Initial Conservative Management of Severe Hemispheric Stroke Reduces Decompressive Craniectomy Rates

Pooled European trial results of early decompressive craniectomy (DC) for severe hemispheric stroke did not require radiographic mass effect as an inclusion criterion. Early surgery for supratentorial cerebral hemorrhage does not improve functional status or survival compared to initial conservative medical management. Early versus delayed DC for hemispheric stroke has not been investigated. A prospective inpatient neurosurgical database from October 2007 to March 2015 was queried for neurocritical care admissions for hemispheric ischemic stroke in patients aged 18-60 under IRB approval. A retrospective chart review was conducted using a structured questionnaire and the electronic medical record. We identified 30 patients who met the inclusion criteria for the pooled European early DC stroke trial. The mean age was 46, and the median NIH stroke score was 19. All hemispheric stroke patients were monitored in the neurocritical care unit with hourly neurochecks and daily CT scans for a minimum of 3 days. Eighteen patients (60 %) were managed with medical treatment only (MTO) with an average maximal septal shift of 5.2 mm and a pineal shift of 3.1 mm. Twelve patients (40 %) underwent DC with an average maximal septal shift of 6.8 mm and a pineal shift of 4.1 mm. Modified Rankin (MR) outcomes at 3 months for the overall group, MTO, and DC were as follows: MR 0-3 60 % versus 67 % versus 50 %; MR 4-5 27 % versus 17 % versus 42 %; and death 13 % versus 17 % versus 8 %, respectively. Four patients in the MTO group declined DC; 3 died and one survived with an MR of 4. No patients developed brainstem herniation prior to referral for DC. Surgical complications occurred in 4/12 (33 %) patients. Delayed DC for hemispheric stroke patients managed under protocol in the neurocritical care unit is a safe alternative to early, prophylactic DC for adults with severe hemispheric stroke. This strategy reduced DC rates by 60 % without an excess of death or survival with severe disabilities.