Decompressive Hemicraniectomy in Elderly Patients With Space-Occupying Infarction (DECAP): A Prospective Observational Study.

Abstract

Decompressive hemicraniectomy improves survival rates and functional outcome in patients with space-occupying middle cerebral artery (MCA) infarction. We sought to determine clinical outcomes in elderly patients with MCA infarction treated with hemicraniectomy and to identify factors associated with functional outcome. We performed a prospective, single-center observational study aiming to include patients aged ≥ 61years with large MCA infarction treated with hemicraniectomy. The primary endpoint was the functional outcome according to modified Rankin Scale (mRS) score at 6months after hemicraniectomy. Secondary endpoints included outcome measures at 12months. A pooled analysis of individual patient data from the single-center cohort and a DESTINY 2 trial subgroup was performed to identify factors associated with functional status at 12months. We included 40 MCA infarction patients who underwent hemicraniectomy between 2012 and 2017 at our university hospital (median [IQR] patient age 64 [62-67] years, National Institutes of Health Stroke Scale score 17 [16-21]). The dominant hemisphere was affected in 22/40 patients. Hemicraniectomy was performed within 31 [23-53] h of symptom onset. At 6months after hemicraniectomy, 6/40 patients (15%) were moderately or moderately severely disabled (mRS score 3 or 4), 19 (47.5%) severely disabled (mRS score 5), and 15 (37.5%) had died. Compared to surgically treated DESTINY 2 patients, the single-center patients less likely exhibited favorable functional outcome at 6months (mRS scores 0-4; odds ratio 0.239 [95% CI 0.082-0.696]). Case-fatality rate at 12months was 43%. In a pooled analysis including 79 patients from DECAP and DESTINY 2, no significant associations of baseline and treatment factors with the clinical status at 12months were observed. In this single-center cohort of elderly patients with space-occupying MCA infarction and decompressive hemicraniectomy, the probability for survival without severe disability was low. Lethality at 6 and 12months was comparable to previously reported data from a randomized trial.