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By Matthew E. Fink, MD,
Professor and Chairman, Department of Neurology, Weill Cornell Medical College, and Neurologist-in-Chief, New York Presbyterian Hospital
Source: Juttler E, et al, for the DESTINY II Investigators. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 2014;370:1091-1100.
In an earlier study of early decompressive hemicraniectomy for large middle cerebral artery strokes, the same investigators demonstrated reduced mortality without increasing the risk of very severe disability among patients ≤ 60 years of age. These investigators now report the results of a similar trial in 112 patients, ≥ 61 years of age (mean age 70 years; range 61-82) who were randomized to either hemicraniectomy within 48 hours or conservative treatment in the intensive care unit. The primary endpoint was survival without severe disability, defined as a modified Rankin score of 0 to 4.
Hemicraniectomy improved the primary outcome, with the proportion of patients who survived without severe disability being 38% in hemicraniectomy group, compared to 18% in the control group. This result was a direct result of a lower mortality in the surgical group, and no difference between the groups in the degree of severe disability. The results of this trial in an older age group is quite similar to what was found in younger patients, and this procedure therefore remains an option for patients of all ages. However, patients and families should be made aware that a successful hemicraniectomy may improve survival, but it will not improve neurological recovery.