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Safety and outcome of decompressive hemicraniectomy after recombinant tissue plasminogen activator (rtPA) thrombolysis for acute ischemic stroke: A systematic review.

K. Pedro,K. Roberto,Annabell E. Chua

Published 2020 in World Neurosurgery

ABSTRACT

BACKGROUND Decompressive hemicraniectomy (DH) is widely recommended as a surgical treatment for intractable increased intracranial pressure following malignant cerebral infarction. A significant number of patients given recombinant tissue plasminogen activator (rtPA) develop cerebral edema following reperfusion or failed recanalization. The safety and efficacy of DH after rtPA administration however remain largely unknown. METHODS A systematic review was performed using PUBMED, EMBASE, Scopus, Cochrane and HERDIN. Studies were eligible if they included patients who underwent DH after intravenous thrombolysis (IVT) for acute ischemic stroke. Unweighted odds ratio for mortality (primary outcome) and good functional outcome defined as mRS 0-3 or GOS 4-5 at 3-6 months (secondary outcome) were compared between the DH + rtPA group and DH alone group. RESULTS Four studies with a total of 98 patients undergoing DH + rtPA were compared to 110 patients undergoing DH alone without prior thrombolysis. Age, vascular risk factors and stroke etiology were comparable between the two groups. Pooled analysis showed that mortality rates and functional outcomes were not statistically different between the DH + rtPA and DH alone groups (OR:0.56, p = .07 and OR:0.83, p = .30, respectively). Likewise, both minor and major hemorrhagic rates were similar between the two groups (37.76% vs 27.27%, p = .053). CONCLUSION DH for malignant cerebral infarction following IV rtPA administration is a viable treatment option, with a comparable mortality and functional outcome to those who had DH without prior thrombolysis.

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