WITHDRAWN: Malignant transformation of ischemic stroke in the era of mechanical thrombectomy: When is decompressive craniectomy required?

Abstract

ObjectiveThe treatment of choice for ischemic stroke due to intracranial arterial occlusion of the anterior circulation has been mechanical thrombectomy (MT). The success rate of MT is described as 71%, but malignant infarction can nonetheless ensue. In these cases, decompressive craniectomy (DHC) is often necessary. To date, only few factors are known to correlate significantly with the need for DHC after MT. MethodsWe conducted a retrospective analysis of patients admitted with anterior circulation stroke at our department who underwent MT with and without subsequent DHC. Patients were matched according to ASPECT score on pre-MT CT scan. Established predictors for neurological outcome, TICI grade of recanalization, as well as imaging were then compared between the groups to elucidate which of them were predictive of DHC. ResultsA total of 86 patients were included in the analysis. DHC was performed in 43 patients (50%). In a univariate analysis, male sex (p = 0.037), lower TICI grade of recanalization (p < 0.001) and hemorrhagic transformation (p = 0.014) were predictive of DHC. Patients who received later intravenous thrombolysis were also at higher risk for needing DHC (p = 0.050). Patients suffering from hypercholesterolemia (p < .001) and who were on antiplatlet agents (p = .039) were at lower risk for needing DHC. ConclusionsPatients with higher rates of recanalization were protected against DHC. Later administration of IV tPA was correlated with DHC, thus suggesting a synergistic effect of IV tPA and MT in protecting against malignant transformation. Prior use of antiplatelet agents appears to be a protective factor against DHC in stroke, which warrants further investigation.