Decompressive Hemicraniectomy in Elderly Patients With Space-Occupying Infarction (DECAP): A Prospective Observational Study
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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 ≥ 61 years with large MCA infarction treated with hemicraniectomy. The primary endpoint was the functional outcome according to modified Rankin Scale (mRS) score at 6 months after hemicraniectomy. Secondary endpoints included outcome measures at 12 months. 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 12 months.
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 6 months 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 6 months (mRS scores 0–4; odds ratio 0.239 [95% CI 0.082–0.696]). Case-fatality rate at 12 months 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 12 months 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 12 months was comparable to previously reported data from a randomized trial.
KeywordsStroke Space-occupying infarction Decompressive surgery Hemicraniectomy Prospective observational study Pooled analysis
We thank the study patients and their relatives for their contribution to the study. The clinical study was conducted at the University Hospital, Technische Universität Dresden, Dresden, Germany. Statistical analyses were mainly performed at the Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany.
JR has acquired, analyzed and interpreted data. SW has acquired and interpreted data. EJ has provided data and interpreted data. LU has analyzed and interpreted data. RL has analyzed and interpreted data. JB has acquired and interpreted data. GS has interpreted data and provided administrative support. HR has interpreted data and provided administrative support. HS has designed and coordinated the study, has acquired, analyzed and interpreted data, and drafted the manuscript. All authors critically revised the manuscript for important intellectual content. All authors read and approved the final version of the manuscript.
Source of support
Compliance with Ethical Standards
Conflict of interest
All authors declare that they have no conflict of interests.
The study was approved by the institutional review board (Ethikkommission an der TU Dresden; IRB00001473). Written informed consent was obtained from patients or their legal representatives.
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