Systematic Review of Decompressive Craniectomy After Endovascular Thrombectomy in Acute Ischemic Stroke

Overview

This systematic review synthesizes current evidence on risk factors and predictors for decompressive craniectomy (DC) following endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) patients. Despite EVT's efficacy in recanalization, a subset of patients develop malignant middle cerebral artery infarction requiring DC, with mortality rates remaining high.

Background

Endovascular thrombectomy is a standard treatment for AIS caused by large artery occlusions in the anterior circulation, improving functional outcomes by restoring blood flow and reducing infarct size. However, malignant middle cerebral artery infarction occurs in some patients post-EVT, often necessitating decompressive craniectomy to reduce mortality and improve outcomes. Predicting which patients will require DC after EVT remains challenging, and understanding associated risk factors is critical for early intervention. This review addresses the gap by systematically analyzing literature on DC following EVT.

Data Highlights

Mortality rates for malignant MCA infarction approach 80% without intervention. Despite EVT, mortality and disability rates remain approximately 40–55.5%. Recanalization failure occurs in 12.0–27% of EVT cases. DC combined with medical treatment reduces mortality and improves functional outcomes in malignant MCA infarction.

Key Findings

• Malignant MCA infarction after EVT occurs despite timely recanalization in a significant minority of patients.
• Risk factors for requiring DC post-EVT include occlusions in the intracranial carotid artery and proximal MCA.
• Mortality rates remain high in malignant MCA infarction, underscoring the importance of DC as a life-saving intervention.
• There is substantial heterogeneity in study designs and outcomes, limiting meta-analysis but allowing qualitative synthesis of effect sizes.
• Early identification of patients at risk for DC after EVT is crucial for clinical decision-making.
• This review is the first to systematically synthesize literature specifically addressing DC following EVT in AIS patients.

Clinical Implications

Clinicians should be vigilant for signs of malignant MCA infarction in AIS patients post-EVT, especially in cases involving ICA and proximal MCA occlusions. Early consideration of decompressive craniectomy can reduce mortality and improve functional outcomes. Further research is needed to refine predictive models to guide timely surgical intervention.

Conclusion

Decompressive craniectomy remains a critical intervention for malignant MCA infarction following EVT in AIS patients. This systematic review highlights the need for early risk stratification to optimize patient outcomes.

References

1. Various Authors/Multiple Years -- Systematic Review of Decompressive Craniectomy Following Endovascular Thrombectomy in Patients with Acute Ischemic Stroke