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 mortalityDoes not increase the number of severely disabled survivorsNNT=2 for survival with mRSlt4 (able to walk)

Vahedi et al Lancet Neurol 20076215-22

Stopped early due to significant between-group differences in mortality favoring surgery

Indications for decompressive hemicrainectomy

bull Age lt 60 yearsbull Severe MCA infarct (NIHSSgt15)bull Fall of conscious level to drowsy (eg a score of

1 or greater on NIHSS 1a or GCS E+M lt=9)bull Signs on CT of an infarct of at least 50 of MCA

territory or infarct volume gt145 cm3

bull Referral within 24 h of stroke onset surgery no later than 48 h after stroke onset

NICE 2008 httpwwwniceorguknicemediapdfCG68NICEGuidelineWorddoc (guidance)NICE 2008 httpwwwniceorgukguidanceindexjspaction=downloadampo=38893 (evidence table)RCP 2008 httpwwwrcplondonacukpubscontents6ad05aab-8400-494c-8cf4-9772d1d5301bpdf based on Vahedi et al Lancet Neurology 2007

See DESTINY II 2012 age limit no longer applies

Indications for decompressive hemicrainectomy

bull Age lt 60 yearsbull Severe MCA infarct (NIHSSgt15)bull Fall of conscious level to drowsy (eg a score of

1 or greater on NIHSS 1a or GCS E+M lt=9)bull Signs on CT of an infarct of at least 50 of MCA

territory or infarct volume gt145 cm3

bull Referral within 24 h of stroke onset surgery no later than 48 h after stroke onset

NICE 2008 httpwwwniceorguknicemediapdfCG68NICEGuidelineWorddoc (guidance)NICE 2008 httpwwwniceorgukguidanceindexjspaction=downloadampo=38893 (evidence table)RCP 2008 httpwwwrcplondonacukpubscontents6ad05aab-8400-494c-8cf4-9772d1d5301bpdf based on Vahedi et al Lancet Neurology 2007

See DESTINY II 2012 age limit no longer applies

Copyright copy2007 American Heart Association

Vahedi K et al Stroke 2007382506-2517

HEMICRANIECTOMY

Age Limit

bull Destiny II showed NNT = 4 for patientsgt60 years (no upper age limit)

bull Stopped by DSMB at n=80 bo efficacy

bull 249 absolute difference between the groups in favour of decompressive surgery

bull 20 of 49 (408) vs 10 of 63 (159) in the non-surgical cohort ( P = 0038) had an mRS 0-4 ( P = 0004)

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 httpwwwspringerlinkcomcontent2q83p5775qx32572fulltextpdf

Hemisphere Effect

Updated Metaanalysis of DESTINY DECIMAL and HAMLET (n=109)

Outcome is similar in dominant and non-dominant hemisphere strokes

Vibbert and Mayer httpwwwspringerlinkcomcontent2q83p5775qx32572fulltextpdf

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 DESTINYJuettler 2007N=32

DECIMALVahedi 2007N=38

HAMLETHofmeijer 2009N=64

18-60 18-55 18-60

and 12-36 h from symptom onset to OP lt30 h from stroke onset to OP lt96 h from stroke onset to OP

and NIHSS 1a ge 1 GCS le13 L hemiparesisle9 R hemiparesis

and NIHSSge18 L hemiparesisge21 R hemiparesis

NIHSSge16 NIHSSge16 L hemiparesisge21 R hemiparesis

and ge frac34 MCA incl at least part of basal ganglia (involvement of ACA or PCA allowed)

ge 50 MCA ge frac34 MCA (involvement of ACA or PCA allowed)

and - DWIge145mm3 -

Exclusions mRSge2 mRSge2 mRSge2

or BI le 95 - BI le 95

or GCS le6 - -

or Fixed dilated pupil bilaterally -

Fixed dilated pupil bilaterally

or Any other clinically relevant brain lesion Signif contralat Infarct ACA MCA and PCA infarcted

or Space occupying brain haemorrhagic transformation

Haemorrhagic transformation gt50 of MCA

or Coagulopathy

or Thrombolysis Thrombolysis le12 h ago

or Other severe comorbidities limiting life expectancy

Other severe comorbidities or life expectancy lt3y

Outcome Mortality 30 d 47 vs 88 p=002mRSlt4 at 12 mo 47 vs 27 p=02

Mortality 12 mo25 vs 78 plt00001mRSlt4 at 12 mo 50 vs 22 p=01

Mortality at 12 month red by 38No difference in mRSlt4

Age Limit

bull Destiny II showed NNT = 4 for patientsgt60 years (no upper age limit)

bull Stopped by DSMB at n=80 bo efficacy

bull 249 absolute difference between the groups in favour of decompressive surgery

bull 20 of 49 (408) vs 10 of 63 (159) in the non-surgical cohort ( P = 0038) had an mRS 0-4 ( P = 0004)

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 httpwwwspringerlinkcomcontent2q83p5775qx32572fulltextpdf

Hemisphere Effect

Updated Metaanalysis of DESTINY DECIMAL and HAMLET (n=109)

Outcome is similar in dominant and non-dominant hemisphere strokes

Vibbert and Mayer httpwwwspringerlinkcomcontent2q83p5775qx32572fulltextpdf

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 DESTINYJuettler 2007N=32

DECIMALVahedi 2007N=38

HAMLETHofmeijer 2009N=64

18-60 18-55 18-60

and 12-36 h from symptom onset to OP lt30 h from stroke onset to OP lt96 h from stroke onset to OP

and NIHSS 1a ge 1 GCS le13 L hemiparesisle9 R hemiparesis

and NIHSSge18 L hemiparesisge21 R hemiparesis

NIHSSge16 NIHSSge16 L hemiparesisge21 R hemiparesis

and ge frac34 MCA incl at least part of basal ganglia (involvement of ACA or PCA allowed)

ge 50 MCA ge frac34 MCA (involvement of ACA or PCA allowed)

and - DWIge145mm3 -

Exclusions mRSge2 mRSge2 mRSge2

or BI le 95 - BI le 95

or GCS le6 - -

or Fixed dilated pupil bilaterally -

Fixed dilated pupil bilaterally

or Any other clinically relevant brain lesion Signif contralat Infarct ACA MCA and PCA infarcted

or Space occupying brain haemorrhagic transformation

Haemorrhagic transformation gt50 of MCA

or Coagulopathy

or Thrombolysis Thrombolysis le12 h ago

or Other severe comorbidities limiting life expectancy

Other severe comorbidities or life expectancy lt3y

Outcome Mortality 30 d 47 vs 88 p=002mRSlt4 at 12 mo 47 vs 27 p=02

Mortality 12 mo25 vs 78 plt00001mRSlt4 at 12 mo 50 vs 22 p=01

Mortality at 12 month red by 38No difference in mRSlt4

TIMING

Time is brain

Earlier hemicraniectomy (within 24 h ) has more independent survivors than late

hemicraniectomy

Vibbert and Mayer httpwwwspringerlinkcomcontent2q83p5775qx32572fulltextpdf

Hemisphere Effect

Updated Metaanalysis of DESTINY DECIMAL and HAMLET (n=109)

Outcome is similar in dominant and non-dominant hemisphere strokes

Vibbert and Mayer httpwwwspringerlinkcomcontent2q83p5775qx32572fulltextpdf

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 DESTINYJuettler 2007N=32

DECIMALVahedi 2007N=38

HAMLETHofmeijer 2009N=64

18-60 18-55 18-60

and 12-36 h from symptom onset to OP lt30 h from stroke onset to OP lt96 h from stroke onset to OP

and NIHSS 1a ge 1 GCS le13 L hemiparesisle9 R hemiparesis

and NIHSSge18 L hemiparesisge21 R hemiparesis

NIHSSge16 NIHSSge16 L hemiparesisge21 R hemiparesis

and ge frac34 MCA incl at least part of basal ganglia (involvement of ACA or PCA allowed)

ge 50 MCA ge frac34 MCA (involvement of ACA or PCA allowed)

and - DWIge145mm3 -

Exclusions mRSge2 mRSge2 mRSge2

or BI le 95 - BI le 95

or GCS le6 - -

or Fixed dilated pupil bilaterally -

Fixed dilated pupil bilaterally

or Any other clinically relevant brain lesion Signif contralat Infarct ACA MCA and PCA infarcted

or Space occupying brain haemorrhagic transformation

Haemorrhagic transformation gt50 of MCA

or Coagulopathy

or Thrombolysis Thrombolysis le12 h ago

or Other severe comorbidities limiting life expectancy

Other severe comorbidities or life expectancy lt3y

Outcome Mortality 30 d 47 vs 88 p=002mRSlt4 at 12 mo 47 vs 27 p=02

Mortality 12 mo25 vs 78 plt00001mRSlt4 at 12 mo 50 vs 22 p=01

Mortality at 12 month red by 38No difference in mRSlt4

Hemisphere Effect

Updated Metaanalysis of DESTINY DECIMAL and HAMLET (n=109)

Outcome is similar in dominant and non-dominant hemisphere strokes

Vibbert and Mayer httpwwwspringerlinkcomcontent2q83p5775qx32572fulltextpdf

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 DESTINYJuettler 2007N=32

DECIMALVahedi 2007N=38

HAMLETHofmeijer 2009N=64

18-60 18-55 18-60

and 12-36 h from symptom onset to OP lt30 h from stroke onset to OP lt96 h from stroke onset to OP

and NIHSS 1a ge 1 GCS le13 L hemiparesisle9 R hemiparesis

and NIHSSge18 L hemiparesisge21 R hemiparesis

NIHSSge16 NIHSSge16 L hemiparesisge21 R hemiparesis

and ge frac34 MCA incl at least part of basal ganglia (involvement of ACA or PCA allowed)

ge 50 MCA ge frac34 MCA (involvement of ACA or PCA allowed)

and - DWIge145mm3 -

Exclusions mRSge2 mRSge2 mRSge2

or BI le 95 - BI le 95

or GCS le6 - -

or Fixed dilated pupil bilaterally -

Fixed dilated pupil bilaterally

or Any other clinically relevant brain lesion Signif contralat Infarct ACA MCA and PCA infarcted

or Space occupying brain haemorrhagic transformation

Haemorrhagic transformation gt50 of MCA

or Coagulopathy

or Thrombolysis Thrombolysis le12 h ago

or Other severe comorbidities limiting life expectancy

Other severe comorbidities or life expectancy lt3y

Outcome Mortality 30 d 47 vs 88 p=002mRSlt4 at 12 mo 47 vs 27 p=02

Mortality 12 mo25 vs 78 plt00001mRSlt4 at 12 mo 50 vs 22 p=01

Mortality at 12 month red by 38No difference in mRSlt4

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 DESTINYJuettler 2007N=32

DECIMALVahedi 2007N=38

HAMLETHofmeijer 2009N=64

18-60 18-55 18-60

and 12-36 h from symptom onset to OP lt30 h from stroke onset to OP lt96 h from stroke onset to OP

and NIHSS 1a ge 1 GCS le13 L hemiparesisle9 R hemiparesis

and NIHSSge18 L hemiparesisge21 R hemiparesis

NIHSSge16 NIHSSge16 L hemiparesisge21 R hemiparesis

and ge frac34 MCA incl at least part of basal ganglia (involvement of ACA or PCA allowed)

ge 50 MCA ge frac34 MCA (involvement of ACA or PCA allowed)

and - DWIge145mm3 -

Exclusions mRSge2 mRSge2 mRSge2

or BI le 95 - BI le 95

or GCS le6 - -

or Fixed dilated pupil bilaterally -

Fixed dilated pupil bilaterally

or Any other clinically relevant brain lesion Signif contralat Infarct ACA MCA and PCA infarcted

or Space occupying brain haemorrhagic transformation

Haemorrhagic transformation gt50 of MCA

or Coagulopathy

or Thrombolysis Thrombolysis le12 h ago

or Other severe comorbidities limiting life expectancy

Other severe comorbidities or life expectancy lt3y

Outcome Mortality 30 d 47 vs 88 p=002mRSlt4 at 12 mo 47 vs 27 p=02

Mortality 12 mo25 vs 78 plt00001mRSlt4 at 12 mo 50 vs 22 p=01

Mortality at 12 month red by 38No difference in mRSlt4

Results expected at 1 year for every 10 patients undergoing decompressive

hemicraniecomty

Inclusions DESTINYJuettler 2007N=32

DECIMALVahedi 2007N=38

HAMLETHofmeijer 2009N=64

18-60 18-55 18-60

and 12-36 h from symptom onset to OP lt30 h from stroke onset to OP lt96 h from stroke onset to OP

and NIHSS 1a ge 1 GCS le13 L hemiparesisle9 R hemiparesis

and NIHSSge18 L hemiparesisge21 R hemiparesis

NIHSSge16 NIHSSge16 L hemiparesisge21 R hemiparesis

and ge frac34 MCA incl at least part of basal ganglia (involvement of ACA or PCA allowed)

ge 50 MCA ge frac34 MCA (involvement of ACA or PCA allowed)

and - DWIge145mm3 -

Exclusions mRSge2 mRSge2 mRSge2

or BI le 95 - BI le 95

or GCS le6 - -

or Fixed dilated pupil bilaterally -

Fixed dilated pupil bilaterally

or Any other clinically relevant brain lesion Signif contralat Infarct ACA MCA and PCA infarcted

or Space occupying brain haemorrhagic transformation

Haemorrhagic transformation gt50 of MCA

or Coagulopathy

or Thrombolysis Thrombolysis le12 h ago

or Other severe comorbidities limiting life expectancy

Other severe comorbidities or life expectancy lt3y

Outcome Mortality 30 d 47 vs 88 p=002mRSlt4 at 12 mo 47 vs 27 p=02

Mortality 12 mo25 vs 78 plt00001mRSlt4 at 12 mo 50 vs 22 p=01

Mortality at 12 month red by 38No difference in mRSlt4

Inclusions DESTINYJuettler 2007N=32

DECIMALVahedi 2007N=38

HAMLETHofmeijer 2009N=64

18-60 18-55 18-60

and 12-36 h from symptom onset to OP lt30 h from stroke onset to OP lt96 h from stroke onset to OP

and NIHSS 1a ge 1 GCS le13 L hemiparesisle9 R hemiparesis

and NIHSSge18 L hemiparesisge21 R hemiparesis

NIHSSge16 NIHSSge16 L hemiparesisge21 R hemiparesis

and ge frac34 MCA incl at least part of basal ganglia (involvement of ACA or PCA allowed)

ge 50 MCA ge frac34 MCA (involvement of ACA or PCA allowed)

and - DWIge145mm3 -

Exclusions mRSge2 mRSge2 mRSge2

or BI le 95 - BI le 95

or GCS le6 - -

or Fixed dilated pupil bilaterally -

Fixed dilated pupil bilaterally

or Any other clinically relevant brain lesion Signif contralat Infarct ACA MCA and PCA infarcted

or Space occupying brain haemorrhagic transformation

Haemorrhagic transformation gt50 of MCA

or Coagulopathy

or Thrombolysis Thrombolysis le12 h ago

or Other severe comorbidities limiting life expectancy

Other severe comorbidities or life expectancy lt3y

Outcome Mortality 30 d 47 vs 88 p=002mRSlt4 at 12 mo 47 vs 27 p=02

Mortality 12 mo25 vs 78 plt00001mRSlt4 at 12 mo 50 vs 22 p=01

Mortality at 12 month red by 38No difference in mRSlt4

Figure 2

Source The Lancet Neurology 2009 8602-603 (DOI101016S1474-4422(09)70157-7)

Terms and Conditions

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 101016S1474-4422(09)70157-7

Figure 1

Source The Lancet Neurology 2009 8602-603 (DOI101016S1474-4422(09)70157-7)

Terms and Conditions

• Early decompressive surgery for stroke
• Indications for decompressive hemicrainectomy
• PowerPoint Presentation
• Age Limit
• TIMING
• Hemisphere Effect
• Lay Summary
• Results expected at 1 year for every 10 patients undergoing decompressive hemicraniecomty
• Slide 9
• Slide 10
• Slide 11