Abstract 128: The Increasing Utilization of Hemicraniectomy for Acute Ischemic Stroke in the United States
Background: The survival outcome of malignant middle cerebral artery infarcts is dismal. In 2007, the pooled analysis from the DECIMAL (Decompressive craniectomy in malignant middle cerebral artery infarcts), DESTINY (Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery) and HAMLET (Hemicraniectomy after middle cerebral artery infarction with life-threatening edema) trials demonstrated a substantial survival benefit from this procedure with a number needed to treat of two for survival. Our objective was to review the nationwide utilization of this potentially life-saving procedure over the last decade.
Methods: Data from the Nationwide Inpatient Sample for the years 2001 through 2009 were reviewed. Hospitalizations with a discharge diagnosis of an acute ischemic stroke (ICD-9 codes: 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 424.01, 434.11, 434.91 and 436) were included. Hemicraniectomy utilization was determined using procedure codes 01.2, 01.25 and 02.01 within this subset. Nationwide estimates of utilization were calculated for each year. The Cochrane Armitage test was used to assess trend across the years.
Results: From 2001 through 2009, there were an estimated 4,917,217 admissions for acute ischemic stroke. Over the 9 years of the study period, the estimated frequency of hemicraniectomy procedures progressively increased from 123 (0.02% of stroke discharges in 2001) to 850 (0.16% of stroke discharges in 2009); trend p<0.0001. The rate of utilization increased largely after 2006. The increase was noted for younger subjects (age < 45 years; trend p<0.0001) and older subjects (age ≥ 45 years; trend p<0.0001). Utilization significantly increased for males and females (trend p<0.0001 for both subgroups). For each year, utilization of hemi-craniectomy was greater amongst males. In contrast with rural and urban nonteaching hospitals, urban teaching hospitals were responsible for the greatest increase in hemicraniectomy utilization: from 0.05% of stroke discharges in 2001 to 0.30% of stroke discharges in 2009.
Conclusion: The utilization of hemicraniectomy for acute ischemic stroke has increased significantly, coinciding with the publication of compelling results from clinical trials. Early transfer of patients with large middle cerebral artery infarcts to urban teaching centers could potentially extend the survival benefit to a larger population.
- © 2012 by American Heart Association, Inc.