Early hemicraniectomy improves survival of elderly MCA stroke patients, but with substantial disability

The New England Journal of Medicine

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.

Alexander A. Khalessi, MD


For hypertensive SICH of moderate to large size in patients without any related contraindication I am in the opinion and practice of MIS as an emergency procedure/ultremergency procedure.Continue treatment in NICU equiped with man and technology. I am practicing it since 1990 as neurosurgeon. When whole clot removal is not possible as in perisylvian area I do instal intrahaematoma urokinase. My result is 100% better then without surgery. Many patients are alive well with some % of disability. cause of death was unrelated to surgery.It was and in my observation are due to delay in decision,respiratory complication,respiratory infection,AMI, URI and metabolic. IN MY OPINION IF NOK WANTS HIS DEAR AND NEAR ONE MUST LIVE FOR SOME MORE YEARS MUST GIVE DECISION FOR MIS FOR HIS PATIENTS WITH ICH.