DESTINY II study: Opening the skull halves mortality

29.05.2013 12:21

In Germany, at least 5,000 people every year suffer a particularly severe stroke, an occlusion of the middle cerebral artery. Half of those affected are over 60 years old, and most die from massive brain swelling. The multicenter study DESTINY II now shows that if neurosurgeons open the skull to reduce the life-threatening pressure inside the skull, the mortality of patients over 60 years of age drops from 73 to 33 percent. However, severe disabilities and the need for care can result, explained Professor Dr. med. Andreas Unterberg at today's press conference on the occasion of the 64th annual meeting of the German Society for Neurosurgery (DGNC). “There are fundamental ethical questions here that we need to discuss,” says Unterberg. The full results of the DESTINY II trial will be presented for the first time at the European Stroke Conference, which began on May 28 in London.

The feared consequence of a severe heart attack is severe brain swelling. Without surgery, up to 80 percent of affected patients die. That's why neurosurgeons have been performing a so-called relief craniectomy on people under 60 for several years, which saves the lives of most patients. During the procedure, doctors temporarily remove a large part of the skull and open the hard meninges over the stroke area with an incision so that the swelling brain mass has enough space. “Many younger patients also initially suffer from paralysis or speech disorders,” explains Professor Dr. Andreas Unterberg, Director of the Clinic and Polyclinic for Neurosurgery at Heidelberg University Hospital. “However, these limitations partially disappear through rehabilitation.”

However, at least half of patients who suffer a severe medial cerebral infarction are over 60 years old. The DESTINY II study therefore examined the question of whether this intervention also makes sense for older people. Two groups were compared, the average age of which was 70 years. A relief craniectomy was performed on 49 randomly selected stroke patients. The doctors treated the other 63 patients with the usual intensive care measures, but without surgery. The results were so clear that the study had to be stopped: While 73 percent of the non-operated patients died, only 33 percent died in the surgically treated group.

“However, many patients survived this procedure with severe, permanent disabilities,” emphasizes Andreas Unterberg. Therefore, the decision about such an intervention in an older stroke patient must be made jointly by neurosurgeons, neurologists, relatives and - if possible - also with the patient himself. “The doctors should discuss with the family what attitude the patient has towards life with a disability,” recommends Unterberg.

The task of the future will now be to identify prognostic factors for the success of a relief craniectomy. “We want to filter out on a scientific basis which older patients benefit from this procedure and survive with a good quality of life and little disability,” explains Unterberg.