Abstract 295: Impact Of Revascularization Therapy And Decompressive Surgery On Outcomes In Large Hemispheric Infarctions
Authors: Ansari J. , Fakhre W. , Simoncini P. , Ayub M. , Bocklud B. , Shah R. , Chokhawala H. , Guthikonda B. , Cuellar H. 
Published: January 2025

Introduction/Purpose
Large hemispheric infarction (LHI) is a severe form of ischemic stroke that affects the majority or entirety of the middle cerebral artery (MCA) territory, potentially involving the anterior cerebral artery and posterior cerebral artery territories, and is characterized by the development of life‐threatening cerebral edema. Although LHI accounts for a small percentage (≤10%) of acute ischemic strokes, it is associated with high morbidity and mortality rates. More than 50% of LHI patients develop malignant cerebral edema (MCE), leading to rapid neurological deterioration within 2 to 3 days of symptom onset. This study aims to assess the impact of revascularization therapies, including intravenous tissue plasminogen activator (tPA) and mechanical thrombectomy (MT), and decompressive hemicraniectomy (DHC) on functional outcomes in patients with LHI, focusing on the distinction between good (mRS 0‐4) and poor (mRS 5‐6) outcomes.

Materials/Methods
We retrospectively analyzed 124 patients with LHI treated at our center from November 2015 to March 2023. Patients were categorized into two groups based on their discharge modified Rankin Scale (mRS): good outcome (mRS 0‐4) and poor outcome (mRS 5‐6). Further subgrouping was based on the use of revascularization therapies (intravenous tPA and/or MT) and whether DHC was performed. Data on demographic variables, clinical parameters, and treatment details were collected. Statistical analyses included logistic regression to evaluate associations between revascularization therapies, DHC, and functional outcomes.

Results
Of the 124 patients with LHI, 48 (38.7%) achieved a good outcome (mRS 0‐4) at discharge, while 76 (61.3%) had a poor outcome (mRS 5‐6). Among those with good outcomes, 22 (45.8%) received intravenous tPA, 19 (39.6%) underwent MT, and 15 (31.3%) underwent DHC. In the poor outcome group, 28 (36.8%) received intravenous tPA, 21 (27.6%) underwent MT, and 23 (30.3%) underwent DHC. Patients who received both intravenous tPA and MT were more likely to have a good outcome (mean mRS 3.6, SD 2.51), whereas those without any revascularization therapy were more likely to have poor outcomes (mean mRS 5.02, SD 1.16). The addition of DHC did not significantly improve outcomes when revascularization therapies were absent. Logistic regression analysis showed no statistically significant association between the use of intravenous tPA, MT, or DHC and achieving a good outcome at discharge.

Conclusion
In our single‐center study of 124 patients with LHI, neither DHC, intravenous tPA, nor MT alone was significantly associated with achieving good functional outcomes at discharge. While the combination of both intravenous tPA and MT showed a trend toward better outcomes, this was not statistically significant. The findings suggest a complex interplay between revascularization strategies and decompressive surgery in managing LHI, highlighting the need for further research to better understand optimal patient selection and timing for these interventions.