Decompressive Craniectomy in supratentorial cerebral ischemic stroke: Where, When and Why. Experience of a Single Center

Study design: A series of 26 patients, submitted to decompressive craniectomy for su-pratentorial cerebral ischemia was retrospectively analyzed. Objectives: The aim of this study is to highlight the experience with this surgical tech-nique in our Institution and to analyze comparatively the preoperative and postoperative clinical and radiological data, as well as the prognostic factors verifying the agreement between our findings and the relevant literature data. Methods: From January 2018 to January 2023, we recruited 26 patients that underwent decompressive craniectomy for supratentorial cerebral ischemia. Demographic, medical history, clinical, laboratory, radiological and surgical data were collected. Statistical analysis was also performed to determine if any variable had a significant impact pre-viously and post-operatively or if they were predictive of favorable outcome. Results: The average age of the patients was 56.55 y, range between 26-80 y. Patients under 60 y were 51.8% and 59,25% of the whole sample were male. The outcome score calculated with the Modified Ranking Scale after about 1 year was < =4 in 11 patient; it distributed as follows: 2 pts with MRS 2, 5 pts with MRS 3 and 4 pts with MRS 4. The remaining were dead or in a vegetative state. Univariate statistical analysis was focused on neuroradiological parameters, studied both in pre- and post-operative CT scans. The variables that proved to be statistically significant were the presence or absence of visible cortical sulci, basal cisterns compression (cisterna ambiens in particular), quadrigeminal and sylvian cisterns. Of these parameters, the only one that maintained statistical sig-nificance even in the multivariate analysis was the presence of visible cisterna ambiens in post-operative radiological studies proving to be associated with a favorable outcome. Conclusions: Our study confirmed that decompressive craniectomy in cerebral ischemic stroke is an effective life-saving treatment in a subgroup of patients with intracranial hypertension. Standardization of the surgical indication remains a challenge and our analysis could suggest potentially useful work patterns in daily clinical practice, eventough our expe-rience had the important limitation of measuring only physical disability; further studies considering psychosocial, financial and caregiving aspects are needed. Moreover, sur-gical management remains in our opinion a tailored choice based on the experience of the surgeon and on the expectations of the patient and family.