Abstract W P228: Delayed Decompression Hemicraniectomy in Massive Hemispheric Infarction Reduces Mortality but Does Not Improve Functional Outcome

Abstract

Background: Massive hemispheric infarctions associated with extensive cerebral edema are associated with grave prognosis. Decompressive hemicraniectomy improves outcomes if performed within 48-hours of stroke-onset. In Asia, surgical decompression is often performed late, often after significant clinic-radiological deterioration occurs. We report our experience with decompressive hemicraniectomy when performed after clinical deterioration, radiologolic herniation or pupil dilatation. Methods: In this retrospective review, we identified acute anterior circulation ischemic stroke patients who underwent ‘delayed’ decompressive hemicraniectomy at our tertiary institution during 2006-2012. We defined ‘delayed’ surgical intervention as the decompressive hemicraniectomy performed after rapid neurological deterioration (drop of 2 or more points on the Glasgow Coma Scale), evidence of cerebral herniation on clinical and/or neuroimaging criteria. Poor functional outcomes were assessed by modified Rankin score 4-6 points at 90 days. Results: A total of 54 patients (11males, mean age 56 years; range 26-77 years) were included in this study, 36 (67%) male. Mean NIHSS at the time of hospital admission was 21 points (range 12-29). All patient developed clinical deterioration, pupil dilatation and/or radiological signs of cerebral herniation before decompressive surgery. Median time elapsed between stroke onset and surgery was 50.5 hours (range 11-144). Poor functional outcomes were noted in 40 (74%) with mortality in 16 (30%). Univariate analysis revealed higher age, late time to surgery, pupil dilatation and rapid neurological deterioration before surgery associated with poor outcomes. However logistic regression revealed only delayed hemicraniectomy (OR 1.153 per hour increase; 95% confidence interval 1.036-1.283, p=0.009) as the independent predictor of poor functional outcome. Conclusions: Although delayed decompressive hemicraniectomy in massive hemispheric ischemic stroke reduces mortality, it results in poor functional outcomes. Our results support early surgical intervention, independent of clinical deterioration or radiological herniation for reducing disabilities and the burden on the families.