Decompressive Craniectomy After Reperfusion Therapy in Acute Ischemic Stroke: A Clinical Experience

Decompressive craniectomy (DC) is a life-saving intervention for malignant cerebral edema following large territorial infarctions. While numerous studies demonstrate reduced mortality with DC, most data are derived from patients who did not receive reperfusion therapy. Outcomes in patients undergoing DC after reperfusion remain insufficiently characterized. This study presents our clinical experience in this population, focusing on demographics, clinical course, complications, and prognostic factors. We retrospectively analyzed 33 patients with acute ischemic stroke treated at Bursa City Hospital between July 2020 and January 2025. All underwent intravenous thrombolysis, endovascular therapy, or both, followed by DC during Neurology Intensive Care Unit stay. Functional outcomes were assessed at 90 days using the modified Rankin Scale (mRS). The mean age was 64.3 ± 14.4 years, and successful recanalization (≥ mTICI 2b) was achieved in 90.3% of cases. Hemorrhagic transformation occurred in 81%, with symptomatic intracerebral hemorrhage in 60.6%. DC was performed within 48 hours in 78.7% of patients. At 3-month follow-up, mortality was 48.4%, and all survivors had severe disability (mRS 4–5). Compared with historical data from patients who did not receive reperfusion therapy, the absence of favorable outcomes in our cohort may relate to the high rate of hemorrhagic transformation after reperfusion, potentially exerting a detrimental effect on neurological recovery. Larger randomized controlled trials are needed to determine which patients who underwent reperfusion therapy may derive meaningful benefit from DC.