Abstract W P299: Impact of an Institutional Guideline on Implementing Early Decompressive Hemicraniectomy (DHC) for Large Middle Cerebral Artery Stroke
Background: Recent AHA Acute Stroke Guidelines endorse DHC (Class 1, Level B) based on clinical trials showing benefit of early DHC on outcome and mortality. In 2011, our multidisciplinary quality improvement team developed a process to translate DHC guideline recommendations into clinical practice.
Methods: Our consensus guideline includes a tool (STATE Criteria, based on inclusion/exclusion criteria of DHC clinical trials) to rapidly identify and triage potential DHC candidates, and provide specific guidelines for pre- and post-surgical management, adjunctive therapy, and DHC after IV/IA thrombolysis. Patients meeting all STATE Criteria including age ≤ 60 years are sent for urgent DHC. Patients meeting all criteria except age ≤ 60 years receive DHC only if age < 75 years and Neurology and Neurosurgery teams reach consensus about benefit. Patients not meeting criteria are observed and referred for DHC if criteria are met within 48 hours of onset. The guideline was disseminated to all stakeholders via email, conferences, and intranet. In this study, we retrospectively analyzed process and outcome measures for DHC before and after guideline implementation in February 2011.
Results: Of 1518 stroke patients age ≤ 60 years admitted between January 2007 and April 2014, 47 (3%) received DHC (22 pre- and 25 post-guideline implementation; 28% female, 13% Hispanic). Mean admission NIHSS was similar (17±7 vs 18±5; p=.82). Mean time from admission to DHC improved significantly from 45±30 hours to 29±18 hours (p=0.04). The percentage of patients undergoing DHC beyond 48 hours decreased from 27% to 16% (p=0 .35). The degree of midline shift evident on CT or MRI prior to DHC significantly decreased from 9±4 mm to 5±4 mm (p=.01). There was no significant difference in length of stay, frequency of tracheostomy, gastrostomy, pneumonia, or urinary tract infection, or percentage of patients who died within 30 days of DHC.
Conclusion: Our institutional guideline has facilitated the rapid identification and triage of patients with large MCA stroke to DHC. Follow-up is ongoing to determine the impact of our guideline on functional outcome after stroke.
Author Disclosures: C. Olm-Shipman: None. V. Marquevich: None. J. Rosand: Research Grant; Significant; NIH. Consultant/Advisory Board; Significant; Boehringer Ingelheim. A. Patel: None. E. Eskandar: None. A. Cordier: None. A. Ayres: None. L.H. Schwamm: None. A.B. Singhal: None.
- © 2015 by American Heart Association, Inc.