Previous trials showed the substantial survival benefit of decompressive hemicraniectomy and duroplasty within 48 hours of malignant MCA strokes (29% versus 78% at 1 year), and achieve a severe disability of 4% versus 5% in controls. The randomized DESTINY II trial with elderly patients (62-82yo) at 13 German Sites from 2009-12 was stopped due to efficacy. Inclusion criteria required NIHSS > 14 for right sided strokes, NIHSS > 19 for left sided strokes. At six months, survival without severe disability (mRS 4 or less) was 38% for surgical patients versus 18% in controls. The surgical survival advantage persisted at 12 months (56% versus 24%). Surgery reduced 1-year mortality by 33%, whereas surgery in younger patients reduced 1-year mortality by 50%. 1-year survival with severe disability (mRS=5) is 19% compared to 4% in younger patients. This trial shows surgery improves survival in elderly patients, with most survivors having substantial disability.
The New England Journal of Medicine