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Decompressive Craniectomy Elderly Stroke — FRCA Final MCQ

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HardNeuroanaesthesiaDecompressive Craniectomy Elderly StrokeFRCA Final

A 70-year-old woman (ASA III) is in the ICU following a large right MCA territory ischaemic stroke. She is intubated for airway protection (GCS 6). Her ICP is 28 mmHg measured via an EVD. The neurosurgical team are considering decompressive craniectomy. According to the DESTINY II trial, what does evidence show about decompressive craniectomy in patients >60 years with malignant MCA infarction?

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Correct answer: D — Reduces mortality but survivors have severe disability

The DESTINY II trial (2014) examined decompressive craniectomy in patients >60 years with malignant MCA infarction. It showed: significant reduction in mortality (33% vs 70%), BUT survivors predominantly had severe disability (mRS 4-5). No patients in the surgical group achieved an mRS of 0-2 (independence). This raises important ethical questions about quality of survival. The decision should involve a multidisciplinary discussion with the patient's family about likely outcomes, respecting the patient's pre-morbid wishes regarding disability.

Reference: Juttler E et al – 2014 – DESTINY II trial; NICE – 2019 – NG128 Stroke