Early hemicraniectomy improves survival of elderly MCA stroke patients, but with substantial disability
Previous trials showed the substantial survival benefit of decompressive hemicraniectomy and duroplasty within 48 hours of malignant MCA strokes (29% versus 78% at 1 year), and achieve a severe disability of 4% versus 5% in controls. The randomized DESTINY II trial with elderly patients (62-82yo) at 13 German Sites from 2009-12 was stopped due to efficacy. Inclusion criteria required NIHSS > 14 for right sided strokes, NIHSS > 19 for left sided strokes. At six months, survival without severe disability (mRS 4 or less) was 38% for surgical patients versus 18% in controls. The surgical survival advantage persisted at 12 months (56% versus 24%). Surgery reduced 1-year mortality by 33%, whereas surgery in younger patients reduced 1-year mortality by 50%. 1-year survival with severe disability (mRS=5) is 19% compared to 4% in younger patients. This trial shows surgery improves survival in elderly patients, with most survivors having substantial disability.