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  • Decompressive Hemicraniectomy: Predictors of Functional Outcome in Patients with Ischemic Stroke

    Final Number:

    Badih Daou MD; Anthony P Kent; Maria Montano; Nohra Chalouhi MD; Robert M. Starke MD MSc; Stavropoula I. Tjoumakaris MD; Robert H. Rosenwasser MD, FACS, FAHA; Pascal Jabbour MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2015 Annual Meeting

    Introduction: Patients presenting with large-territory ischemic strokes may develop intractable cerebral edema that risks death unless intervention is performed. The purpose of this study is to identify predictors of outcome for decompressive hemicraniectomy (DH) in ischemic stroke.

    Methods: Retrospective electronic medical record review of 1,624 subjects from 2006 to 2014 was conducted. Subjects were screened for DH secondary to ischemic stroke involving the middle cerebral artery, internal carotid artery or both. 95 subjects were identified. Univariate and multivariate analyses were performed for an array of clinical variables in relationship to functional outcome according to the modified Rankin Scale (mRS).

    Results: Mean mRS score at 90 days post-DH was 4. Good functional outcome was observed in 40% of patients and mortality at 90 days was 18%. Univariate analysis identified a greater likelihood of poor functional outcome (mRS 4-6) in patients with previous history of stroke (OR = 6.54; p = 0.017; [1.39-30.66]), peak midline shift (MLS) >10mm (OR = 3.35; p = 0.011; [1.33-8.47]), or history of myocardial infarction (OR = 8.95; p = 0.04; [1.10-72.76]). Multivariate analysis demonstrated elevated odds of poor functional outcome for previous history of stroke (OR = 9.14; p = 0.008; [1.78-47.05]), MLS >10mm (OR = 5.08; p = 0.002; [1.79-14.36]), history of diabetes (OR=3.07; [1.03-9.16]; P=0.045) and delayed time from onset of stroke to DH (OR=1.32; [1.02-1.72]; P=0.037).

    Conclusions: History of stroke, diabetes, MI, peak MLS >10mm and increasing duration from onset of stroke to decompressive hemicraniectomy are associated with a worse functional outcome.

    Patient Care: This paper will help physicians to make a better patient selection for decompressive hemicraniectomy by providing predictors of clinical outcome after the procedure.

    Learning Objectives: To identify predictors of outcome for decompressive hemicraniectomy (DH) in the treatment of acute ischemic stroke.

    References: Ropper AH, Shafran B. Brain edema after stroke. Clinical syndrome and intracranial pressure. Archives of neurology. Jan 1984;41(1):26-29. 2. Walz B, Zimmermann C, Bottger S, Haberl RL. Prognosis of patients after hemicraniectomy in malignant middle cerebral artery infarction. Journal of neurology. Sep 2002;249(9):1183-1190. 3. Juttler E, Unterberg A, Woitzik J, et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. The New England journal of medicine. Mar 20 2014;370(12):1091-1100. 4. Holtkamp M, Buchheim K, Unterberg A, et al. Hemicraniectomy in elderly patients with space occupying media infarction: improved survival but poor functional outcome. Journal of neurology, neurosurgery, and psychiatry. Feb 2001;70(2):226-228. 5. Leonhardt G, Wilhelm H, Doerfler A, et al. Clinical outcome and neuropsychological deficits after right decompressive hemicraniectomy in MCA infarction. Journal of neurology. Oct 2002;249(10):1433-1440. 6. Foerch C, Lang JM, Krause J, et al. Functional impairment, disability, and quality of life outcome after decompressive hemicraniectomy in malignant middle cerebral artery infarction. Journal of neurosurgery. Aug 2004;101(2):248-254. 7. Schwab S, Steiner T, Aschoff A, et al. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke; a journal of cerebral circulation. Sep 1998;29(9):1888-1893. 8. Chen CC, Cho DY, Tsai SC. Outcome of and prognostic factors for decompressive hemicraniectomy in malignant middle cerebral artery infarction. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. Apr 2007;14(4):317-321. 9. Malm J, Bergenheim AT, Enblad P, et al. The Swedish Malignant Middle cerebral artery Infarction Study: long-term results from a prospective study of hemicraniectomy combined with standardized neurointensive care. Acta neurologica Scandinavica. Jan 2006;113(1):25-30. 10. Rahme R, Curry R, Kleindorfer D, et al. How often are patients with ischemic stroke eligible for decompressive hemicraniectomy? Stroke; a journal of cerebral circulation. Feb 2012;43(2):550-552.

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