Abstract Background and aims Malignant cerebral infarction (MCI), particularly when complicated by hemorrhagic transformation (HT), has been associated with a high morbidity and mortality. HT has been reported to occur in 18–42% of patients with MCI. While the role of decompressive craniectomy (DC) for MCI has been validated in randomized controlled trials, its role in the setting of MCI with HT remains less clear. Thus, this study aims to investigate mortality and neurological outcome after DC in MCI with HT. Methods We performed a multicentric retrospective study including patients diagnosed with MCI with HT undergoing DC from four German centers treated between 2013 and 2023. HT was described and objectified using the Heidelberg Bleeding Classification. Primary end point was in-hospital mortality. Secondary end point was the neurological outcome defined by the modified Rankin Scale at discharge. Results 119 patients with MCI and HT prior to DC were included. Mean age was 61.4 years (SD ± 10.5) with a male predominance (74:45). 48.7% of patients received intravenous thrombolysis and 63% underwent thrombectomy prior to surgery. Mean time from ictus to DC was 23.0 hours (SD ± 39.0). The overall mortality rate was 38.5%, with in-hospital mortality of 27.7%. Excluding the patients who died, median mRS at discharge was 4 (range: 2-5), with an unfavorable outcome (mRS 3) in 92.9%. Conclusions Approximately one-third of patients who underwent DC for MCI with HT died during hospitalization, and 90% had a poor neurological outcome. Caution should be exercised when considering DC in these cases. Conflict of interest Silvia Hernandez: Nothing to declare
Silvia Hernandez Duran (2026) studied this question.