Predictors of Decompressive Hemicraniectomy in Successfully Recanalized Patients With Anterior Circulation Emergency Large-Vessel Occlusion

Background Mechanical thrombectomy (MT) has been shown to improve functional outcome in patients with anterior circulation strokes and emergent large-vessel occlusion (ELVO). Despite successful recanalization, some of these patients require decompressive hemicraniectomy (DHC). We aimed to study the predictors of DHC in successfully recanalized anterior circulation ELVO patients. Methods Consecutive patients with anterior circulation ELVO treated with MT during a 6-year period were evaluated. Only successfully recanalized patients (modified Thrombolysis in Cerebral Infarction grades 2b, 2c, or 3) after MT were included in the analysis. Baseline demographic, clinical, and procedural variables were compared between patients requiring DHC after successful recanalization versus those who did not. Results Of 453 successfully recanalized patients with ELVO, 47 who underwent DHC had higher admission blood glucose levels (170 +/- 88 versus 142 +/- 66 mg/dL; P=0.008), lower median Alberta Stroke Program Early CT Scores (9 [interquartile range, 8-10] versus 10 [interquartile range, 9-10]; P=0.002), higher prevalence of poor collaterals on pretreatment computed tomography angiogram (75% versus 26%; P<0.001), and required more passes during MT (median, 3 [interquartile range, 3-4] versus 2 [interquartile range, 1-2]; P=0.001) compared with those who did not undergo DHC. In a multivariable model after adjusting for multiple confounders, higher admission blood glucose levels (P=0.031), poor collaterals on computed tomography angiography (P<0.001), and higher number of passes during MT (P<0.001) emerged as independent predictors of DHC in successfully recanalized patients with ELVO. Conclusions Higher admission blood glucose levels, poor collateral pattern on computed tomography angiography, and higher number of passes during MT were independently associated with DHC in patients with anterior circulation ELVO achieving successful recanalization following MT.