Decompressive Hemicraniectomy Research Articles

Cerebral Edema Monitoring and Management Strategies: Results from an International Practice Survey.

Cerebral edema is a common, potentially life-threatening complication in critically ill patients with acute brain injury. However, uncertainty remains regarding best monitoring and treatment strategies, which may result in wide practice variations. A 20-question digital survey on monitoring and management practices was disseminated between July 2022 and May 2023 to clinicians who manage cerebral edema. The survey was promoted through email, social media, medical conferences, and the Neurocritical Care Society Web site. We used the χ2 test, Fisher's exact test, analysis of variance, and logistic regression to report factors associated with practice variation, diagnostic monitoring methods, and therapeutic triggers based on practitioner and institutional characteristics. Of 321 participants from 160 institutions in 30 countries, 65% were from university-affiliated centers, 74% were attending physicians, 38% were woman, 38% had neurology training, and 55% were US-based. Eighty-four percent observed practice variations at their institutions, with "provider preference" being cited most (87%). Factors linked to variation included gender, experience, university affiliation, and practicing outside the United States. University affiliates tended to use more tests (median 3.87 vs. 3.43, p = 0.01) to monitor cerebral edema. Regarding management practices, 20% of respondents' preferred timing for decompressive hemicraniectomy was after 48h, and 37% stated that radiographic findings only would be sufficient to trigger surgery. Fifty percent of respondents reported initiating osmotic therapy based on radiographic indications or prophylactically. There were no significant associations between management strategies and respondent or center characteristics. Twenty-seven percent of respondents indicated that they acquired neuroimaging at intervals of 24h or less. Within this group, attending physicians were more likely to follow this practice (65.5% vs. 34.5%, p = 0.04). Cerebral edema monitoring and management strategies vary. Features associated with practice variations include both practitioner and institutional characteristics. We provide a foundation for understanding practice patterns that is crucial for informing educational initiatives, standardizing guidelines, and conducting future trials.

Decompressive Hemicraniectomy without Evacuation of Acute Intraparenchymal Hemorrhage

Decompressive Hemicraniectomy without Evacuation of Acute Intraparenchymal Hemorrhage

The Silent Threat: Unraveling the Rare Catastrophic Complication after Elective Cranioplasty

AbstractAlthough cranioplasty seems to be a simple procedure, fatal complication of development of diffuse severe cerebral edema following cranioplasty although unusual have been reported in a few cases. The mechanism for this occurrence is still speculative. A 38-year-old male patient presented with a history of having undergone left decompressive hemicraniectomy following a road traffic accident with traumatic left intracranial internal carotid artery dissection leading to anterior cerebral artery and middle cerebral artery territory infarct and endovascular embolization of traumatic type 1 left caroticocavernous fistula. The preoperative computed tomography scan of the brain revealed left frontotemperoparietal craniectomy defect with sunken flap and diffuse encephalomalacia with gliosis of the entire left cerebral hemisphere. Immediately following an uneventful cranioplasty surgery with titanium mesh, the patient developed severe hypotension and dilated fixed pupils. Postoperative imaging revealed diffuse severe cerebral edema in bilateral hemispheres with a significant midline shift toward the ipsilateral (left) side, that is, toward the side of cranioplasty. The patient immediately underwent removal of the titanium mesh, and despite all efforts, the patient had a fatal outcome on postoperative day 5. Although this type of fatal complication of diffuse severe cerebral edema is rare in postcranioplasty patients, neurosurgeons must be aware of this complication and close monitoring postprocedure is important, especially in patients with a large craniectomy defect and sunken skin flap.

Association of Dynamic Trajectories of Time-Series Data and Life-Threatening Mass Effect in Large Middle Cerebral Artery Stroke.

Life-threatening, space-occupying mass effect due to cerebral edema and/or hemorrhagic transformation is an early complication of patients with middle cerebral artery stroke. Little is known about longitudinal trajectories of laboratory and vital signs leading up to radiographic and clinical deterioration related to this mass effect. We curated a retrospective data set of 635 patients with large middle cerebral artery stroke totaling 95,463 data points for 10 longitudinal covariates and 40 time-independent covariates. We assessed trajectories of the 10 longitudinal variables during the 72h preceding three outcomes representative of life-threatening mass effect: midline shift ≥ 5mm, pineal gland shift (PGS) > 4mm, and decompressive hemicraniectomy (DHC). We used a "backward-looking" trajectory approach. Patients were aligned based on outcome occurrence time and the trajectory of each variable was assessed before that outcome by accounting for cases and noncases, adjusting for confounders. We evaluated longitudinal trajectories with Cox proportional time-dependent regression. Of 635 patients, 49.0% were female, and the mean age was 69years. Thirty five percent of patients had midline shift ≥ 5mm, 24.3% of patients had PGS > 4mm, and 10.7% of patients underwent DHC. Backward-looking trajectories showed mild increases in white blood cell count (10-11K/UL within 72h), temperature (up to half a degree within 24h), and sodium levels (1-3mEq/L within 24h) before the three outcomes of interest. We also observed a decrease in heart rate (75-65 beats per minute) 24h before DHC. We found a significant association between increased white blood cell count with PGS > 4mm (hazard ratio 1.05, p value 0.007). Longitudinal profiling adjusted for confounders demonstrated that white blood cell count, temperature, and sodium levels appear to increase before radiographic and clinical indicators of space-occupying mass effect. These findings will inform the development of multivariable dynamic risk models to aid prediction of life-threatening, space-occupying mass effect.

Duration of spreading depression is the electrophysiological correlate of infarct growth in malignant hemispheric stroke.

Spreading depolarizations (SD) contribute to lesion progression after experimental focal cerebral ischemia while such correlation has never been shown in stroke patients. In this prospective, diagnostic study, we investigate the association of SDs and secondary infarct progression after malignant hemispheric stroke. SDs were continuously monitored for 3-9 days with electrocorticography after decompressive hemicraniectomy for malignant hemispheric stroke. To ensure valid detection and analysis of SDs, a threshold based on the electrocorticographic baseline activity was calculated to identify valid electrocorticographic recordings. Subsequently SD characteristics were analyzed in association to infarct progression based on serial MRI. Overall, 62 patients with a mean stroke volume of 289.6 ± 68 cm3 were included. Valid electrocorticographic recordings were found in 44/62 patients with a mean recording duration of 139.6 ± 26.5 hours and 52.5 ± 39.5 SDs per patient. Infarct progression of more than 5% was found in 21/44 patients. While the number of SDs was similar between patients with and without infarct progression, the SD-induced depression duration per day was significantly longer in patients with infarct progression (593.8 vs. 314.1 minutes; *p = 0.046). Therefore, infarct progression is associated with a prolonged SD-induced depression duration. Real-time analysis of electrocorticographic recordings may identify secondary stroke progression and help implementing targeted management strategies.

Influence of cerebrospinal fluid drainage in the first days after aneurysm rupture on the severity of early brain injury following aneurysmal subarachnoid hemorrhage

PurposeProgressive cerebral edema with refractory intracranial hypertension (ICP) requiring decompressive hemicraniectomy (DHC) is a severe manifestation of early brain injury (EBI) after aneurysmal subarachnoid hemorrhage (aSAH). The purpose of the study was to investigate whether a more pronounced cerebrospinal fluid (CSF) drainage has an influence on cerebral perfusion pressure (CPP) and the extent of EBI after aSAH.MethodsPatients with aSAH and indication for ICP-monitoring admitted to our center between 2012 and 2020 were retrospectively included. EBI was categorized based on intracranial blood burden, persistent loss of consciousness, and SEBES (Subarachnoid Hemorrhage Early Brain Edema Score) score on the third day after ictus. The draining CSF and vital signs such as ICP and CPP were documented daily.Results90 out of 324 eligible aSAH patients (28%) were included. The mean age was 54.2 ± 11.9 years. DHC was performed in 24% (22/90) of patients. Mean CSF drainage within 72 h after ictus was 168.5 ± 78.5 ml. A higher CSF drainage within 72 h after ictus correlated with a less severe EBI and a less frequent need for DHC (r=-0.33, p = 0.001) and with a higher mean CPP on day 3 after ictus (r = 0.2351, p = 0.02).ConclusionA more pronounced CSF drainage in the first 3 days of aSAH was associated with higher CPP and a less severe course of EBI and required less frequently a DHC. These results support the hypothesis that an early and pronounced CSF drainage may facilitate blood clearance and positively influence the course of EBI.

Treatment for intracerebral hemorrhage: Dawn of a new era.

Intracerebral hemorrhage (ICH) is a devastating disease, causing high rates of death, disability, and suffering across the world. For decades, its treatment has been shrouded by the lack of reliable evidence, and consequently, the presumption that an effective treatment is unlikely to be found. Neutral results arising from several major randomized controlled trials had established a negative spirit within and outside the stroke community. Frustration among researchers and a sense of nihilism in clinicians has created the general perception that patients presenting with ICH have a poor prognosis irrespective of them receiving any form of active management. All this changed in 2023 with the positive results on the primary outcome in randomized controlled trials showing treatment benefits for a hyperacute care bundle approach (INTERACT3), early minimal invasive hematoma evacuation (ENRICH), and use of factor Xa-inhibitor anticoagulation reversal with andexanet alfa (ANNEXa-I). These advances have now been extended in 2024 by confirmation that intensive blood pressure lowering initiated within the first few hours of the onset of symptoms can substantially improve outcome in ICH (INTERACT4) and that decompressive hemicraniectomy is a viable treatment strategy in patients with large deep ICH (SWITCH). This evidence will spearhead a change in the perception of ICH, to revolutionize the care of these patients to ultimately improve their outcomes. We review these and other recent developments in the hyperacute management of ICH. We summarize the results of randomized controlled trials and discuss related original research papers published in this issue of the International Journal of Stroke. These exciting advances demonstrate how we are now at the dawn of a new, exciting, and brighter era of ICH management.

Association of large core middle cerebral artery stroke and hemorrhagic transformation with hospitalization outcomes.

Historically, investigators have not differentiated between patients with and without hemorrhagic transformation (HT) in large core ischemic stroke at risk for life-threatening mass effect (LTME) from cerebral edema. Our objective was to determine whether LTME occurs faster in those with HT compared to those without. We conducted a two-center retrospective study of patients with ≥ 1/2 MCA territory infarct between 2006 and 2021. We tested the association of time-to-LTME and HT subtype (parenchymal, petechial) using Cox regression, controlling for age, mean arterial pressure, glucose, tissue plasminogen activator, mechanical thrombectomy, National Institute of Health Stroke Scale, antiplatelets, anticoagulation, temperature, and stroke side. Secondary and exploratory outcomes included mass effect-related death, all-cause death, disposition, and decompressive hemicraniectomy. Of 840 patients, 358 (42.6%) had no HT, 403 (48.0%) patients had petechial HT, and 79 (9.4%) patients had parenchymal HT. LTME occurred in 317 (37.7%) and 100 (11.9%) had mass effect-related deaths. Parenchymal (HR 8.24, 95% CI 5.46-12.42, p < 0.01) and petechial HT (HR 2.47, 95% CI 1.92-3.17, p < 0.01) were significantly associated with time-to-LTME and mass effect-related death. Understanding different risk factors and sequelae of mass effect with and without HT is critical for informed clinical decisions.

124 Craniotomy Versus Craniectomy for Traumatic Acute Subdural Hematoma Coarsened Exact Matched Analysis of Outcomes

INTRODUCTION: Previous studies comparing craniotomy (CO) versus decompressive hemicraniectomy (DC) for acute subdural hematoma (aSDH) evacuation after traumatic brain injury have not found significant association between surgical approach and patient outcome. We hoped to provide a more granular and real-world assessment of outcomes. METHODS: One hundred thirty-eight patients underwent CO (N = 76) or DC (N = 62) for traumatic aSDH. DC patients were on average 21.4 years younger (P &lt; 0.001), more likely to be male (80.6% vs 60.5%, P = 0.011), and present with GCS = 8 (64.5% vs 36.8%, P = 0.001). Age (P &lt; 0.001), EDH (P = 0.01), skull fracture (P = 0.001), and cisternal effacement (P = 0.02) were independently associated with surgical approach. After coarsened exact matching, DC (P = 0.008), older age (P = 0.007), male sex (P = 0.04), and IVH (P = 0.02), were independently associated with inpatient mortality. Multivariate Cox proportional-hazards regression demonstrated that DC was independently associated with mortality at 90-days (P = 0.001) and 1-year post-operation (P = 0.003) for matched patients. RESULTS: One hundred thirty-eight patients underwent CO (N = 76) or DC (N = 62) for traumatic aSDH. DC patients were on average 21.4 years younger (P &lt; 0.001), more likely to be male (80.6% vs 60.5%, P = 0.011), and present with GCS = 8 (64.5% vs 36.8%, P = 0.001). Age (P &lt; 0.001), EDH (P = 0.01), skull fracture (P = 0.001), and cisternal effacement (P = 0.02) were independently associated with surgical approach. After coarsened exact matching, DC (P = 0.008), older age (P = 0.007), male sex (P = 0.04), and IVH (P = 0.02), were independently associated with inpatient mortality. Multivariate Cox proportional-hazards regression demonstrated that DC was independently associated with mortality at 90-days (P = 0.001) and 1-year post-operation (P = 0.003) for matched patients. CONCLUSIONS: aSDH patients who receive surgical evacuation via DC as opposed to CO are younger, more likely to be male, and have worse clinical exam. After controlling for patient differences via coarsened exact matching, DC is an independent predictor of mortality at discharge, as well as at 90-days and 1-year after surgery.

701 A Modified Frailty Index to Predict Adverse Outcomes After Decompressive Hemicraniectomy for Acute Ischemic Stroke

INTRODUCTION: Surgical decision-making for decompressive hemicraniectomy (DHC) is challenging because of the heterogeneity of health status and the paucity of tools for predicting the operative risk of DHC for malignant edema following acute infarction. METHODS: The 2008–2018 National Surgical Quality Improvement Program (NSQIP) data set was accessed for patients undergoing DHC for Acute ischemic stroke (AIS) based on Current Procedural Terminology (CPT) codes. We used a modified frailty index (mFI) based on eleven preoperative clinical NSQIP variables. The outcomes assessed were 30-day occurrences of adverse events. RESULTS: A total of 394 patients were identified in the database, there were 55 (14%) patients with mFI 0, 118 patients (30%) with mFI 0.09, 115(29.2 %) with mFI 0.18 and 106 (27%) patients with mFI = 0.27. The rate of return to the operating room for a second procedure significantly increased from 4/55 (7.3%) in patients with mFI 0 to 23/106 (31.1%) in patients with mFI = 0.27. The discharge disposition was significantly different in patients with higher mFI (mFI &gt; 0.27), with only 6/106 (5.7%) discharged to home versus 8/55 (14.5%) with mFI 0. Multivariate logistic regression analysis showed that compared to age, gender, ASA class, and pre albumin levels, mFI was a better predictor of the development of pneumonia (OR 6.278, 95 % CI 1.8, 22.0, p = 0.004) and return to the operating room (OR 4.0, 95 % CI 1.2 ,13.4, p = 0.02). CONCLUSIONS: A higher mFI was associated with an increased risk of return to the operating room and worse discharge disposition. The mFI is based on easily identifiable patient characteristics and can be an additional tool to improve perioperative risk stratification in elderly patients considered for DHC after AIS.

253 Tissue Partial Pressure of Oxygen During Spreading Depolarization in Malignant Stroke is Associated With Outcome

INTRODUCTION: Spreading depolarization (SD) describes a propagating neuronal mass depolarization within the cerebral cortex that likely represents a relevant mechanism of secondary lesion progression. METHODS: This prospective observational study included 25 patients with MHS that underwent decompressive hemicraniectomy (DC) followed by subdural placement of an electrocorticography (ECoG) strip electrode and cortical implantation of a PtiO2 probe within in the periinfarct tissue. Continuous ECoG and PtiO2 recordings were obtained at bedside for five days and analyzed for the occurrence of SD and SD-associated PtiO2 changes, as well as their association with clinical outcome at 6 months. RESULTS: The overall simultaneous ECoG and PtiO2 recording time was 2603 hours, during which 796 SDs were detected. The overall SD duration and SD frequency did not correlate with outcome. During the observation period, the overall PtiO2baseline changed significantly with an almost linear increase that reached a peak around 100 hours (*p=0.0055), followed by a PtiO2 drop until the end of the monitoring period (*p = 0.0048). Accordingly, low baseline PtiO2 (&lt;15 mmHg) was mainly noted during the first 24 hours but did not correlate with outcome (p = 0.916). Conversely, 20 out of 25 patients showed SD-associated PtiO2 changes in 363 out of 796 SDs (45.6%), which were categorized as biphasic (222), hypoxic (119) and hyperoxic (22). Among these SD-associated PtiO2 responses, a high occurrence rate, biphasic response pattern and high amplitude correlated significantly with favorable outcome (mRS 1-3) at 6 months. CONCLUSIONS: SD-associated PtiO2 coupling in patients suffering hemispheric stroke appears to be associated with clinical outcome and could reflect the presence of viable and metabolically less impaired peri-infarct tissue.

A 24-Hour Shift in the Neurosurgeon's World : Decompressive Hemicraniectomy during the Night.

A 24-Hour Shift in the Neurosurgeon's World : Decompressive Hemicraniectomy during the Night.

Letter to editor: Exploring complications following cranioplasty after decompressive hemicraniectomy: A retrospective bicenter assessment of autologous, PMMA and CAD implants.

This study presents a critical analysis of complications following cranioplasty (CP) after decompressive hemicraniectomy, focusing on autologous, polymethylmethacrylate (PMMA), and computer-aided design (CAD) implants. The analysis encompasses a retrospective bicenter assessment, evaluating factors influencing surgical outcomes and emphasizing the significance of material selection in minimizing postoperative complications. The study's comprehensive examination of complication rates associated with various implant materials contributes significantly to understanding CP outcomes. While polymethylmethacrylate (PMMA) and autologous bone flaps (ABFs) exhibited higher rates of surgical site infection (SSI) and explantation, a meta-analysis revealed a contrasting lower infection rate for polyether ether ketone (PEEK) implants. The study underscores the critical role of material selection in mitigating postoperative complications. Despite its strengths, the study's retrospective design, reliance on data from two centers, and limited sample size pose limitations. Future research should prioritize prospective, multicenter studies with standardized protocols to enhance diagnostic accuracy and treatment efficacy in CP procedures.

Scalp incision technique for decompressive hemicraniectomy: comparative systematic review and meta-analysis of the reverse question mark versus alternative retroauricular and Kempe incision techniques

Decompressive hemicraniectomy (DHC) is a critical procedure used to alleviate elevated intracranial pressure (ICP) in emergent situations. It is typically performed to create space for the swelling brain and to prevent dangerous and potentially fatal increases in ICP. DHC is indicated for pathologies ranging from MCA stroke to traumatic subarachnoid hemorrhage—essentially any cause of refractory brain swelling and elevated ICPs. Scalp incisions for opening and closing the soft tissues during DHC are crucial to achieve optimal outcomes by promoting proper wound healing and minimizing surgical site infections (SSIs). Though the reverse question mark (RQM) scalp incision has gained significant traction within neurosurgical practice, alternatives—including the retroauricular (RA) and Kempe incisions—have been proposed. As choice of technique can impact postoperative outcomes and complications, we sought to compare outcomes associated with different scalp incision techniques used during DHC. We queried three databases according to PRISMA guidelines in order to identify studies comparing outcomes between the RQM versus “alternative” scalp incision techniques for DHC. Our primary outcome of interest in the present study was postoperative wound infection rates according to scalp incision type. Secondary outcomes included estimated blood loss (EBL) and operative duration. We identified seven studies eligible for inclusion in the formal meta-analysis. The traditional RQM technique shortened operative times by 36.56 min, on average. Additionally, mean EBL was significantly lower when the RQM scalp incision was used. Postoperatively, there was no significant association between DHC incision type and mean intensive care unit (ICU) length of stay (LOS), nor was there a significant difference in predisposition to developing wound complications or infections between the RQM and retroauricular/Kempe incision cohorts. Superficial temporal artery (STA) preservation and reoperation rates were collected but could not be analyzed due to insufficient number of studies reporting these outcomes. Our meta-analysis suggests that there is no significant difference between scalp incision techniques as they relate to surgical site infection and wound complications. At present, it appears that outcomes following DHC can be improved by ensuring that the bone flap is large enough to enable sufficient cerebral expansion and decompression of the temporal lobe, the latter of which is of particular importance. Although previous studies have suggested that there are several advantages to performing alternative scalp incision techniques during DHC, the present study (which is to our knowledge the first to meta-analyze the literature on outcomes in DHC by scalp incision type) does not support these findings. As such, further investigations in the form of prospective trials with high statistical power are merited.

No Harmful Effect of Endovascular Treatment before Decompressive Surgery—Implications for Handling Patients with Space-Occupying Brain Infarction

This study explored short- and mid-term functional outcomes in patients undergoing decompressive hemicraniectomy (DHC) due to space-occupying cerebral infarction and asked whether there is a potentially harmful effect of a priorly performed endovascular treatment (EVT). Medical records were screened for patients requiring DHC due to space-occupying cerebral infarction between January 2016 and July 2021. Functional outcomes at hospital discharge and at 3 months were assessed by the modified Rankin Scale (mRS). Out of 65 patients with DHC, 39 underwent EVT before DHC. Both groups, i.e., EVT + DHC and DHC alone, had similar volumes (280 ± 90 mL vs. 269 ± 73 mL, t-test, p = 0.633) and proportions of edema and infarction (22.1 ± 6.5% vs. 22.1 ± 6.1%, t-test, p = 0.989) before the surgical intervention. Patients undergoing EVT + DHC tended to have a better functional outcome at hospital discharge compared to DHC alone (mRS 4.8 ± 0.8 vs. 5.2 ± 0.7, Mann–Whitney-U, p = 0.061), while the functional outcome after 3 months was similar (mRS 4.6 ± 1.1 vs. 4.8 ± 0.9, Mann–Whitney-U, p = 0.352). In patients initially presenting with a relevant infarct demarcation (Alberta Stroke Program Early CT Score ≤ 5), the outcome was similar at hospital discharge and after 3 months between patients with EVT + DHC and DHC alone. This study provided no evidence for a harmful effect of EVT before DHC in patients with space-occupying brain infarction.

Abstract 155: Critical Care Decisions After Large Core Cerebral Infarctions: A Secondary Analysis From the SELECT2 Trial

Background/hypothesis: The SELECT2 trial randomly assigned patients with LVO and large ischemic cores to either endovascular thrombectomy (EVT) or medical management (MM). This population is at high risk for cerebral edema and other complications, often leading to critical decisions about decompressive hemicraniectomy (DHC) or early withdrawal of care (WOC). We hypothesized that patients initially treated with EVT were more likely to get life-sustaining care regardless of recanalization success, presumably because initial treatment with EVT led toward an expectation of aggressive care, while those treated with MM expected futility. Methods: We analyzed the full SELECT2 study population using the as-treated principle, comparing the use of DHC and early (within 7 days from randomization) transition to comfort measures/WOC. We also compared these decisions based on recanalization success in those receiving EVT. We further tested baseline characteristics for association with these outcomes. Results: Patients treated with EVT were as likely to undergo DHC (aRR:1.19 [0.75-1.88], p=0.46) or WOC (aRR:0.94 [0.66-1.34], p=0.72) as those given MM (Table). Time to DHC was also similar (EVT 47[19-74] vs. MM 36[27-61] hours, p=0.95). Patients with successful (mTICI≥2b) recanalization were numerically less likely to undergo DHC than those with unsuccessful (TICI 0-2a) recanalization (aRR:0.66 [0.33-1.3], p=0.23), while WOC was similar (Table). Larger estimated core volumes were associated with both DHC and WOC, with DHC used more in younger and WOC more in older patients. Conclusions: In the SELECT2 trial of patients with large infarct cores, DHC was performed in ~1 in 6 and WOC in ~1 in 5, without an observed difference based on treatment with EVT or MM. The similar distribution of decisions to proceed with DHC or to change goals of care to acute palliative measures provides reassurance that the overall trial outcomes were not biased by open-label treatment allocation.

Abstract TP198: Factors Associated With Need for Decompressive Hemicraniectomy After Mechanical Thrombectomy in Stroke Patients

Background: Mechanical thrombectomy (MT) has significantly reduced morbidity and mortality in acute ischemic stroke (AIS). This study aims to analyze the outcomes and factors associated with decompressive hemicraniectomy (DHC) in AIS patients who underwent MT. Methods: We retrospectively analyzed data from an ongoing, multicenter database to investigate AIS patients who underwent MT for ICA, M1, or M2 occlusion. We compared clinical and procedural variables between patients who underwent DHC and those who did not. Propensity score (PS) matching between the two groups was conducted using age, sex, admission NIHSS, occluded vessel, ASPECTS, time from symptoms onset to arterial puncture, intracranial hemorrhage (ICH), and symptomatic ICH (sICH). Results: Among the 3,135 MT patients who met our inclusion criteria, 113 underwent DHC. A 1:3 propensity matching yielded a well-matched cohort of 113 in the DHC group versus 339 in the non-DHC group. The DHC group had a significantly higher rate of successful recanalization (mTICI ≥ 2C) (175 [51.6%] versus 36 [31.9%], P &lt; 0.001) and a longer procedure duration, with a median of 30 minutes (IQR: 17-54) compared to 44 minutes (IQR: 25-78) in the non-DHC group (P = &lt;0.001). Further comparison of patients with low ASPECTS (≤ 5) who underwent DHC (n = 36) with those who did not (n = 99) showed no significant difference in successful recanalization rates (15 [41.7%] versus 43 [43.4%], P &gt; 0.90). However, procedure duration was significantly longer in the DHC group with a median of 29 minutes (IQR: 13-52), compared to 39 minutes (IQR: 27-86) in the non-DHC group (P = 0.02). Conclusions: Successful recanalization can help in preventing DHC in AIS patients with high ASPECTS, but not those with low ASPECTS. Procedure duration is independently related to DHC following MT, especially in low ASPECTS patients.

Abstract HUP17: Outcome Of Decompressive Hemicraniectomy Correlated With Age: An Analysis Of Nationwide Readmission Database (nrd) 2016-2019

Introduction: Decompressive hemicraniectomy (DHC) is recommended in adults 60yrs and younger to improve survival and functional benefits in patients experiencing malignant unilateral MCA stroke with neurological decline after 48 hours. However, the AHA/ASA guidelines are less clear regarding the mortality benefit for elderly patients, and there is a paucity of data on the correlation of age and outcomes after DHC. Objective: To correlate age with mortality and length of stay (LOS) after DHC for malignant unilateral MCA stroke. Methods: Adult patients with unilateral MCA stroke were identified in NRD 2016-2019 using ICD-10 codes. Patients who died in the ED or were transferred were excluded from the analysis. CPT codes were used to identify patients who underwent DHC. Outcomes of interest included age, sex, total LOS, income, and mortality. Results: 285,727 patients undergoing DHC for malignant unilateral MCA stroke were identified, with 52.81% being female. There was disproportionate representation of patients from the bottom two income quartiles (Q1: 28.02%, Q2: 26.73%), representing patients who make &lt;$60,999 annually. The average age was 70.99yrs with 45.57% of patients 60-79yrs and 33.32% 80yrs and older, for a total of 213,907 patients 60yrs and older. Mortality rate for patients undergoing DHC was 10.59% overall. The mortality rate was nearly double in patients 80yrs and older compared to patients 18-39yrs (7.17% vs 13.98%) with a mortality rate of 10.17% for patients 60-79yrs. The average LOS was 9.81 days. Adjusting for patients who died in the hospital, 25.1% of patients 80yrs+ and 33.9% of patients 18-39yrs had a longer than average LOS. Conclusion: Patients undergoing DHC for malignant unilateral MCA stroke were disproportionately elderly patients with poorer survival outcomes than younger adults. Patients 80yrs and older have a higher incidence of mortality than younger patients and are nearly twice as likely to die after DHC than adult patients 39yrs or younger. Average LOS decreased with increased age adjusted for patients who died in hospital. Future research should focus on factors affecting mortality rate in older adults undergoing DHC.

Abstract TMP62: The Delayed Seizure CVT Score Predicts Delayed Seizure After Cerebral Venous Thrombosis - A Secondary Analysis of ACTION-CVT

Introduction: Seizures are a common initial manifestation of cerebral venous thrombosis (CVT). We sought to establish predictive factors for delayed seizures to stratify risk and guide clinical management. Methods: We analyzed data from the Direct Oral Anticoagulants Versus Warfarin in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT) study of consecutive patients with CVT from 2015 - 2020. The primary outcome was delayed seizure(s), occurring after 7 days from CVT diagnosis. Patients with outcome data for late seizures and follow-up of at least 7 days from time of diagnosis were included. Univariate analysis was performed using Chi-square, rank-sum, and t-tests. Variables with P-value &lt; 0.2 were included in the backward stepwise regression model with 0.2 as cutoff, based on which we constructed the Delayed Seizure CVT (Delayed Seizures after CVT) score. Results: We identified 599 patients who met inclusion criteria: mean age 44.9(± 16.6) years, 62.9% female. Delayed seizures occurred in 37 (6.1%) patients. Risk factors included intracranial hemorrhage (OR 2.0 95% CI 0.7-5.74 p=0.196), alcohol abuse (OR 3.88 95% CI 1.45-10.38 p=0.007), focal neurologic deficit (OR 2.05 95% CI 0.95-4.44 p=0.067), seizure on presentation (OR 2.88 95% CI 1.32-6.29 p=0.008), hormonal birth control (OR 2.38 95% CI 1.06-5.37 p=0.0036), endovascular therapy (OR 2.86 95% CI 1.16-7.07 p=0.023) and decompressive hemicraniectomy (OR 3.357 95% CI 1.02-10.99 p=0.046), respectively. Based on coefficients of these variables, a 7-item score was created with acceptable performance for seizure prediction (AUC 0.796, 95% CI 0.72 - 0.86) (Table 1). Conclusions: Delayed seizure CVT score is a clinical tool to identify risk of delayed seizure in CVT. Further research is needed to validate these findings in an external cohort.

Exploring complications following cranioplasty after decompressive hemicraniectomy: A retrospective bicenter assessment of autologous, PMMA and CAD implants

Cranioplasty (CP) after decompressive hemicraniectomy (DHC) is a common neurosurgical procedure with a high complication rate. The best material for the repair of large cranial defects is unclear. The aim of this study was to evaluate different implant materials regarding surgery related complications after CP. Type of materials include the autologous bone flap (ABF), polymethylmethacrylate (PMMA), calcium phosphate reinforced with titanium mesh (CaP-Ti), polyetheretherketone (PEEK) and hydroxyapatite (HA). A retrospective, descriptive, observational bicenter study was performed, medical data of all patients who underwent CP after DHC between January 1st, 2016 and December 31st, 2022 were analyzed. Follow-up was until December 31st, 2023. 139 consecutive patients with a median age of 54 years who received either PMMA (56/139; 40.3%), PEEK (35/139; 25.2%), CaP-Ti (21/139; 15.1%), ABF (25/139; 18.0%) or HA (2/139; 1.4%) cranial implant after DHC were included in the study. Median time from DHC to CP was 117 days and median follow-up period was 43 months. Surgical site infection was the most frequent surgery-related complication (13.7%; 19/139). PEEK implants were mostly affected (28.6%; 10/35), followed by ABF (20%; 5/25), CaP-Ti implants (9.5%; 2/21) and PMMA implants (1.7%, 1/56). Explantation was necessary for 9 PEEK implants (25.7%; 9/35), 6 ABFs (24.0%; 6/25), 3 CaP-Ti implants (14.3%; 3/21) and 4 PMMA implants (7.1%; 4/56). Besides infection, a postoperative hematoma was the most common cause. Median surgical time was 106 min, neither longer surgical time nor use of anticoagulation were significantly related to higher infection rates (p = 0.547; p = 0.152 respectively). Ventriculoperitoneal shunt implantation prior to CP was noted in 33.8% (47/139) and not significantly associated with surgical related complications. Perioperative lumbar drainage, due to bulging brain, inserted in 38 patients (27.3%; 38/139) before surgery was protective when it comes to explantation of the implant (p = 0.035). Based on our results, CP is still related to a relatively high number of infections and further complications. Implant material seems to have a high effect on postoperative infections, since surgical time, anticoagulation therapy and hydrocephalus did not show a statistically significant effect on postoperative complications in this study. PEEK implants and ABFs seem to possess higher risk of postoperative infection. More biocompatible implants such as CaP-Ti might be beneficial. Further, prospective studies are necessary to answer this question.