RCTs:
DESTINY
|
DECIMAL
|
HAMLET
|
DESTINY II
|
|
| N (final) |
32
|
38
|
64
|
112
|
| Year |
2004-2005
|
2001-2005
|
2002-2007
|
2009-2013
|
| Age range |
18-60
|
18-55
|
18-60
|
>60
|
| Median age |
45
|
43 (mean)
|
47-50
|
70
|
| NIHSS (R/L) |
>18/20
|
>16
|
>16/21
|
>14/19
|
| Infarct size (CT) |
> 2/3 MCA territory
|
>1/2 MCA territory + DWI vol > 145 cm2
|
> 2/3 MCA territory
|
> 2/3 MCA territory
|
| Median Time to surgery |
24 hours
|
20 hours
|
>41 hours
|
28 hours
|
| Exclusion Criteria |
mRS >1, bilateral blown pupils, GCS <6, IPH, other serious illness.
|
mRS>1, big contralateral infarct, big IPH
|
thrombolysis w/in 12 hrs, mRS > 1, bilateral blown pupils, entire hemisphere stroke
|
mRS >1, bilateral blown pupils, GCS <6, IPH, other serious illness.
|
Pooled results from DESTINY, DECIMAL, AND HAMLET:
- half of the HAMLET trial pts excluded for being randomized too late (> 45 hours after symptom onset -- assuming >48 hours to treatment)
Thoughts:
- Decompressive hemicraniectomy (DH) is associated with a significantly reduced proportion of death, but a significantly increased proportion of severe disability (mRS 4-5).
- Incidence of very good outcome (mRS) is much higher in the surgical intervention group - 14% than the nonoperative group - 2%
DESTINY II:
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