Efficacy and safety of decompressive craniectomy in acute ischemic stroke patients treated with intravenous thrombolysis

INTRODUCTION: The optimal timing for decompressive hemicraniectomy (DHC) after intravenous thrombolysis (IVT) remains unclear. This study in patients with acute ischemic stroke treated with IVT aimed to assess the safety of DHC and patient outcome.METHODS: Data was extracted from the Tabriz stroke registry from June 2011 up to September 2020. In all, 881 patients were treated with IVT. Among these, 23 patient underwent DH. Six patients were excluded due to symptomatic intracranial hemorrhage (parenchymal hematoma type 2 based on the SITS-MOST definition) after IVT; the remaining 17 patients were enrolled in the study. Functional outcome at three months was assessed by the modified Rankin Scale, where 0-3 was considered moderate disability and 4-6 was considered severe disability. Safety outcome was assessed by comparison of two scans just prior to and after craniectomy. Any new hemorrhage or worsening of previous hemorrhage was reported. Parenchymal hematoma type 2, based on ECASS II definition, was considered as major surgical complication. This study was approved by the local ethics committee of the Tabriz University of Medical Sciences (Ethics Code: IR.TBZMED.REC.1398.420). RESULTS: At the three-month mRS follow up, six patients (36%) had moderate and five (28%) had severe disability. The outcome of death was observed in six patients (36%). Nine of 15 patients (60%) underwent surgery in the first 48 hours after onset of symptoms. No patient over 60 years of age survived to the three-month follow up; 67% of those who were under 60 years and underwent DH in the first 48 hours had favorable outcome. Hemorrhagic complication was seen in 60% of patients but none was major.CONCLUSION: outcome of DHC after IVT was comparable to other patients who underwent DHC and did not receive IVT. Although the rate of all bleeding was higher, none was major and DHC was safe even in the first 48 hours after onset of symptoms.