Decompressive craniectomy for ischemic stroke [Neurosurgery Wiki]

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====== Decompressive craniectomy for ischemic stroke ======

Anterior and posterior circulation acute ischemic stroke carries significant morbidity and mortality as a result of [[malignant cerebral edema]]. Decompressive craniectomy has evolved as a viable neurosurgical intervention in the armamentarium of treatment options for this life-threatening edema 
((Agarwalla PK, Stapleton CJ, Ogilvy CS. Craniectomy in acute ischemic stroke.
Neurosurgery. 2014 Feb;74 Suppl 1:S151-62. doi: 10.1227/NEU.0000000000000226.
PubMed PMID: 24402484.)).
----

Daou et al conducted a retrospective electronic medical record review of 1624 patients from 2006 to 2014. Subjects were screened for [[decompressive hemicraniectomy]] (DH) secondary to [[ischemic stroke]] involving the [[middle cerebral artery]], [[internal carotid artery]], or both. Ninety-five individuals 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). Clinical outcome was assessed at 90 days and at the latest follow-up (mean duration 16.5 months). 

The mean mRS score at 90 days and at the latest follow-up post-DH was 4. Good functional outcome was observed in 40% of patients at 90 days and in 48% of patient at the latest follow-up. The mortality rate at 90 days was 18% and at the last follow-up 20%. Univariate analysis identified a greater likelihood of poor functional outcome (mRS scores of 4-6) in patients with a history of stroke (OR 6.54 [95% CI1.39-30.66]; p = 0.017), peak [[midline shift]] (MLS) > 10 mm (OR 3.35 [95% CI 1.33-8.47]; p = 0.011), or a history of [[myocardial infarction]] (OR 8.95 [95% CI1.10-72.76]; p = 0.04). Multivariate analysis demonstrated elevated odds of poor functional outcome associated with a history of stroke (OR 9.14 [95% CI 1.78-47.05]; p = 0.008), MLS > 10 mm (OR 5.15 [95% CI 1.58-16.79; p = 0.007), a history of diabetes (OR 5.63 [95% CI 1.52-20.88]; p = 0.01), delayed time from onset of stroke to DH (OR 1.32 [95% CI 1.02-1.72]; p = 0.037), and evidence of pupillary dilation prior to DH (OR 4.19 [95% CI 1.06-16.51]; p = 0.04). Patients with infarction involving the dominant hemisphere had higher odds of unfavorable functional outcome at 90 days (OR 4.73 [95% CI 1.36-16.44]; p = 0.014), but at the latest follow-up, cerebral dominance was not significantly related to outcome (OR 1.63 [95% CI 0.61-4.34]; p = 0.328). 

History of stroke, diabetes, myocardial infarction, peak MLS > 10 mm, increasing duration from onset of stroke to DH, and presence of pupillary dilation prior to intervention are associated with a worse functional outcome
((Daou B, Kent AP, Montano M, Chalouhi N, Starke RM, Tjoumakaris S, Rosenwasser 
RH, Jabbour P. Decompressive hemicraniectomy: predictors of functional outcome in
patients with ischemic stroke. J Neurosurg. 2016 Jun;124(6):1773-9. doi:
10.3171/2015.6.JNS15729. Epub 2015 Nov 27. PubMed PMID: 26613165.
)).

===== Indications =====

[[Decompressive craniectomy for ischemic stroke indications]]