title: Timing of Decompressive Hemicraniectomy for Stroke: A Nationwide Inpatient Sample Analysis.
abstract: Previous clinical trials were not designed to discern the optimal timing of decompressive craniectomy for stroke, and the ideal surgical timing in patients with space-occupying infarction who do not exhibit deterioration within 48 hours is debated.
  
  
  
  Patients undergoing decompressive craniectomy for stroke were extracted from the Nationwide Inpatient Sample (2002-2011). Multivariable logistic regression evaluated the association of surgical timing with mortality, discharge to institutional care, and poor outcome (a composite end point including death, tracheostomy and gastrostomy, or discharge to institutional care). Covariates included patient demographics, comorbidities, year of admission, and hospital characteristics. However, standard stroke severity scales and infarct volume were not available.
  
  
  
  Among 1301 admissions, 55.8% (n=726) underwent surgery within 48 hours. Teaching hospital admission was associated with earlier surgery (P=0.02). The timing of intervention was not associated with in-hospital mortality. However, when evaluated continuously, later surgery was associated with increased odds of discharge to institutional care (odds ratio, 1.17; 95% confidence interval, 1.05-1.31,P=0.005) and of a poor outcome (odds ratio, 1.12; 95% confidence interval, 1.02-1.23;P=0.02). When evaluated dichotomously, the odds of discharge to institutional care and of a poor outcome did not differ at 48 hours after hospital admission, but increased when surgery was pursued after 72 hours. Subgroup analyses found no association of surgical timing with outcomes among patients who had not sustained herniation.
  
  
  
  s-In this nationwide analysis, early decompressive craniectomy was associated with superior outcomes. However, performing decompression before herniation may be the most important temporal consideration.
authors.affiliation: From the Department of Neurosurgery, Cushing Neurological Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Hormuzdiyar H
authors.initials: HH
authors.lastname: Dasenbrock
authors.affiliation: From the Department of Neurosurgery, Cushing Neurological Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Faith C
authors.initials: FC
authors.lastname: Robertson
authors.affiliation: From the Department of Neurosurgery, Cushing Neurological Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Henrikas
authors.initials: H
authors.lastname: Vaitkevicius
authors.affiliation: From the Department of Neurosurgery, Cushing Neurological Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: M Ali
authors.initials: MA
authors.lastname: Aziz-Sultan
authors.affiliation: From the Department of Neurosurgery, Cushing Neurological Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Donovan
authors.initials: D
authors.lastname: Guttieres
authors.affiliation: From the Department of Neurosurgery, Cushing Neurological Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Ian F
authors.initials: IF
authors.lastname: Dunn
authors.affiliation: From the Department of Neurosurgery, Cushing Neurological Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Rose
authors.initials: R
authors.lastname: Du
authors.affiliation: From the Department of Neurosurgery, Cushing Neurological Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. wgormley@partners.org.
authors.forename: William B
authors.initials: WB
authors.lastname: Gormley
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D056424:Decompressive Craniectomy; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000401:mortality / Q000601:surgery*; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D020521:Stroke / Q000401:mortality / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
keywords: cerebral infarction; decompressive craniectomy; early intervention; middle cerebral artery; stroke; time