Early Decompressive Hemicraniectomy Research Articles

Early decompressive hemicraniectomy in thrombolyzed acute ischemic stroke patients from the international ENCHANTED trial

Decompressive hemicraniectomy (DHC) can improve outcomes for patients with severe forms of acute ischemic stroke (AIS), but the evidence is mainly derived from non-thrombolyzed patients. We aimed to determine the characteristics and outcomes of early DHC in thrombolyzed AIS participants of the international Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED). Post-hoc analyses of ENCHANTED, an international, partial-factorial, open, blinded outcome-assessed, controlled trial in 4557 thrombolysis-eligible AIS patients randomized to low- versus standard-dose intravenous alteplase (Arm A, n = 2350), intensive versus guideline-recommended blood pressure control (Arm B, n = 1280), or both (Arms A + B, n = 947). Logistic regression models were used to identify baseline variables associated with DHC, with inverse probability of treatment weights employed to eliminate baseline imbalances between those with and without DHC. Logistic regression was also used to determine associations of DHC and clinical outcomes of death/disability, major disability, and death (defined by scores 2–6, 3–5, and 6, respectively, on the modified Rankin scale) at 90 days post-randomization. There were 95 (2.1%) thrombolyzed AIS patients who underwent DHC, who were significantly younger, of non-Asian ethnicity, and more likely to have had prior lipid-lowering treatment and severe neurological impairment from large vessel occlusion than other patients. DHC patients were more likely to receive other management interventions and have poor functional outcomes than non-DHC patients, with no relation to different doses of intravenous alteplase. Compared to other thrombolyzed AIS patients, those who received DHC had a poor prognosis from more severe disease despite intensive in-hospital management.

Volumetric Analysis of Malignant Middle Cerebral Infarction (MMI): Infarction Volume Before Decompressive Hemicraniectomy for MMI is Associated With Poor Consciousness

Objective In patients with malignant middle cerebral infarction (MMI), early decompressive hemicraniectomy (DHC) is well-known to reduce mortality and improve clinical outcome. Nevertheless, its effectiveness in clinical outcomes has only been confirmed by defining outcomes in terms of the modified Rankin scale (mRS), and many studies have already suggested that survival with severe dependency, such as mRS 4 or 5, is not acceptable. However, several other important domains are closely related to quality of life, such as consciousness or cognition, and these are not directly measured in the mRS. Therefore, the present study aimed to identify significant factors associated with poor consciousness, such as minimally conscious state (MCS) or vegetative state (VS) in patients undergoing DHC to treat MMI. Methods Between January 2011 and December 2017, 22 patients who survived from MMI after DHC and had more than 6 months of follow-up were enrolled our study. Clinical outcomes 6 months after DHC were measured, and the patients were divided into two groups based on their level of consciousness. Preserved consciousness was categorized as a favorable outcome, while poor consciousness such as MCS or VS constituted an unfavorable outcome. Clinical and radiological variables using volumetric measurement were analyzed to identify factors that were significantly associated with unfavorable outcome. Results Of the entire cohort, eight patients (36.36%) were placed in the unfavorable outcome (MCS or VS) 6 months after DHC to treat MMI. In univariate and multivariate logistic analysis, only infarction volume in the preoperative CT was a significant independent predictor of unfavorable outcome (odds ratio: 1.021, 95% confidence interval: 1.001–1.042, p = 0.023). Conclusions The present study suggested that defining unfavorable outcome based on level of consciousness to reflect quality of life should be considered. We identified infarction volume as a significant predictor of poor consciousness. Keywords: Decompressive craniectomy; MCA infarction; Outcome; Consciousness; mRS.

Surgical Outcome Following Early Decompressive Hemicraniectomy in Patients of Severe Traumatic Brain Injury: A Retrospective Study

Introduction: Traumatic Brain Injury (TBI) has become an epidemic and remains the leading cause of death and disability in people of 2nd to 4th decade. Road Traffic Accidents (RTA) are responsible for the majority of cases. Primary brain injury sustained on impact and secondary brain injury that develops in following hours and days contribute together to overall injury and decides ultimate outcome. The goal of management in any TBI patient aims to prevent secondary brain injury. Understanding the importance of Intracranial Pressure (ICP) is key to minimise secondary injury. Decompressive hemicraniectomy is a novel technique of reducing ICP in patients of severe brain injury. It’s judicious and timely performance not only saves life but also prevents the dreaded consequences of raised ICP. Aim: To evaluate the role of early decompressive hemicraniectomy in improving the survival rate among patients of severe TBI and analysing the important factors (glasgow coma scale, airway status, timing of surgery) affecting the surgical outcome. Materials and Methods: It was a retrospective study conducted at the Department of Neurosurgery, Veer Surendra Sai Institute of Medical Sciences and Research, Burla, Odisha, India between September 2016 to March 2020. Case records of 60 patients of TBI who had undergone unilateral Decompressive Craniectomy (DECRA) were analysed. The decision for decompressive hemicraniectomy was purely based upon Glasgow Coma Scale GCS) and Computed Topography (CT) findings. The presence of an evacuable mass lesion, diffuse oedema and obliteration of basal cistern in CT was considered to be the most important criteria for the early decompressive procedure. Patients were assessed until their discharge from ward. Statistical analysis was performed by statistical package for science version 12. Results: A total of 60 patients with severe TBI, who underwent DECRA were analysed. Road Traffic Accident (RTA) was the predominant mechanism of injury. All had presence of a surgically evacuable mass lesion along with compression/obliteration of the basal cistern. The majority of mass lesions (n=42) were frontotemporal contusions (70%). Forty patients of total achieved good surgical outcome (66.67%) and rest 20 patients (33.33%) had poor outcomes. Overall incidence of complications was around 40%. The most important factors associated with good outcomes were GCS of 7 and and above, patent airway, and early surgery. Conclusion: Decompressive hemicraniectomy is a novel technique of reducing ICP which acts by directly breaking the rigid box phenomenon of Monro-Kellie doctrine. However patient selection, prompt decision, earliest intervention, adoption of standard technique of DECRA and post operative critical care management are important aspects behind the successful outcome.

A Nomogram Model to Predict Malignant Cerebral Edema in Ischemic Stroke Patients Treated with Endovascular Thrombectomy: An Observational Study.

PurposeMalignant cerebral edema (MCE) in patients undergoing endovascular thrombectomy (EVT) is not uncommon and can reduce the benefit of EVT. We aimed to develop a nomogram model to predict the risk of MCE in ischemic stroke patients after EVT.Patients and MethodsWe retrospectively collected patients treated with EVT caused by anterior circulation large vessel occlusion stroke at two comprehensive stroke centers. MCE was defined as midline shift >5 mm at the septum pellucidum or pineal gland with obliteration of the basal cisterns or the need for early decompressive hemicraniectomy. A multivariate logistic model was utilized to construct the best-fit nomogram model. The discrimination and calibration of the nomogram were estimated using the area under the receiver operating characteristic curve (AUC-ROC) and Hosmer–Lemeshow test.ResultsA total of 370 patients (mean age, 67.2±11.9 years; male, 56.8%) were enrolled in the final analysis. Among them, 71 (19.2%) patients experienced MCE after EVT treatment. After adjustment for potential confounders, age, baseline National Institutes of Health Stroke Scale score, collateral circulation, fast blood glucose level and recanalization were independent predictors of MCE and were incorporated into the nomogram. The AUC-ROC value of the nomogram was 0.805 (95% confidence interval [CI]: 0.750–0.860). The Hosmer–Lemeshow goodness-of-fit test showed good calibration of the nomogram (P = 0.681).ConclusionThe nomogram composed of age, baseline National Institutes of Health Stroke Scale score, blood glucose level, collateral circulation and recanalization may predict the probability of MCE in anterior circulation large vessel occlusion stroke patients treated with EVT.

COVID-19 and Decompressive Hemicraniectomy for Acute Ischemic Stroke.

Background and Purpose:Young patients with malignant cerebral edema have been shown to benefit from early decompressive hemicraniectomy. The impact of concomitant infection with coronavirus disease 2019 (COVID-19) and how this should weigh in on the decision for surgery is unclear.Methods:We retrospectively reviewed all COVID-19–positive patients admitted to the neuroscience intensive care unit for malignant edema monitoring. Patients with >50% of middle cerebral artery involvement on computed tomography imaging were considered at risk for malignant edema.Results:Seven patients were admitted for monitoring of whom 4 died. Cause of death was related to COVID-19 complications, and these were either seen both very early and several days into the intensive care unit course after the typical window of malignant cerebral swelling. Three cases underwent surgery, and 1 patient died postoperatively from cardiac failure. A good outcome was attained in the other 2 cases.Conclusions:COVID-19–positive patients with large hemispheric stroke can have a good outcome with decompressive hemicraniectomy. A positive test for COVID-19 should not be used in isolation to exclude patients from a potentially lifesaving procedure.

Arterial Ischemic Stroke in Childhood

Arterial ischemic stroke in children is a severe disorder with significant morbidity and mortality. Urgent diagnosis is mandatory in order to save lives or minimize neurological sequelae. However, recognition of stroke in children is more difficult than in adults. Barriers such as low suspicion, diverse risk factors, difficulties performing neuroimages, and a lack of protocols for diagnosis and treatment make stroke management in children a challenge. This article aims to review the approach to arterial stroke in children. Recently, more focus has been placed in the development of comprehensive stroke centers for treatment of stroke in children. Shortening time for diagnosis allows initiating a prompt and successful hyperacute treatment. Neuroprotection must be initiated before diagnosis confirmation. As in adult patients, widening the thrombolytic treatment time window and optimizing secondary stroke prevention are main points to develop. Early decompressive hemicraniectomy in children with malignant infarct should be considered. A multidisciplinary team is necessary for the diagnosis and treatment of children with brain attack. A particular “stroke code” must be established in each institution for stroke management and evidence-based guidelines should be developed.

Outcomes of Hypothermia in Addition to Decompressive Hemicraniectomy in Treatment of Malignant Middle Cerebral Artery Stroke

Moderate hypothermia in addition to early decompressive hemicraniectomy has been suggested to further reduce mortality and improve functional outcome in patients with malignant middle cerebral artery (MCA) stroke. To investigate whether moderate hypothermia vs standard treatment after early hemicraniectomy reduces mortality at day 14 in patients with malignant MCA stroke. This randomized clinical trial recruited patients from August 2011 through September 2015 at 6 German university hospitals with dedicated neurointensive care units. Of the patients treated with hemicraniectomy and assessed for eligibility, patients were randomly assigned to either standard care or moderate hypothermia. Data analysis was completed from December 2016 to June 2018. Moderate hypothermia (temperature, 33.0 ± 1.0°C) was maintained for at least 72 hours immediately after hemicraniectomy. The primary outcome was mortality rate at day 14 compared with the Fisher exact test and expressed as odds ratio (ORs) with 95% CIs. Rates of patients with serious adverse events were estimated for the period of the first 14 days after hemicraniectomy and 12 months of follow-up. Secondary outcome measures included functional outcome at 12 months. Of the 50 study participants, 24 were assigned to standard care and 26 to moderate hypothermia. Twenty-eight were male (56%); the mean (SD) patient age was 51.3 (6.6) years. Recruitment was suspended for safety concerns: 12 of 26 patients (46%) in the hypothermia group and 7 of 24 patients (29%) receiving standard care had at least 1 serious adverse event within 14 days (OR, 2.05 [95% CI, 0.56-8.00]; P = .26); after 12 months, rates of serious adverse events were 80% (n = 20 of 25) in the hypothermia group and 43% (n = 10 of 23) in the standard care group (hazard ratio, 2.54 [95% CI, 1.29-5.00]; P = .005). The mortality rate at day 14 was 19% (5 of 26 patients) in the hypothermia group and 13% (3 of 24 patients) in the group receiving standard care (OR, 1.65 [95% CI, 0.28-12.01]; P = .70). There was no significant difference regarding functional outcome after 12 months of follow-up. In patients with malignant MCA stroke, moderate hypothermia early after hemicraniectomy did not improve mortality and functional outcome compared with standard care, but may cause serious harm in this specific setting. http://www.drks.de, identifier DRKS00000623.

Early Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction in Asian Patients: A Single-Center Study.

Early decompression craniectomy (within 48 hours of stroke onset) in acute and malignant middle cerebral artery (MCA) ischemic stroke (IS) reduces mortality and increases the proportion of patients with favorable functional outcome. Various cultural and social issues among Asians lead to some differences in clinical practice, especially when surgical interventions are involved. Accordingly, decompressive craniectomy in Asian patients with stroke is often delayed. Data for all patients with acute IS hospitalized in our center were entered into a prospectively maintained registry. In this retrospective analysis, data for all patients with malignant MCA IS who underwent decompressive craniectomy were extracted. Various demographic, clinical, and neuroimaging factors were analyzed for identifying independent predictors of favorable functional outcome at 6 months, which was defined as modified Rankin Scale score of 0-3 points. From January 2005 to December 2014, a total of 75 patients with acute MCA IS underwent decompressive craniectomy. Median age was 55 years (interquartile range 44-64) with male preponderance (66%) and median National Institute of Health Stroke Scale score 21 points (interquartile range 18-24). A considerable proportion of these patients (38.7%) received intravenous thrombolysis. The majority (70%) of patients suffered right MCA IS, and decompressive surgery was performed within 48 hours of symptom onset in 50 (67%) of the patients. Favorable functional outcome was achieved in 25 (33.3%) patients at 6 months. Right MCA stroke (odds ratio 9.158; 95% confidence interval 1.881-44.596, P= 0.006) and early decompression surgery (odds ratio 4.011; 95% confidence interval 1.058-15.208, P= 0.041) were independent predictors of favorable functional outcome at 6 months. Early decompression craniectomy, especially in right MCA ischemic stroke, is associated with better favorable functional outcome.

Early Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction: A single centre retrospective study (P4.290)

Early Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction: A single centre retrospective study (P4.290)

Early computed tomography-based scores to predict decompressive hemicraniectomy after endovascular therapy in acute ischemic stroke.

BackgroundIdentification of patients requiring decompressive hemicraniectomy (DH) after endovascular therapy (EVT) is crucial as clinical signs are not reliable and early DH has been shown to improve clinical outcome. The aim of our study was to identify imaging-based scores to predict the risk for space occupying ischemic stroke and DH.MethodsProspectively derived data from patients with acute large artery occlusion within the anterior circulation and EVT was analyzed in this monocentric study. Predictive value of non-contrast cranial computed tomography (ncCT) and cerebral blood volume (CBV) Alberta Stroke Program Early CT score (ASPECTS) were investigated for DH using logistic regression models and Receiver Operating Characteristic Curve analysis.ResultsFrom 218 patients with EVT, DH was performed in 20 patients (9.2%). Baseline- (7 vs. 9; p = 0.009) and follow-up ncCT ASPECTS (1 vs. 7, p<0.001) as well as baseline CBV ASPECTS (5 vs. 7, p<0.001) were significantly lower in patients with DH. ncCT (baseline: OR 0.71, p = 0.018; follow-up: OR 0.32, p = <0.001) and CBV ASPECTS (OR 0.63, p = 0.008) predicted DH. Cut-off ncCT-ASPECTS on baseline was 7-, ncCT-ASPECTS on follow-up was 4- and CBV ASPECTS on baseline was 5 points.ConclusionsASPECTS could be useful to early identify patients requiring DH after EVT for acute large vessel occlusion.

Abstract TP316: Early Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction in Asian Patients

Background and purpose: Decompression craniectomy in acute malignant middle cerebral artery (MCA) ischemic stroke (IS) reduces mortality. However, its role in reducing disability in this group of patients is often questioned in the stroke community since previous studies have employed variable time intervals for surgical decompression as well as criteria for defining severe disability. We evaluated our Asian cohort of acute IS patients for determining the factors associated with favorable functional outcome. Methods: Data for all acute IS patients hospitalized to our tertiary center were entered into a prospectively maintained registry. In this retrospective analysis, data for all malignant MCA IS patients who underwent decompressive hemicraniectomy were extracted. Various demographic, clinical and neuroimaging factors were analyzed for identifying independent predictors of favorable functional outcome at 6 months, which was defined as modified Rankin Scale of 0-3. Results: From January 2005 to December 2014, a total of 75 patients with anterior circulation IS underwent decompressive hemicraniectomy. Median age was 55 years (IQR 44-64) with male preponderance (66%) and median NIH Stroke Scale (NIHSS) score 21 points (IQR 18-24). Considerable proportion of them (60%) received intravenous thrombolysis with tissue plasminogen activator (IV-tPA). Majority (70%) of patients suffered from acute right MCA IS and median time from symptom-onset to surgery was 31 hours (range18-51). Decompressive surgery was performed within 48 hours of symptom-onset in 50 (67%) of the patients. Favorable functional outcome was achieved by 25 (33.3%) patients at 6 months. Right sided stroke (OR 5.333; 95% CI 1.359- 20.927, p=0.016 ) and early decompression surgery (performed within 48 hours from symptom-onset (OR 3.636; 95% CI 1.032- 12.809, p=0.045 ) were independent predictors of favorable functional outcome at 6 months. Conclusion: Early decompression craniectomy, especially in right MCA ischemic stroke is associated with better favorable functional outcome at 6 months.

Early Decompressive Hemicraniectomy Optimizes Highest Rehabilitation Potential in Patients with Acute Malignant Middle Cerebral Artery (MCA) Syndromes (P1.219)

Early Decompressive Hemicraniectomy Optimizes Highest Rehabilitation Potential in Patients with Acute Malignant Middle Cerebral Artery (MCA) Syndromes (P1.219)

Abstract TP433: Early Decompressive Hemicraniectomy Optimizes Highest Rehabilitation Potential in Patients With Acute Malignant Middle Cerebral Artery Syndromes

Objectives: Early decompressive hemicraniectomy in malignant middle cerebral artery (MCA ) syndrome is shown to improve long term clinical outcomes in patients. Longer hospitalization and ventilator days expose patients to increased risk of complications. We explore pertinent short term clinical predictors for the highest potential of functional recovery with acute rehabilitation in patients who present with malignant MCA syndromes requiring decompressive hemicraniectomy. Methods: This is a retrospective review of 53 patients from 2008-2013 on patients with acute ischemic malignant MCA strokes who underwent decompressive hemicraniectomy. We quantified midline shifts on brain imaging obtained prior to surgery. The primary objective was identifying patient factors leading to acute rehabilitation compared to other discharge outcomes including long term acute care facilities (LTAC), subacute nursing facilities (SNF), or expiration. Results: See Table. Conclusions: Younger patients presenting with malignant MCA syndromes receiving decompressive hemicraniectomies at smaller midline shifts are observed to achieve less ventilator days, reduced hospital length of stay and discharge with optimal rehabilitation potential.

Abstract W P299: Impact of an Institutional Guideline on Implementing Early Decompressive Hemicraniectomy (DHC) for Large Middle Cerebral Artery Stroke

Background: Recent AHA Acute Stroke Guidelines endorse DHC (Class 1, Level B) based on clinical trials showing benefit of early DHC on outcome and mortality. In 2011, our multidisciplinary quality improvement team developed a process to translate DHC guideline recommendations into clinical practice. Methods: Our consensus guideline includes a tool (STATE Criteria, based on inclusion/exclusion criteria of DHC clinical trials) to rapidly identify and triage potential DHC candidates, and provide specific guidelines for pre- and post-surgical management, adjunctive therapy, and DHC after IV/IA thrombolysis. Patients meeting all STATE Criteria including age ≤ 60 years are sent for urgent DHC. Patients meeting all criteria except age ≤ 60 years receive DHC only if age &lt; 75 years and Neurology and Neurosurgery teams reach consensus about benefit. Patients not meeting criteria are observed and referred for DHC if criteria are met within 48 hours of onset. The guideline was disseminated to all stakeholders via email, conferences, and intranet. In this study, we retrospectively analyzed process and outcome measures for DHC before and after guideline implementation in February 2011. Results: Of 1518 stroke patients age ≤ 60 years admitted between January 2007 and April 2014, 47 (3%) received DHC (22 pre- and 25 post-guideline implementation; 28% female, 13% Hispanic). Mean admission NIHSS was similar (17±7 vs 18±5; p=.82). Mean time from admission to DHC improved significantly from 45±30 hours to 29±18 hours (p=0.04). The percentage of patients undergoing DHC beyond 48 hours decreased from 27% to 16% (p=0 .35). The degree of midline shift evident on CT or MRI prior to DHC significantly decreased from 9±4 mm to 5±4 mm (p=.01). There was no significant difference in length of stay, frequency of tracheostomy, gastrostomy, pneumonia, or urinary tract infection, or percentage of patients who died within 30 days of DHC. Conclusion: Our institutional guideline has facilitated the rapid identification and triage of patients with large MCA stroke to DHC. Follow-up is ongoing to determine the impact of our guideline on functional outcome after stroke.

Value of early decompressive hemicraniectomy in patients with malignant infarction in the middle cerebral artery region treated with intravenous rt-PA: A retrospective analysis of six patients

Abstract Background Malignant middle cerebral artery (MCA) infarction accounts for ≤10% of ischemic strokes, and is associated with 80% mortality. Decompressive hemicraniectomy is the most effective intervention to improve survival. The aim of this paper is to report on the outcomes of combined therapy with alteplase (rt-PA) and decompressive hemicraniectomy in patients with malignant MCA infarction. Methods 215 patients who suffered an ischemic stroke were treated with rt-PA between 2009 and 2012. Malignant MCA infarction with space-occupying edema was diagnosed clinically with the National Institute of Health Stroke Scale (NIHSS) when the score was ≥16, including the score ≥1 for the level of consciousness (1a). Patients ≤62 years agreed to undergo hemicraniectomy procedure. Risk factors, condition of patients, time from the beginning of the stroke to the intravenous application (IV) of rt-PA, and to surgery, 30-days, 3-months, and 1-year mortality, and functional outcome using the modified Rankin scale (mRs) were analyzed. A favorable functional outcome was defined as a mRs score ≤3. Results Malignant MCA infarction with space-occupying edema developed in six (2.3%) patients, out of whom two were female. The mean NIHSS on admission was 15.8 points. Four patients had clinical manifestations of edema on day one, and two on day two. The NIHSS score was >15 when the patients qualified for hemicraniectomy. CT scans showed massive brain swelling, and in two patients also secondary hemorrhagic transformation before hemicraniectomy. One patient died from the brain edema on day 11, following hemicraniectomy and, one died suddenly on day 40, from heart-related problems. The four remaining patients survived in good condition (2–3 points on mRs). Conclusion Decompressive hemicraniectomy in malignant – MCA infarction – following intravenous administration of rt-PA has proved to be safe for all patients treated in this way. It appears that a hemicraniectomy performed after an earlier rt-PA treatment has contributed to the favorable functional outcome in our patients who have survived 1 year and longer after the procedure. Secondary hemorrhagic transformation after rt-PA before surgery should not be a contraindication for decompressive hemicraniectomy. Decompressive hemicraniectomy should be performed promptly when malignant brain edema develops, before herniation occurs. The procedure can be performed in every neurosurgery hospital ward.

Treatment for Large Cerebral Infarction: Past, Present, and Future

As Cushing wrote, decompressive hemicraniectomy (DHC) has been used to palliate increased intracranial pressure from brain tumors whose localization was not detected with available neurologic or radiologic diagnostic techniques or those from head injury. After World War II, experimental studies showed that removing a bone flap over the site of acute closed cerebral lesion characterized by hemorrhage, necrosis, and edema was of definite benefit, even after the onset of symptoms indicating impending death (18), and internal and external decompressive surgeries were performed for mass effect in patients with cerebral or cerebellar infarctions, which was diagnosed as a brain tumor by radiographical examinations before the operations. Several reports have shown the effectiveness of surgical decompression in treating edema secondary to cerebral and cerebellar infarctions (7, 12). In the first prospective, nonrandomized, control trial, Rieke et al. (13) reported that DHC decreased rates of mortality to less than 35% in patients with space-occupying hemispheric infarction. Early DHC after such an infarction leads to a significant reduction in the length of time in which critical care therapy is necessary and trends toward a better outcome (15). Walz et al. (21) reported that survivors were significantly younger than nonsurvivors after DHC and that younger patients had a significantly better outcome than older patients in survivors. Based on previously reported promising

Low Alberta Stroke Program Early CT Score (ASPECTS) Associated with Malignant Middle Cerebral Artery Infarction

Background: Early decompressive hemicraniectomy following malignant middle cerebral artery (MCA) infarction reduces mortality and improves clinical outcome. Imaging predictors of malignant infarction may serve as ‘red flags', prompting intensive neurological monitoring and timely intervention. Our objective is to investigate whether lower ASPECTS (Alberta Stroke Program Early CT Score) is associated with malignant MCA infarction. Methods: A retrospective cohort study of all patients with MCA territory ischemic strokes who were admitted to the Royal Melbourne Hospital (RMH) between 1 January 2009 and 31 December 2009 (226 patients included). The main outcome measures were ASPECTS on admission for each patient and the development of malignant MCA infarction. Results: One-hundred-and-eight patients out of 226 (48%) developed malignant MCA infarction. Good (>0.8) inter-rater agreement between observers scoring ASPECTS was observed using weighted kappa, intra-class correlation coefficient and Lin's concordance coefficients. Using receiver operating characteristic (ROC) curve analysis, we validated that ASPECTS 7 was the optimal cut-off score to determine progression to malignant infarction, providing 50% sensitivity and 86% specificity. One hundred and fifty six patients had ASPECTS >7 (69%) and 70 patients had ASPECTS ≤7 (31%). Patients with ASPECTS ≤7 were significantly younger than those with ASPECTS >7, with the median age of each group being 72.5 and 78 respectively (p = 0.02); otherwise the groups were well-matched. With ASPECTS ≤7, 54 out of 70 patients (77%) developed malignant MCA infarction, compared with 54 out of 156 patients (35%) with ASPECTS >7 (age-adjusted OR = 0.12, 95% CI: 0.06, 0.25; p < 0.0001). If ASPECTS ≤7 is a positive result, then the positive predictive value is 77% and the negative predictive value is 65%. The median ASPECTS for developing malignant MCA infarction was 7.5 (IQR: 5 to 10), while the median ASPECTS for not developing MCA infarction was 10 (IQR: 8 to 10), resulting in a significant age-adjusted median difference of 2 (95% CI: 0.8, 3.2; p < 0.0001). We also found that coma on admission is associated with the development of malignant MCA infarction (OR = 22.63, 95% CI: 1.3, 393.7; p = 0.0323) and that a history of hypertension is not associated with the development of malignant MCA infarction (OR = 0.9707, 95% CI: 0.54, 1.75; p = 0.9213). Conclusions: ASPECTS ≤7 on initial brain CT in a patient with MCA infarction is associated with the development of malignant MCA infarction. We recommend close monitoring of, and early consideration of decompressive hemicraniectomy for, acute stroke patients with ASPECTS ≤7.

Abstract T P120: Clinical Demographic Effects on Functional Outcome in Patients Following Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction

Background: Malignant MCA infarction is a devastating disease representing 1-10% of strokes. Evidence from recent randomized controlled trials show improved survival and functional outcomes following decompressive hemicraniectomy (DHC) compared with optimal medical. Ideal patient selection remains somewhat controversial. The current study examines the effects of demographic and clinical variables on functional outcomes in patients surviving one or more years following DHC. Methods: We retrospectively reviewed patients who underwent DHC for malignant MCA infarction at our institution from 03/2006 to 04/2012. We collected and compared demographic and clinical variables including age, gender, race, timing of DHC, side of infarction, IV TPA administration, and additional cerebral territorial involvement (ACA or PCA). The mean mRs was calculated for each group and the Wilcoxon-Mann-Whitney two tailed test was used to calculate statistical significance. Results: A total of 32 patients met inclusion/exclusion criteria. There was no statistical difference in functional outcomes between patients ≤60 years of age and those &gt;60 years (p=0.51). No statistical difference was observed between males and females (p=0.84)). Patients who received their DHC within 48 hours of their stroke were more likely to have a better outcome than patients who received DHC after 48 hours (p=0.024). Other variables including race, cerebral dominance involvement, IV TPA administration, or additional cerebral territory involvement did not show statistical significance with respect to functional outcomes (p=0.22, p=0.462, p=0.597, and p=0.614 respectively). Conclusion: In this retrospective study, early DHC done within 48 hours of stroke was the only clinical variable shown to improve functional outcomes 1 year or more later among survivors of patients receiving DHC for malignant MCA infarction. No difference in functional outcome was seen based on age, gender, race, IV TPA administration, dominant MCA involvement, and additional cerebral territorial co infarction. Patient selection should be individualized and larger studies are needed to better assess this patient population, especially in the elderly.

Decompressive Hemicraniectomy Remains a Physician’s Individual Decision

Although the latest trials (DESTINY, DESTINY II, HAMLET, DECIMAL) have provided evidence that decompressive hemicraniectomy in malignant MCA infarction (MMI) can improve survival rates and neurological outcomes, the decision for or against the procedure remains challenging in respect of the inclusion and exclusion criteria, such as the definition of MMI, severity of symptoms at stroke onset and neuroimaging findings. This report focuses on a young patient who suffered an MMI of the right hemisphere. Because of a rapid deterioration in the clinical symptoms, we decided to perform an early decompressive hemicraniectomy after 24h. The patient survived without any complications, and with a favourable outcome (mRS 1). The case shows that young patients in particular can have a remarkable potential for full recovery after an MMI, and that the benefits of surgery outweigh the risks, provided that 1) the hemicraniectomy is performed promptly (after careful consideration of whether brain swelling might occur soon after MMI), and 2) the elective brain territories have not yet been affected.

DEcompressive Surgery plus hypoTHermia for Space-Occupying Stroke (DEPTH-SOS): A Protocol of a Multicenter Randomized Controlled Clinical Trial and a Literature Review

Although decompressive hemicraniectomy clearly reduces mortality in severe space-occupying middle cerebral artery infarction (so-called malignant middle cerebral artery infarction), every fifth patient still dies in the acute phase and every third patient is left with moderate to severe disability. Therapeutic hypothermia is a neuroprotective and antiedematous treatment option that has shown promising effects in severe stroke. A combination of both treatment strategies may have the potential to further reduce mortality and morbidity in malignant middle cerebral artery infarction, but needs evaluation of its efficacy within the setting of a randomized clinical trial. The DEcompressive surgery Plus hypoTHermia for Space-Occupying Stroke (DEPTH-SOS) trial aims to investigate safety and feasibility of moderate therapeutic hypothermia (33°C ± 1) over at least 72 h in addition to early decompressive hemicraniectomy (≤48 hours after symptom onset) in patients with malignant middle cerebral artery infarction. The DEcompressive surgery Plus hypoTHermia for Space-Occupying Stroke is a prospective, multicenter, open, two-arm (1:1) comparative, randomized, controlled trial. The primary end-point is mortality at day 14. The secondary end-points include functional outcome at day 14 and at 12 months follow-up, and complications related to hypothermia. The results of this trial will provide data on safety and feasibility of moderate hypothermia in addition to decompressive hemicraniectomy in malignant middle cerebral artery infarction. Furthermore, efficacy data on early mortality and long-term functional outcome will be obtained, forming the basis of subsequent trials.