Hurting More Than Helping? Decompressive Craniectomy in Patients With Symptomatic Intracerebral Hemorrhage After Mechanical Thrombectomy in Acute Ischemic Stroke: Insights From Stroke Thrombectomy and Aneurysm Registry

Elliot Pressman; Kunal Vakharia; Waldo R Guerrero; Mohammad-Mahdi Sowlat; Samantha Schimmel; Ilko Maier; Ansaar Raai; Pascal Jabbour; Joon-Tae Kim; Jonathan A Grossberg; Ali Alawieh; Stacey Q Wolfe; Robert M Stark; Marios-Nikos Psychogios; Edgar A Samaniego; Nitin Goyal; Justin Dye; Ali Alaraj; Shinichi Yoshimura; Mohamad Ezzeldin; David Fiorella; Omar Tanweer; Daniele G Romano; Pedro Navia; Hugo Cuellar; Isabel Fragata; Adam Polifka; Justin Mascitelli; Joshua Osbun; Fazeel Siddiqui; Mark Moss; Kaustubh Limaye; Charles Matouk; Min S Park; Waleed Brinjikji; Ergun Daglioglu; Richard Williamson Jr; David J Altschul; Christopher S Ogilvy; Roberto Crosa; Michael R Levitt; Benjamin Gory; Ramesh Grandhi; Alexandra R Paul; Peter Kan; Walter Casagrande; Shakeel Chowdhry; Michael F Stiefel; Alejandro M Spiotta; Maxim Mokin; STAR

doi:10.1227/neu.0000000000003563

Hurting More Than Helping? Decompressive Craniectomy in Patients With Symptomatic Intracerebral Hemorrhage After Mechanical Thrombectomy in Acute Ischemic Stroke: Insights From Stroke Thrombectomy and Aneurysm Registry

Neurosurgery. 2025 Jun 9. doi: 10.1227/neu.0000000000003563. Online ahead of print.

Authors

Elliot Pressman¹, Kunal Vakharia¹, Waldo R Guerrero¹, Mohammad-Mahdi Sowlat², Samantha Schimmel¹, Ilko Maier³, Ansaar Raai⁴, Pascal Jabbour⁵, Joon-Tae Kim⁶, Jonathan A Grossberg⁷, Ali Alawieh⁷, Stacey Q Wolfe⁸, Robert M Stark⁹, Marios-Nikos Psychogios¹⁰, Edgar A Samaniego¹¹, Nitin Goyal¹², Justin Dye¹³, Ali Alaraj¹⁴, Shinichi Yoshimura¹⁵, Mohamad Ezzeldin¹⁶, David Fiorella¹⁷, Omar Tanweer¹⁸, Daniele G Romano¹⁹, Pedro Navia²⁰, Hugo Cuellar²¹, Isabel Fragata²², Adam Polifka²³, Justin Mascitelli²⁴, Joshua Osbun²⁵, Fazeel Siddiqui²⁶, Mark Moss²⁷, Kaustubh Limaye²⁸, Charles Matouk²⁹, Min S Park³⁰, Waleed Brinjikji³¹, Ergun Daglioglu³², Richard Williamson Jr³³, David J Altschul³⁴, Christopher S Ogilvy³⁵, Roberto Crosa³⁶, Michael R Levitt³⁷, Benjamin Gory³⁸, Ramesh Grandhi³⁹, Alexandra R Paul⁴⁰, Peter Kan⁴¹, Walter Casagrande⁴², Shakeel Chowdhry⁴³, Michael F Stiefel⁴⁴, Alejandro M Spiotta², Maxim Mokin¹; STAR

Affiliations

¹ Department of Neurosurgery & Brain Repair, University of South Florida, Tampa, Florida, USA.
² Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
³ Department of Neurology, Universitätsmedizin Göttingen, Göttingen, Germany.
⁴ Department of Neuroradiology, West Virginia University, Morgantown, West Virginia, USA.
⁵ Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
⁶ Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea.
⁷ Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
⁸ Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
⁹ Department of Neurosurgery, University of Miami, Miami, Florida, USA.
¹⁰ Department of Diagnostic and Interventional Neuroradiology, Universitätsspital Basel, Basel, Switzerland.
¹¹ Department of Neurology, University of Iowa, Iowa City, Iowa, USA.
¹² Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
¹³ Department of Neurosurgery, Loma Linda University, Loma Linda, California, USA.
¹⁴ Department of Neurosurgery, University of Illinois, Chicago, Illinois, USA.
¹⁵ Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
¹⁶ Department of Clinical Sciences, University of Houston, HCA Houston Healthcare, Kingwood, Texas, USA.
¹⁷ Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA.
¹⁸ Department of Neurosurgery, NYU Langone Health, New York, New York, USA.
¹⁹ Department of Neurosurgery, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy.
²⁰ Department of Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain.
²¹ Department of Neurosurgery, LSUHSC, Shreveport, Louisiana, USA.
²² Department of Neurosurgery, Centro Hospitalar de Lisboa Central, Lisboa, Portugal.
²³ Department of Neurosurgery, University of Florida, Gainesville, Florida, USA.
²⁴ Department of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
²⁵ Department of Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA.
²⁶ Neurosciences, University of Michigan Health-West, Wyoming, Michigan, USA.
²⁷ Department of Neurosurgery, Washington Regional Medical Center, Fayetteville, Arkansas, USA.
²⁸ Department of Neurology, Indiana University Bloomington, Bloomington, Indiana, USA.
²⁹ Department of Neurosurgery, Yale University, New Haven, Connecticut, USA.
³⁰ Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.
³¹ Department of Neurosurgery, Mayo Clinic Minnesota, Rochester, Minnesota, USA.
³² Department of Neurosurgery, Ankara City Hospital, Ankara, Turkey.
³³ Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
³⁴ Department of Neurovascular Surgery, Montefiore Medical, Bronx, New York, USA.
³⁵ Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
³⁶ Department of Neurosurgery, Médica Uruguaya, Montevideo, Uruguay.
³⁷ Department of Neurosurgery, University of Washington School of Medicine, Seattle, Washington, USA.
³⁸ Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, France.
³⁹ Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA.
⁴⁰ Department of Neurosurgery, Albany Medical Center, Albany, New York, USA.
⁴¹ Department of Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA.
⁴² Department of Neurosurgery, Hospital Juan A. Fernandez, Buenos Aires, Argentina.
⁴³ Department of Neurosurgery, NorthShore University Health System, Evanston, Illinois, USA.
⁴⁴ Department of Vascular Neurosurgery, Piedmont Hospital, Atlanta, Georgia, USA.

PMID: 40488514
DOI: 10.1227/neu.0000000000003563

Abstract

Background and objectives: It remains unclear whether decompressive craniectomy (DC) is beneficial in patients who suffer symptomatic intracerebral hemorrhage (sICH) after acute ischemic stroke (AIS). We sought to study the effect of DC on functional outcomes in patients with sICH after AIS who underwent mechanical thrombectomy (MT).

Methods: Patients with AIS from anterior circulation large vessel occlusion who underwent MT and subsequently developed sICH were identified from the Stroke Thrombectomy and Aneurysm Registry database. The primary outcome was acceptable 90-day functional neurological outcome, defined as modified Rankin scale (mRS) 0-3. Multivariable logistic regression and propensity-score matching were used to identify and quantify risk factors.

Results: Of 464 patients identified with sICH after AIS after MT, 97 patients (20.9%) underwent DC. Patients who underwent DC were more likely to be female (P < .001), younger (P < .001), have a measured medical comorbidity, have higher baseline mRS (P = .02), and have higher-grade hemorrhages (P = .01). At 90 days, 14% of patients had the primary outcome of mRS 0-3 and 56% had died. The primary outcome was observed in 11 patients who underwent DC (11%) and 55 (15%) of those without DC (odds ratio [OR] 0.7, 95% CI 0.4-1.4, P = .40). DC did not affect mRS shift at 90 days (P = .10) but was associated with lower mortality (OR 0.5, 95% CI 0.3-0.8, P = .01). Multivariable analysis demonstrated that DC decreased the odds of primary outcome (adjusted OR 0.2, 95% CI 0.02-0.9, P = .045), but did not affect mortality (P = .94), mRS shift (P = .50), or length of stay (P = .90). Propensity-matched analysis similarly demonstrated that non-DC patients were more likely to achieve the primary outcome (24% vs 8%, P = .045).

Conclusion: In patients with sICH after AIS after MT, those selected for DC had less favorable outcomes and similar rates of mortality at 90 days.

Keywords: Cerebral ischemia; Craniectomy; Intracerebral hemorrhage; Stroke.