Efficacy and safety of decompressive craniectomy in acute ischemic stroke patients treated with intravenous thrombolysis

Abstract

Introduction The optimal timing for decompressive hemicraniectomy (DHC) after intravenous thrombolysis (IVT) remains unclear. This study in patients with acute ischemic stroke treated with IVT aimed to assess the safety of DHC and patient outcome. Methods Data was extracted from the Tabriz stroke registry from June 2011 up to September 2020. In all, 881 patients were treated with IVT. Among these, 23 patients underwent DH. Six patients were excluded due to symptomatic intracranial hemorrhage (parenchymal hematoma type 2 based on SITS-MOST definition) after IVT, but other types of bleeding after venous thrombolysis, including HI1, HI2, and PH1 were not excluded; so the remaining 17 patients were enrolled in the study. Functional Outcome was defined as the proportion of patients who achieved mRS score of 2–3 (moderate disability), 4–5 (severe disability), or 6 (mortality) at 90 days after stroke. mRSwas assess by trained neurologist at the hospital clinic with direct interview Safety outcome was assessed by comparison of two scans just prior to and after craniectomy. Any new hemorrhage or worsening of previous hemorrhage was reported. Parenchymal hematoma type 2, based on ECASS II definition, was considered as major surgical complication. This study was approved by the local ethics committee of the Tabriz University of Medical Sciences (Ethics Code: IR.TBZMED.REC.1398.420). Results At the three-month mRS follow up, six patients (35%) had moderate and five (29%) had severe disability. The outcome of death was observed in six patients (35%).Nine of 15 patients (60%) underwent surgery in the first 48 hours after onset of symptoms. No patient over 60 years of age survived to the three-month follow up; 67% of those who were under60 years and underwent DH in the first 48 hours had favorable outcome. Hemorrhagic complication was seen in 64% of patients but none was major. Conclusion Results of this study showed that the rate of major bleeding and outcome of acute ischemic stroke patients who underwent DHC after IVT is comparable with the reported data in the literature and intentionally waiting for the fibrinolytic effects of IVT to disappear may not outweigh the benefits of DHC. Although the findings of the study should be interpreted with caution and larger studies are needed to confirm the results.

Efficacy and safety of mechanical thrombectomy in the posterior cerebral circulation—a single center study

“…While the impact of DH on outcomes following malignant middle cerebral artery infarction (mMCAi) remains a subject of debate, there is a dearth of literature that reports on its effects after posterior vascular strokes. In one study of DH after IVT, no patient over 60 years old survived to 3-month follow-up, and moderate disability at 3 months was present in 35.5% 51 . Inamasu et al showed that despite the absence of differences in any of the demographic variables evaluated, the mortality rate was significantly higher in the group of individuals over 70 years old who underwent DH compared to those aged 61–70 52 .…”

“…Thirdly, NIHSS Scale was utilized to evaluate the clinical condition of patients undergoing AMT and PMT procedures. It is worth noting that the NIHSS scale may not comprehensively capture the severity of the clinical condition in patients with posterior circulation stroke 51 . Fourthly, our study primarily relied on the clinical status of patients at discharge and on the 90th day after the procedure, whereas some investigations extend their focus to outcomes after one year.…”

Efficacy and safety of mechanical thrombectomy in the posterior cerebral circulation– a single center study

“…While the impact of DH on outcomes following malignant middle cerebral artery infarction (mMCAi) remains a subject of debate, there is a dearth of literature reports on its effects after posterior vascular strokes. In one study of DH after IVT, no patient over 60 years old survived to 3-month follow-up, and moderate disability at 3 months was present in 35.5% 49 .…”