Your seventy-year-old patient has just suffered a large stroke. The circumstances are not good: an extensive middle-cerebral-artery (MCA) infarction and massive brain edema, which mean an eighty-percent chance of mortality in the first week. For younger patients, a hemicraniectomy — the removal of half the skull — has been shown to help relieve pressure and prevent herniation as the brain expands. For a patient older than sixty years, though, it’s unclear whether such surgery is helpful or harmful. Time is precious, and you have to make a decision quickly.
A study by Juttler et al., reported in this week’s NEJM, sought to answer precisely this question: for patients sixty-one years of age or older, does hemicraniectomy improve outcomes? The Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY) II trial randomly assigned over a hundred patients who had suffered a malignant MCA infarction to either hemicraniectomy or conservative treatment in an intensive care unit. The primary outcome was survival without severe disability at six months, as measured by the modified Rankin scale (where 0 is no symptoms, and 6 is death; absence of severe disability means a score of 4 or lower).
The study found that a higher percentage of patients in the hemicraniectomy group survived without severe disability, as compared to the control group (38% vs. 18%; odds ratio 2.91, P=0.04). At one year, the survival rate was also higher for the hemicraniectomy group (57% vs. 24%). The trial was stopped early due to the demonstrated efficacy of hemicraniectomy relative to conservative management.
Although patients in the hemicraniectomy group did relatively better, it must be acknowledged that the survivors in both groups remained greatly disabled by their strokes. No patients had a modified Rankin score of 0-2. As Allan Ropper, M.D., a neurologist at the Brigham and Women’s Hospital, points out in an accompanying editorial, half of the survivors a year later had a score of 4, meaning “unable to walk without assistance and unable to attend to own bodily needs without assistance,” while another third had a score of 5, meaning “bedridden, incontinent, and requiring constant nursing care and attention.” That was true for both groups. Hemicraniectomy helped, but the damage from the stroke was still devastating.
These findings raise broader questions about goals of care. Ropper writes: “In many ways, hemicraniectomy tests the fortitude of patients and their families who, in the moment, must make a decision about survival. Numerical values for the likelihood of severe disability have now been provided by the trial and may be discussed with the patient or a surrogate decision maker. However, the choice must be made early and quickly, just as the brain begins to swell, and advance directives typically do not cover these specific circumstances.”
NEJM Deputy Editor Mary Beth Hamel, M.D., M.P.H., states: “This trial provides valuable information for families who face difficult decisions about their loved ones who suffer these devastating events. The results also highlight the importance of advance care planning, to inform family and health care providers about patients’ preferences if they were to face this difficult choice.”
It’s time to make a decision about how to treat your seventy-year-old patient. You discuss the options with his care proxy and loved ones. They want whatever will keep him alive. So you call a neurosurgeon — because based on the results of the DESTINY II study, the best chance of survival means a hemicraniectomy.
In your current practice, under what circumstances do you recommend hemicraniectomy? To what extent does patient age factor into your treatment choice? How will the findings of the DESTINY II study change your approach?