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DECOMPRESS-2

Outcomes of Decompressive Surgery for Patients With Severe Cerebral Venous Thrombosis: DECOMPRESS2 Observational Study

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Year of Publication: 2024

Authors: Sanjit Aaron, Jorge M. Ferreira, Jonathan M. Coutinho, ..., José M. Ferro

Journal: Stroke

Citation: Stroke. 2024;55:1218–1226. DOI: 10.1161/STROKEAHA.123.045051

Link: https://www.ahajournals.org/doi/10.1161/STROKEAHA.123.045051

Clinical Question

What are the outcomes and predictors of decompressive surgery in patients with severe cerebral venous thrombosis (CVT)?

Bottom Line

Decompressive surgery in severe CVT patients resulted in 66% survival and 34% functional independence at 12 months. Coma and fixed pupils were predictors of poor outcome, but a substantial portion still recovered, supporting guideline recommendations for surgery in malignant CVT.

        Major Points
        Largest prospective international cohort of decompressive surgery in CVT
66% survival at 12 months; 34% were independent (mRS 0–2)
Coma and fixed pupils predicted poor outcome (OR ~2.3)
Substantial functional recovery occurred over 12 months: mRS 0–1 rose from 2% at discharge to 16%
Surgery judged worthwhile by 4 out of 5 patients and caregivers at 1 year
Surgical complications included bleeding (14%), infections (23%), and seizures (10%)
Supports ESO-EAN guideline recommendations for decompression in malignant CVT

      

Design

Study Type: Prospective observational cohort

Randomization:

Blinding: Unblinded, but mRS assessed by independent investigators

Enrollment Period: December 2011 – December 2019

Follow-up Duration: 12 months

Centers: 15

Countries: Portugal, India, Netherlands, Brazil, Mexico, Singapore, Finland, Germany, UK, Spain

Sample Size: 118

Analysis: Descriptive and multivariable logistic regression for predictors of death/disability; subgroup and sensitivity analyses

Inclusion Criteria

Confirmed CVT by CT/MR venography or intra-arterial venography
Treated with decompressive craniectomy and/or hematoma evacuation
Informed consent per local law

Exclusion Criteria

CVT diagnosed at autopsy or exploratory neurosurgery
CVT with head trauma or other brain disorders needing surgery (e.g., AVM, SDH)

Arms

Field	Decompressive Neurosurgery
Intervention	Decompressive craniectomy with/without hematoma evacuation (as per local judgment)
Duration	Single procedure; median 1 day after diagnosis

Outcomes

Outcome	Type	Intervention	P-value
Death or severe disability (mRS 5–6) at 12 months	Primary	39%
	Secondary	34%
	Secondary	16.1%
	Secondary	34%
10% (discharge), 13–16% during follow-up			Adverse
14%			Adverse
23%			Adverse
5%			Adverse
15%			Adverse
26% (total)			Adverse

Subgroup Analysis

Worse outcomes in >60 y/o, bilateral surgery, hematoma-only evacuation; no subgroup showed statistically significant difference. Coma and fixed pupils were strongest predictors of death/severe disability (OR 2.39 and 2.22, respectively) [oai_citation:0‡DECOMPRESS-2.pdf](file-service://file-4wmnZqi4MoivR4i3aoh41B)

Criticisms

No control group, observational design limits causal inference
Selection bias possible due to inclusion only of surgical patients
High variability in timing and technique across centers
Generalizability limited by low representation of posterior fossa cases and elderly

Funding

Instituto de Medicina Molecular João Lobo Antunes

Based on: DECOMPRESS-2 (Stroke, 2024)

Authors: Sanjit Aaron, Jorge M. Ferreira, Jonathan M. Coutinho, ..., José M. Ferro

Citation: Stroke. 2024;55:1218–1226. DOI: 10.1161/STROKEAHA.123.045051

Content summarized and formatted by NeuroTrials.ai.

DECOMPRESS-2

(2024)

Objective

Long-term outcomes and predictors of decompressive surgery in patients with severe cerebral venous thrombosis (CVT).

Study Summary

• Two-thirds of patients survived and over one-third regained independence after decompressive surgery for CVT, supporting its use in malignant cases with impending herniation.

Intervention

Decompressive craniectomy (unilateral or bilateral) with or without hematoma evacuation. Median surgery timing was 1 day after diagnosis. All patients received standard supportive care.

Inclusion Criteria

Patients with CVT confirmed by MR/CT venography, treated with decompressive surgery, and without other neurosurgical indications (e.g., trauma, AVM, SDH).

Study Design

Arms: Single Arm: Decompressive Surgery

Patients per Arm: 118

Outcome

• Primary (mRS 5–6 at 12 months): 39%, including 34% mortality.• mRS 0–2 at 12 months: 34%; mRS 0–1: 16%.• At discharge: mRS 0–2 in 8%, mRS 5–6 in 44%.• mRS 0–2 improved from 8% at discharge to 34% at 12 months.• Seizures occurred in 13% at 6 months and 16% at 12 months.• New intracranial hemorrhage: 14%, pulmonary infection: 23%, PE: 5%.• Reoperation in 15% during admission; additional surgery in 13% by 12 months.• Coma (OR 2.39) and fixed pupils (OR 2.22) predicted poor outcome.• Age >37 predicted dependence (mRS >2) at 12 months (OR 2.61).• 4 of 5 patients and caregivers judged surgery worthwhile at 12 months.

Bottom Line

Major Points

Largest prospective international cohort of decompressive surgery in CVT
66% survival at 12 months; 34% were independent (mRS 0–2)
Coma and fixed pupils predicted poor outcome (OR ~2.3)
Substantial functional recovery occurred over 12 months: mRS 0–1 rose from 2% at discharge to 16%
Surgery judged worthwhile by 4 out of 5 patients and caregivers at 1 year
Surgical complications included bleeding (14%), infections (23%), and seizures (10%)
Supports ESO-EAN guideline recommendations for decompression in malignant CVT

Study Design

Study Type: Prospective observational cohort
Randomization: No
Blinding: Unblinded, but mRS assessed by independent investigators
Sample Size: 118
Follow-up: 12 months
Centers: 15
Countries: Portugal, India, Netherlands, Brazil, Mexico, Singapore, Finland, Germany, UK, Spain

Primary Outcome

Definition: Death or severe disability (mRS 5–6) at 12 months

Control	Intervention	HR/OR	P-value
	39%	-

Limitations & Criticisms

No control group, observational design limits causal inference
Selection bias possible due to inclusion only of surgical patients
High variability in timing and technique across centers
Generalizability limited by low representation of posterior fossa cases and elderly

Citation

Stroke. 2024;55:1218–1226. DOI: 10.1161/STROKEAHA.123.045051

View Original Publication →

DECOMPRESS-2

Outcomes of Decompressive Surgery for Patients With Severe Cerebral Venous Thrombosis: DECOMPRESS2 Observational Study

Clinical Question

Bottom Line

Major Points

Design

Inclusion Criteria

Exclusion Criteria

Arms

Outcomes

Subgroup Analysis

Criticisms

Funding

Ask about DECOMPRESS-2