Early decompressive surgery for stroke Malignant cerebral oedema

Early decompressive surgery for stroke Malignant cerebral oedema has 80% mortality Analysis of 3 RCTs (DECIMAL*, DESTINY*, HAMLET-ongoing) n=93 Age 18 -60 with space occupying MCA infarction Decompressive surgery within 48 h of stroke onset Reduces mortality Does not increase the number of severely disabled survivors NNT=2 for survival with m. RS<4 (able to walk) Vahedi et al, Lancet Neurol. 2007; 6: 215 -22. *Stopped early due to significant between-group differences in mortality, favoring surgery

Indications for decompressive hemicrainectomy • Age < 60 years*** • Severe MCA infarct (NIHSS>15) • Fall of conscious level to drowsy (e. g. a score of 1 or greater on NIHSS 1 a or GCS E+M <=9) • Signs on CT of an infarct of at least 50% of MCA territory or infarct volume >145 cm 3 • Referral within 24 h of stroke onset, surgery no later than 48 h after stroke onset NICE 2008 http: //www. nice. org. uk/nicemedia/pdf/CG 68 NICEGuideline. Word. doc (guidance) NICE 2008 http: //www. nice. org. uk/guidance/index. jsp? action=download&o=38893 (evidence table) RCP 2008 http: //www. rcplondon. ac. uk/pubs/contents/6 ad 05 aab-8400 -494 c-8 cf 4 -9772 d 1 d 5301 b. pdf based on Vahedi et al Lancet Neurology 2007. ****See DESTINY II 2012: age limit no longer applies

HEMICRANIECTOMY Vahedi, K. et al. Stroke 2007; 38: 2506 -2517 Copyright © 2007 American

Age Limit? • Destiny II showed NNT = 4 for patients>60 years (no upper age limit!) • Stopped by DSMB at n=80 b/o efficacy • 24. 9% absolute difference between the groups in favour of decompressive surgery • 20 of 49 (40. 8%) vs 10 of 63 (15. 9%) in the non-surgical cohort ( P =. 0038) had an m. RS 0 -4 ( P = 0. 004) Hacke et al , European Stroke Conference 2013

TIMING Time is brain Earlier hemicraniectomy (within 24 h ) has more independent survivors than late hemicraniectomy Vibbert and Mayer http: //www. springerlink. com/content/2 q 83 p 5775 qx 32572/fulltext. pdf

Hemisphere Effect? Updated Metaanalysis of DESTINY, DECIMAL and HAMLET (n=109) Outcome is similar in dominant and nondominant hemisphere strokes Vibbert and Mayer http: //www. springerlink. com/content/2 q 83 p 5775 qx 32572/fulltext. pdf

Lay Summary Large cortical infarcts (strokes) are invariably associated with brain swelling The brain shrinks with age and in older people there is usually enough space in the skull for the brain to swell In young patients there is no spare space in the skull and therefore the brain swelling causes compression of vital centres in the brain stem Young patients with very large strokes are therefore at high risk of rapid deterioration and death within the first 48 hours. Surgery may be required. This may be life saving, but will not reverse the damage the of the initial stroke.

Results expected at 1 year for every 10 patients undergoing decompressive hemicraniecomty

Inclusions DESTINY Juettler 2007 N=32 DECIMAL Vahedi 2007 N=38 HAMLET Hofmeijer 2009 N=64 and 18 -60 12 -36 h from symptom onset to OP 18 -55 <30 h from stroke onset to OP 18 -60 <96 h from stroke onset to OP and NIHSS 1 a ≥ 1 GCS ≤ 13 L hemiparesis ≤ 9 R hemiparesis and NIHSS ≥ 18 L hemiparesis ≥ 21 R hemiparesis NIHSS≥ 16 NIHSS ≥ 16 L hemiparesis ≥ 21 R hemiparesis and ≥ ¾ MCA incl. at least part of basal ganglia ≥ 50% MCA (involvement of ACA or PCA allowed) ≥ ¾ MCA (involvement of ACA or PCA allowed) and Exclusions m. RS≥ 2 DWI≥ 145 mm 3 m. RS≥ 2 or or or BI ≤ 95 GCS ≤ 6 Fixed dilated pupil bilaterally BI ≤ 95 Fixed dilated pupil bilaterally or Any other clinically relevant brain lesion Signif contralat. Infarct or Space occupying brain haemorrhagic transformation Haemorrhagic transformation >50% of MCA or or or Coagulopathy Thrombolysis Other severe comorbidities limiting life expectancy Thrombolysis ≤ 12 h ago Other severe comorbidities or life expectancy <3 y Outcome Mortality 30 d 47% vs. 88% p=0. 02 m. RS<4 at 12 mo 47% vs. 27% p=0. 2 Mortality 12 mo 25% vs. 78% p<0. 0001 m. RS<4 at 12 mo 50% vs. 22% p=0. 1 Mortality at 12 month red by 38% No difference in m. RS<4 ACA MCA and PCA infarcted

Figure 2 Reassessment of the HAMLET study Patrick Mitchell, Barbara A Gregson, John Crossman, Chris Gerber, Alastair Jenkins, Claire Nicholson, Nick V Todd, Nick Ross, Parameswaran Bhattathiri, Justin Nissen, Peter J Crawford, Guy Wynne-Jones, Robin P Sengupta, Laura Graham, Akif Gani, Michelle Davis, Chris Gray, David Barer, Paul Dorman, David Millar, Julia Williamson, Holly Durham, Alison Jones, Helen Hastie and A David Mendelow The Lancet Neurology Volume 8, Issue 7, Pages 602 -603 (July 2009) DOI: 10. 1016/S 1474 -4422(09)70157 -7 Source: The Lancet Neurology 2009; 8: 602 -603 (DOI: 10. 1016/S 1474 -4422(09)70157 -7) Terms and Conditions

Figure 1 Source: The Lancet Neurology 2009; 8: 602 -603 (DOI: 10. 1016/S 1474 -4422(09)70157 -7) Terms and Conditions