysis of NIS data found similar rates of IV-tPA and MT (11.2% and 5.8%, respectively), but a decrease in DHC from 11.4% in 2012 to 4.8% in 2016. 19 Another analysis of NIS data showed a trend toward decreased DHC, from 7.07% in 2006 to 6.43% in 2016.…”

Section: Discussionmentioning

confidence: 93%

“…16 With increasing use of MT, many centers have anecdotally noted decreasing rates of DHCs at their centers, presumably secondary to smaller infarct volumes after successful revascularization. 17 Several nationwide database studies have supported this phenomenon; [18][19][20][21] however, this methodology has significant limitations and does not include data since the extended time windows seen after the 2018 trials.…”

Section: Introductionmentioning

confidence: 99%

Trends in mechanical thrombectomy and decompressive hemicraniectomy for stroke: A multicenter study

et al. 2021

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Background and purpose Acute ischemic stroke has increasingly become a procedural disease following the demonstrated benefit of mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) on clinical outcomes and tissue salvage in randomized trials. Given these data and anecdotal experience of decreased numbers of decompressive hemicraniectomies (DHCs) performed for malignant cerebral edema, we sought to correlate the numbers of strokes, thrombectomies, and DHCs performed over the timeline of the 2013 failed thrombolysis/thrombectomy trials, to the 2015 modern randomized MT trials, to post-DAWN and DEFUSE 3. Materials and methods This is a multicenter retrospective compilation of patients who presented with ELVO in 11 US high-volume comprehensive stroke centers. Rates of tissue plasminogen activator (tPA), thrombectomy, and DHC were determined by current procedural terminology code, and specificity to acute ischemic stroke confirmed by each institution. Endpoints included the incidence of stroke, thrombectomy, and DHC and rates of change over time. Results Between 2013 and 2018, there were 55,247 stroke admissions across 11 participating centers. Of these, 6145 received tPA, 4122 underwent thrombectomy, and 662 patients underwent hemicraniectomy. The trajectories of procedure rates over time were modeled and there was a significant change in MT rate ( p = 0.002) without a concomitant change in the total number of stroke admissions, tPA administration rate, or rate of DHC. Conclusions This real-world study confirms an increase in thrombectomy performed for ELVO while demonstrating stable rates of stroke admission, tPA administration and DHC. Unlike prior studies, increasing thrombectomy rates were not associated with decreased utilization of hemicraniectomy.

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“…15 Incomplete recanalization (less than TICI grade 2b) is frequent in these patients: it is comprised between 14% and 60%, and can lead to a large ischemic stroke which are classic indication of DC. 5,15 The place of DC after partial recanalization in large ischemic stroke has never been extensively studied: one study reported the same neurological outcomes of patients after DC whether or not they had EVT before. 5 However, the sample size was small and the occurrence of HTs was not reported.…”

Section: Discussionmentioning

confidence: 99%

Impact of Decompressive Craniectomy on Hemorrhagic Transformation in Malignant Ischemic Stroke in Mice

Borha

Lebrun

Touzé

et al. 2023

Stroke

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BACKGROUND: Endovascular thrombectomy has changed the management of ischemic stroke. The reperfusion can however lead to a hemorrhagic transformation (HT). Decompressive craniectomy (DC) is a surgical procedure used for malignant ischemic stroke. However, its efficacy was demonstrated before the era of endovascular thrombectomy trials. Here, we hypothesized that DC for ischemic stroke after thrombectomy could lead to a higher risk of HT. We thus evaluated this hypothesis in a mouse model of stroke induced by occlusion of the middle cerebral artery (MCAO) with or without mechanical reperfusion. METHODS: Ninety mice subjected to MCAO were divided into 6 groups: permanent MCAO with or without DC; MCAO followed by a mechanical reperfusion with or without DC and MCAO with a mechanical reperfusion followed by r-tPA (recombinant tissue-type plasminogen activator)-induced reperfusion with or without DC. Mice were evaluated by magnetic resonance imaging 24 hours after the MCAO to assess ischemic lesion volumes, and the rate, type, and volume of HTs. RESULTS: The ischemic volume was higher in the 2 groups without reperfusion than in the 4 groups with reperfusion independently of r-tPA treatment and DC. The distribution of HT types was different between the 6 groups. The HT volumes and HT scores was smaller in the 2 groups without reperfusion and in the reperfusion group without r-tPA and without DC. In mice having reperfusion, the mean HT score was higher in mice who had DC without r-tPA (HT score 5; P =0.048) or with r-tPA (HT score 8; P =0.02), than in mice without DC (HT score 1). CONCLUSIONS: DC for a malignant stroke, after reperfusion, corresponding to an endovascular thrombectomy failure, increases the risk of severe hemorrhagic transformations in a model of ischemic stroke in mice. This result support the need of clinical studies to evaluate the added value of DC at the era of endovascular thrombectomy.

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Decompressive craniectomy in malignant MCA infarction in times of mechanical thrombectomy

Cited by 21 publications

References 26 publications

Risk profile of decompressive hemicraniectomy for malignant stroke after revascularization treatment

Risk profile of decompressive hemicraniectomy for malignant stroke after revascularization treatment

Trends in mechanical thrombectomy and decompressive hemicraniectomy for stroke: A multicenter study

Impact of Decompressive Craniectomy on Hemorrhagic Transformation in Malignant Ischemic Stroke in Mice

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