Decompressive Craniectomy in Malignant Stroke After Hemorrhagic Transformation.

Abstract

HomeStrokeVol. 52, No. 8Decompressive Craniectomy in Malignant Stroke After Hemorrhagic Transformation Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessLetterPDF/EPUBDecompressive Craniectomy in Malignant Stroke After Hemorrhagic Transformation Silvia Hernández-Durán, MD Dorothee Mielke, MD, MBA Veit Rohde, MD Christian von der BrelieMD Silvia Hernández-DuránSilvia Hernández-Durán Correspondence to: Silvia Hernández-Durán, MD, Department of Neurological Surgery, Universitätsmedizin Göttingen, Robert-Koch-Straße 40, 37075 Göttingen, Germany. Email E-mail Address: [email protected] https://orcid.org/0000-0003-0959-8697 Department of Neurological Surgery, Universitätsmedizin Göttingen, Germany. Search for more papers by this author , Dorothee MielkeDorothee Mielke https://orcid.org/0000-0002-1462-4864 Department of Neurological Surgery, Universitätsmedizin Göttingen, Germany. Search for more papers by this author , Veit RohdeVeit Rohde Department of Neurological Surgery, Universitätsmedizin Göttingen, Germany. Search for more papers by this author , and Christian von der BrelieChristian von der Brelie Department of Neurological Surgery, Universitätsmedizin Göttingen, Germany. Search for more papers by this author Originally published25 Jun 2021https://doi.org/10.1161/STROKEAHA.121.035072Stroke. 2021;52:e486–e487While the role of decompressive craniectomy (DC) for malignant cerebral infarction (MCI) has been validated in randomized controlled trials, no studies have systematically assessed its effect on patients with hemorrhagic transformation (HT) of their ischemic insults. In this study, we aim to elucidate whether DC can achieve mortality reduction in MCI with HT.MethodsWe conducted a monocentric retrospective analysis of DC for MCI from 2011 to 2019, identifying patients with preoperative HT and matching them to patients without HT based on established prognostic characteristics (Data Supplement). Internal review board approval was obtained, requirement of patient informed consent waived, all in accordance with the 1964 Declaration of Helsinki. The data that support the findings of this study are available from the corresponding author upon reasonable request. HT was objectivized with the Heidelberg Bleeding Classification.1 Primary end point was in-house mortality. Secondary end point was modified Rankin Scale at discharge. Results are reported in odds ratios with 95% CIs and significance assumed at P<0.05. Statistics were performed with IBM SPSS v. 21.ResultsA total of 111 patients were screened; 35 (32%) had HT before DC. Baseline characteristics of HT and non-HT cohorts are summarized in Table I in the Data Supplement. HT occurred mostly after thrombectomy (19; 54%); 11 (31%) patients had initial, spontaneous HT and 5 (14%) after thrombolysis. Patients with HT had a statistically significant higher mortality than their non-HT counterparts (odds ratio, 3.2 [95% CI, 1.8–6.0]; P=0.024). Heidelberg Bleeding Class ≥2 was predictive of mortality (odds ratio, 4.1 [95% CI, 1.0–16.6]; P<0.001; Figure).Download figureDownload PowerPointFigure. Outcome, as objectivized by the modified Rankin Scale, in patients with and without hemorrhagic transformation of their malignant stroke. A, Entire cohort. B, Hemorrhagic transformation stratified according to the Heidelberg classification.DiscussionThis is the only study assessing the effect of preoperative HT on mortality and outcome in a cohort of MCI with DC in a matched cohort analysis. HT is not an infrequent complication of ischemic stroke, with an incidence of up to 68%.2 Both the DECIMAL (The Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarction) and DESTINY (Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery) trials excluded patients with HT, leaving an important gap in surgical decision-making and patient counseling when indicating DC in MCI with HT. In line with our results, Fatima et al3 noted that the absence of HT was associated with improved functional outcome in a study of radiological outcome predictors in MCI after DC. Research on spontaneous intracerebral hemorrhage suggests a potential benefit from DC in space-occupying intracerebral hemorrhage.4 Al-Jehani et al5 reported on 13 patients who developed HT after DC for their MCI and found no statistically significant difference in outcome or mortality in patients with HT post-DC versus no HT post-DC. These contradictory results point to differing pathophysiologies underlying these three clinical entities.SummaryOur study suggests that DC in MCI with HT, particularly in HT class ≥2, is associated with worse outcome and higher mortality. While further studies are needed to confirm these preliminary findings, we advise caution when indicating DC in MCI with HT, with best supportive care being a valid alternative based on the current evidence.AcknowledgmentsWe thank Leonie Meinen for her support in data acquisition.Sources of FundingNone.Supplemental MaterialsExpanded Materials and MethodsOnline Table IDisclosures Dr Rohde receives unrelated personal fees from Aesculap and Storz. The other authors report no conflicts.FootnotesThe Data Supplement is available with this article at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.121.035072.For Sources of Funding and Disclosures, see page e487.Correspondence to: Silvia Hernández-Durán, MD, Department of Neurological Surgery, Universitätsmedizin Göttingen, Robert-Koch-Straße 40, 37075 Göttingen, Germany. Email silvia.[email protected]uni-goettingen.de