Decompressive hemicraniectomy improves outcome in patients with failed arterial recanalization after acute carotid artery occlusion

Background and objectives: Decompressive hemicraniectomy reduces morbidity and mortality in patients with large hemispheric stroke. However, its role in patients that underwent failed endovascular reperfusion remains unknown. Methods: Patients with acute stroke secondary to internal carotid artery occlusion who underwent endovascular multimodal reperfusion therapy were evaluated. Patients with failed revascularization who were referred for decompressive hemicraniectomy were compared with patients with failed reperfusion who did not undergo decompressive hemicraniectomy. Functional outcome was assessed with the modified Rankin Score (mRS) and neurological disability with the NIH Stroke Scale Score (NIHSS) at 90 days from stroke onset. Results: Six decompressive hemicraniectomy-treated patients were included (four females, mean age: 36.7 years, mean NIHSS: 24.5). None of the decompressive hemicraniectomy-treated patients died compared to six of seven patients with failed multi-modal reperfusion therapy that did not undergo decompressive hemicraniectomy. All decompressive hemicraniectomy-treated patients were discharged to a rehabilitation facility whereas the only surviving non-decompressive hemicraniectomy-treated patient was discharged to a nursing facility. Five of the six decompressive hemicraniectomy-treated (84%) and none of the non-decompressive hemicraniectomy-treated patients had an mRS a3 at 90 days post-stroke. Discussion: Decompressive hemicraniectomy can significantly improve functional outcome in patients with large carotid artery strokes that failed to recanalize following multi-modal reperfusion therapy. These results imply that decompressive hemicraniectomy should be planned in patients who undergo multi-modal reperfusion therapy for large carotid artery stroke.