Decompressive Hemicraniectomy for Stroke in Older Adults: A Review.

William Gormley

doi:10.29245/2572.942x/2017/2.942x/2017/1.1103

Abstract

Malignant cerebral edema is a potential consequence of large territory cerebral infarction, as the resultant elevation in intracranial pressure may progress to transtentorial herniation, brainstem compression, and death. In appropriate patients, decompressive hemicraniectomy (DHC) reduces mortality without increasing the risk of severe disability. However, as the foundational DHC randomized, controlled trials excluded patients greater than 60 years of age, the appropriateness of DHC in older adults remains controversial. Recent clinical trials among elderly participants, including DESTINY II, reported that DHC reduces mortality, but may leave patients with substantial morbidity. Nationwide analyses have demonstrated generalizability of such data. However, what constitutes an acceptable outcome – the perspective on quality of life after survival with substantial disability – varies between clinicians, patients, and caregivers. Consequently, quality of life measures are being increasingly incorporated into stroke research. This review summarizes the impact of DHC in space-occupying cerebral infarction, and the influence of patient age on postoperative survival, functional capacity, and quality of life—all key factors in the clinical decision process. Ultimately, these data underscore the inherent complexity in balancing scientific evidence, clinical expertise, and patient and family preference when pursuing hemicraniectomy among the elderly.

Highlights

Acute ischemic stroke disproportionally affects older individuals[47] and as benefits of procedural interventions for stroke can vary by age[20] it is imperative to understand how medical and surgical expectations change for older patients
We summarize the utility of decompressive hemicraniectomy (DHC), the current understanding of how age influences postoperative survival, functional capacity, and quality of life, and how that data impacts the complex decision analysis in the clinical setting
While the utility of DHC in patients with malignant cerebral edema has been shown in patients

Summary

Introduction

Acute ischemic stroke disproportionally affects older individuals[47] and as benefits of procedural interventions for stroke can vary by age[20] it is imperative to understand how medical and surgical expectations change for older patients. The benefit of surgical intervention was demonstrated in the last decade when three European randomized trials were conducted simultaneously to compare decompressive hemicraniectomy (DHC) to conservative management[17,21,26,37] These trials excluded patients over 60 years of age, leaving to question the appropriateness of DHC for elderly patients. In 2001, an institutional study of patients >55 years old showed that DHC decreased mortality, but all survivors had mRS scores >422. 31.2% (n=16) of DHC patients experienced poor outcome (mRS >4), versus 92.3% (n=13) of individuals allocated to the medical treatment arm. Interpretation of this data is limited by the small sample size and fact that >60% of patients were from a single institution.

Key Findings

Findings

Conclusion