Published Online
on August 9, 2007

A more recent version of this article appeared on September 1, 2007

This Article Full Text (PDF) CME: Take the course for this article: Stroke: September 2007, Volume 38, Number 9 All Versions of this Article: 38/9/2518    most recent STROKEAHA.107.485649v1 Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Jüttler, E. Search for Related Content PubMed PubMed Citation Articles by Jüttler, E. Pubmed/NCBI databases Medline Plus Health Information Stroke Related Collections Acute Cerebral Infarction Brain Circulation and Metabolism Other Stroke Treatment - Surgical

Submitted on February 22, 2007
Revised on April 27, 2007
Accepted on May 3, 2007

Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY). A Randomized, Controlled Trial

Eric Jüttler MD; Stefan Schwab MD, PhD; Peter Schmiedek MD, PhD; Andreas Unterberg MD, PhD; Michael Hennerici MD, PhD; Johannes Woitzik MD; Steffen Witte PhD; Ekkehart Jenetzky MD; Werner Hacke MD, PhD^*; for the DESTINY Study Group

From the Department of Neurology (E.J., S.S., W.H.), University Hospital Heidelberg, University of Heidelberg, Heidelberg; the Department of Neurology (S.S.), University Hospital Erlangen, University of Erlangen, Erlangen; the Department of Neurosurgery (P.S., J.W.), University Hospital Mannheim, University of Heidelberg, Heidelberg; the Department of Neurosurgery (A.U.), University Hospital Heidelberg, University of Heidelberg, Heidelberg; the Department of Neurology (M.H.), University Hospital Mannheim, University of Heidelberg, Heidelberg; and the Institute of Medical Biometry and Informatics (S.W., E.J.), University of Heidelberg, Heidelberg, Germany.

^* To whom correspondence should be addressed. E-mail: werner.hacke{at}med.uni-heidelberg.de.

Background and Purpose—Decompressive surgery (hemicraniectomy) for life-threatening massive cerebral infarction represents a controversial issue in neurocritical care medicine. We report here the 30-day mortality and 6- and 12-month functional outcomes from the DESTINY trial.

Methods—DESTINY (ISRCTN01258591) is a prospective, multicenter, randomized, controlled, clinical trial based on a sequential design that used mortality after 30 days as the first end point. When this end point was reached, patient enrollment was interrupted as per protocol until recalculation of the projected sample size was performed on the basis of the 6-month outcome (primary end point=modified Rankin Scale score, dichotomized to 0 to 3 versus 4 to 6). All analyses were based on intention to treat.

Results—A statistically significant reduction in mortality was reached after 32 patients had been included: 15 of 17 (88%) patients randomized to hemicraniectomy versus 7 of 15 (47%) patients randomized to conservative therapy survived after 30 days (P=0.02). After 6 and 12 months, 47% of patients in the surgical arm versus 27% of patients in the conservative treatment arm had a modified Rankin Scale score of 0 to 3 (P=0.23).

Conclusions—DESTINY showed that hemicraniectomy reduces mortality in large hemispheric stroke. With 32 patients included, the primary end point failed to demonstrate statistical superiority of hemicraniectomy, and the projected sample size was calculated to 188 patients. Despite this failure to meet the primary end point, the steering committee decided to terminate the trial in light of the results of the joint analysis of the 3 European hemicraniectomy trials.

Key words: decompressive surgery • malignant middle cerebral artery infarction • randomized trials

This article has been cited by other articles:

				T. Pfefferkorn, U. Eppinger, J. Linn, T. Birnbaum, J. Herzog, A. Straube, M. Dichgans, and S. Grau Long-Term Outcome After Suboccipital Decompressive Craniectomy for Malignant Cerebellar Infarction Stroke, September 1, 2009; 40(9): 3045 - 3050. [Abstract] [Full Text] [PDF]

				V. Prinz and M. Endres The Acute (Cerebro)Vascular Effects of Statins Anesth. Analg., August 1, 2009; 109(2): 572 - 584. [Abstract] [Full Text] [PDF]

				J. Diedler, M. Sykora, M. Blatow, E. Juttler, A. Unterberg, and W. Hacke Decompressive Surgery for Severe Brain Edema J Intensive Care Med, May 1, 2009; 24(3): 168 - 178. [Abstract] [PDF]

				S. A. Mayer, S. M. Davis, B. E. Skolnick, N. C. Brun, K. Begtrup, J. P. Broderick, M. N. Diringer, and T. Steiner Can a Subset of Intracerebral Hemorrhage Patients Benefit From Hemostatic Therapy With Recombinant Activated Factor VII? Stroke, March 1, 2009; 40(3): 833 - 840. [Abstract] [Full Text] [PDF]

				The Optimising the Analysis of Stroke Trials (OAST Should Stroke Trials Adjust Functional Outcome for Baseline Prognostic Factors? Stroke, March 1, 2009; 40(3): 888 - 894. [Abstract] [Full Text] [PDF]

				S. Nagel, P. D. Schellinger, M. Hartmann, E. Juettler, H. B. Huttner, P. Ringleb, S. Schwab, and M. Kohrmann Therapy of Acute Basilar Artery Occlusion: Intraarterial Thrombolysis Alone vs Bridging Therapy Stroke, January 1, 2009; 40(1): 140 - 146. [Abstract] [Full Text] [PDF]

				H.-C. Diener, H. Mattle, M. Böhm, and F. Ruschitzka CHAPTER 15a The Heart and the Brain ESC Textbook of Cardiovascular Medicine, January 1, 2009; 2(1): med-9780199566990-chapter - med-9780199566990-chapter. [Abstract] [Full Text]

				V. Ramaswamy, V. Mehta, M. Bauman, L. Richer, P. Massicotte, and J. Y. Yager Decompressive Hemicraniectomy in Children With Severe Ischemic Stroke and Life-Threatening Cerebral Edema J Child Neurol, August 1, 2008; 23(8): 889 - 894. [Abstract] [PDF]

				S. A. Mayer Hemicraniectomy: A Second Chance on Life for Patients With Space-Occupying MCA Infarction Stroke, September 1, 2007; 38(9): 2410 - 2412. [Full Text] [PDF]