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  • The Impact of Early Intervention on the Outcomes After Decompressive Craniectomy for Stroke: A Nationwide Analysis

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    Hormuzdiyar H. Dasenbrock MD; Faith C Robertson BS; Mohammad Ali Aziz-Sultan MD; Donnovan Guitierres; Rose Du MD, PhD; Ian F. Dunn MD; William B. Gormley MD

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    Meeting: Congress of Neurological Surgeons 2015 Annual Meeting

    Introduction: Although evidence supports the performance of decompressive craniectomy for malignant cerebral infarction within 48 hours of presentation, no nationwide analysis has evaluated the predictors of undergoing early intervention in the United States.

    Methods: Data were retrospectively extracted from the Nationwide Inpatient Sample (2002-2011). Patients with a primary diagnosis of an anterior circulation acute ischemic stroke who underwent decompressive craniectomy with or without lobectomy were included. Multivariate regression analysis evaluated independent predictors of undergoing early intervention (within 48 hours of admission). Potential predictors evaluated included patient sex; admission year; comorbidities; stroke risk factors (atrial fibrillation, cardiac valvular disease, carotid stenosis, carotid dissection, and hypercogulability); longterm antithrombotic medication usage; treatment variables (including the administration of intravenous thrombolytics, interventional stroke therapy, and ventriculostomy placement); cerebral herniation; and hospital characteristics including size, teaching status, and region.

    Results: 1,432 admissions were included, of whom 53.3% (n=763) underwent surgery within 48 hours. Atrial fibrillation, anticoagulation usage, and teaching hospital admission were associated with increased odds of undergoing early surgery (P=0.02). Age greater than 70 years, cardiac valvular disease, diabetes, and carotid stenosis were associated with a lower odds of early intervention (P=0.03). No significantly different adjusted odds of in-hospital death were seen based on the timing of intervention (Odds Ratio (OR): 1.12, 95% Confidence Interval (CI): 0.85-1.46, P=0.43). However, early intervention was associated with lower adjusted odds of undergoing a tracheostomy or gastrostomy (OR: 0.75, 95% CI: 0.60-0.94, P=0.001) and of a hospital stay of at least 24 days (OR: 0.62, 95% CI: 0.47-0.85, P=0.002).

    Conclusions: In this nationwide analysis, patient age, stroke etiology, and hospital characteristics were associated with differential odds of undergoing early surgery. Although early intervention was not associated with differential mortality, superior outcomes were seen favoring early surgery on some measures including tracheostomy or gastrostomy placement and length of stay.

    Patient Care: This study highlights the potential importance of the performance of early intervention in patients undergoing craniectomy for malignant cerebral infarction.

    Learning Objectives: By the conclusion of this session, participants will be able to 1) identify the predictors of undergoing early craniectomy for stroke in the United States and 2) discuss the impact of early surgery on the peri-operativie outcomes, including mortality, the placement of a tracheostomy or gastrostomy, and length of stay.


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