Inverse National Trends in Decompressive Craniectomy versus Endovascular Thrombectomy for Stroke

Khattar, Nicolas K; Ugiliweneza, Beatrice; Fortuny, Enzo; Adams, Shawn; Meyer, Kimberly; Sharma, Mayur; Wang, Dengzhi; Chandler, Thomas; Boakye, Maxwell; James, Robert F.; Ding, Dale

doi:10.1016/j.wneu.2020.03.022

Cited by 13 publications

(12 citation statements)

References 24 publications

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“…Prior TL in patients receiving mechanical thrombectomy (MT) may enhance survival without additional risk of symptomatic hemorrhagic transformation [26]. The use of MT in acute stroke patients continuously increased during the last years, which has led to a decrease in the rates of decompressive hemicraniectomy (DHC) [27][28][29]. We documented sixteen patients with thrombectomy prior to DHC, of which seven patients were treated with both, MT and TL in the absence of antiplatelet treatment.…”

Section: Discussionmentioning

confidence: 99%

Risk profile of decompressive hemicraniectomy for malignant stroke after revascularization treatment

Alzayiani

Schmidt

Veldeman

et al. 2021

Journal of the Neurological Sciences

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Revascularization by pharmacological and/or endovascular treatment is an effective therapy for acute ischemic stroke caused by artery occlusion. In the context of malignant middle cerebral artery infarction (MMI), decompressive hemicraniectomy (DHC) can be life-saving. However, its effectiveness and safety after revascularization have not been thoroughly assessed. This retrospective study aimed to determine the risk profile of presurgical revascularization treatment (RT) for subsequent DHC. Methods: A total of 152 consecutive patients treated by DHC after MMI were identified between 2012 and 2015. After elimination of cases with previous stroke and cases pre-treated with antiplatelets or anticoagulants (increased postoperative bleeding), twenty-four out of fifty patients (n = 24/50, 48%) received pre-surgical revascularization treatment by intravenous thrombolysis (TL), mechanical thrombectomy (MT) or a combination of both. Demographic data was compared alongside perioperative, postoperative complications (intra− / extracerebral hemorrhage, revision surgery due to hemorrhage or infection, and overall mortality) and economic parameters.Results: Comparing patients with and without prior RT, there was no statistically significant difference in duration of surgery min vs. no-RT: 96 [69-119] min, p = 0.308), intraoperative blood loss (RT: 300 [225-375] ml vs. no-RT: 300 [250-400] ml, p = 0.763), intraoperative transfusion requirement (RT: 12.5% vs. no-RT: 26.9%, p = 0.294), or need for volume substitution (RT: 1300 [1200-1400] ml vs. no-RT: 1200 [1100-1400] ml, p = 0.359). The rate of postoperative complications was also comparable in both groups, including intra− /extracerebral hemorrhage, revision due to hemorrhage or infections, and mortality (p = 0.814, p = 0.520, p = 0.697, and p = 0.769). Health economic parameters were not affected (ventilation time: hrs.,

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Section: Discussionmentioning

confidence: 99%

Risk profile of decompressive hemicraniectomy for malignant stroke after revascularization treatment

Alzayiani

Schmidt

Veldeman

et al. 2021

Journal of the Neurological Sciences

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“…This observation is in contradistinction to recent studies using data from the Nationwide Inpatient Sample (NIS), as well as data from a single center in Germany. [19][20][21] Analysis of NIS data found similar rates of IV-tPA and MT (11.2% and 5.8%, respectively), but a decrease in DHC from 11.4% in 2012 to 4.8% in 2016. 19 Another analysis of NIS data showed a trend toward decreased DHC, from 7.07% in 2006 to 6.43% in 2016.…”

Section: Discussionmentioning

confidence: 92%

“…19 Another analysis of NIS data showed a trend toward decreased DHC, from 7.07% in 2006 to 6.43% in 2016. 20 The German study also showed a modest reduction in DHC rates: 2.8% in 2009 to 1.9% in 2017. One theory explaining the changes in rates observed by these studies is a progressive shift towards centralized consolidation of stroke care at tertiary stroke centers.…”

Section: Discussionmentioning

confidence: 93%

“…16 With increasing use of MT, many centers have anecdotally noted decreasing rates of DHCs at their centers, presumably secondary to smaller infarct volumes after successful revascularization. 17 Several nationwide database studies have supported this phenomenon; [18][19][20][21] however, this methodology has significant limitations and does not include data since the extended time windows seen after the 2018 trials.…”

Section: Introductionmentioning

confidence: 99%

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Trends in mechanical thrombectomy and decompressive hemicraniectomy for stroke: A multicenter study

et al. 2021

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Background and purpose Acute ischemic stroke has increasingly become a procedural disease following the demonstrated benefit of mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) on clinical outcomes and tissue salvage in randomized trials. Given these data and anecdotal experience of decreased numbers of decompressive hemicraniectomies (DHCs) performed for malignant cerebral edema, we sought to correlate the numbers of strokes, thrombectomies, and DHCs performed over the timeline of the 2013 failed thrombolysis/thrombectomy trials, to the 2015 modern randomized MT trials, to post-DAWN and DEFUSE 3. Materials and methods This is a multicenter retrospective compilation of patients who presented with ELVO in 11 US high-volume comprehensive stroke centers. Rates of tissue plasminogen activator (tPA), thrombectomy, and DHC were determined by current procedural terminology code, and specificity to acute ischemic stroke confirmed by each institution. Endpoints included the incidence of stroke, thrombectomy, and DHC and rates of change over time. Results Between 2013 and 2018, there were 55,247 stroke admissions across 11 participating centers. Of these, 6145 received tPA, 4122 underwent thrombectomy, and 662 patients underwent hemicraniectomy. The trajectories of procedure rates over time were modeled and there was a significant change in MT rate ( p = 0.002) without a concomitant change in the total number of stroke admissions, tPA administration rate, or rate of DHC. Conclusions This real-world study confirms an increase in thrombectomy performed for ELVO while demonstrating stable rates of stroke admission, tPA administration and DHC. Unlike prior studies, increasing thrombectomy rates were not associated with decreased utilization of hemicraniectomy.

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“…Endovascular therapy (EVT) is the most effective treatment for patients with large vessel occlusion ( 5 ). Recent studies showed that revascularization was associated with a reduced risk of MBE ( 4 ) and that EVT was inversely associated with the use of decompressive craniectomy for patients with AIS ( 6 ). However, about 20% of patients with large vessel occlusion still developed MBE despite successful recanalization ( 7 , 8 ).…”

Section: Introductionmentioning

confidence: 99%

Association Between Post-procedure Cerebral Blood Flow Velocity and Severity of Brain Edema in Acute Ischemic Stroke With Early Endovascular Therapy

Pan

et al. 2022

Front. Neurol.

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ObjectivesWe aimed to investigate the association between post-procedure cerebral blood flow velocity (CBFV) and severity of brain edema in patients with acute ischemic stroke (AIS) who received early endovascular therapy (EVT).MethodsWe retrospectively included patients with AIS who received EVT within 24 h of onset between February 2016 and November 2021. Post-procedure CBFV of the middle cerebral artery was measured in the affected and the contralateral hemispheres using transcranial Doppler ultrasound. The severity of brain edema was measured using the three-level cerebral edema grading from the Safe Implementation of Thrombolysis in Stroke-Monitoring Study, with grades 2–3 indicating severe brain edema. The Association between CBFV parameters and severity of brain edema was analyzed.ResultsA total of 101 patients (mean age 64.2 years, 65.3% male) were included, of whom 56.3% (57/101) suffered brain edema [grade 1, 23 (22.8%); grade 2, 10 (9.9%); and grade 3, 24 (23.8%)]. Compared to patients with non-severe brain edema, patients with severe brain edema had lower affected/contralateral ratios of systolic CBFV (median 1 vs. 1.2, P = 0.020) and mean CBFV (median 0.9 vs. 1.3, P = 0.029). Multivariate logistic regression showed that severe brain edema was independently associated with affected/contralateral ratios of systolic CBFV [odds ratio (OR) = 0.289, 95% confidence interval (CI): 0.069–0.861, P = 0.028] and mean CBFV (OR = 0.278, 95% CI: 0.084–0.914, P = 0.035) after adjusting for potential confounders.ConclusionPost-procedure affected/contralateral ratio of CBFV may be a promising predictor of brain edema severity in patients with AIS who received early EVT.

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Inverse National Trends in Decompressive Craniectomy versus Endovascular Thrombectomy for Stroke

Cited by 13 publications

References 24 publications

Risk profile of decompressive hemicraniectomy for malignant stroke after revascularization treatment

Risk profile of decompressive hemicraniectomy for malignant stroke after revascularization treatment

Trends in mechanical thrombectomy and decompressive hemicraniectomy for stroke: A multicenter study

Association Between Post-procedure Cerebral Blood Flow Velocity and Severity of Brain Edema in Acute Ischemic Stroke With Early Endovascular Therapy

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