How often are patients with ischemic stroke eligible for decompressive hemicraniectomy?
OBJECTIVE
Malignant middle cerebral artery infarction is estimated to occur in 10% of ischemic strokes, but few patients undergo decompressive hemicraniectomy, a proven therapy. We determined the proportion of patients with ischemic stroke without significant baseline disability with large middle cerebral artery infarction who would have been potentially eligible for hemicraniectomy in an era before publication of recent hemicraniectomy trials.


METHODS
Ischemic stroke cases that occurred in 2005 among residents of the 5-county Greater Cincinnati/Northern Kentucky area were ascertained. Two study physicians reviewed all clinical and neuroimaging data for patients with baseline modified Rankin Scale score < 2, age ≥ 18 years with National Institutes of Health Stroke Scale score ≥ 10. Large middle cerebral artery infarction was defined as >50% of the middle cerebral artery territory or >145 mL on diffusion-weighted MRI. Other eligibility criteria for hemicraniectomy, based on the pooled analysis of recent clinical trials, were age 18 to 60 years and National Institutes of Health Stroke Scale score > 15.


RESULTS
Of 2227 ischemic strokes, 39 (1.8%) with baseline modified Rankin Scale score < 2 had large middle cerebral artery infarction. None underwent hemicraniectomy, and 16 (41.0%) died within 30 days. Six patients (0.3% of all ischemic strokes) were potentially eligible for hemicraniectomy; 1 died within 30 days.


CONCLUSIONS
Based on criteria from clinical trials, only 0.3% of cases were eligible for hemicraniectomy. Given the survival and functional outcome benefit in treated patients, future studies should determine whether additional subgroups of patients with ischemic stroke may benefit from hemicraniectomy.
Department of Neurosurgery, University of Cincinnati, Cincinnati, OH 45267, USA.
Ralph
R
Rahme
Richard
R
Curry
Dawn
D
Kleindorfer
Jane C
JC
Khoury
Andrew J
AJ
Ringer
Brett M
BM
Kissela
Kathleen
K
Alwell
Charles J
CJ
Moomaw
Matthew L
ML
Flaherty
Pooja
P
Khatri
Daniel
D
Woo
Simona
S
Ferioli
Joseph
J
Broderick
Opeolu
O
Adeoye
D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000150:complications / Q000401:mortality / Q000601:surgery*; D003399:Craniotomy; D019299:Decompression, Surgical; D038524:Diffusion Magnetic Resonance Imaging; D005260:Female; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000473:pathology / Q000601:surgery; D007629:Kentucky; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures; D009820:Ohio; D018579:Patient Selection; D020127:Recovery of Function; D020521:Stroke / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D016019:Survival Analysis; D016896:Treatment Outcome