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Background:Decompressive hemicraniectomy (DHC), performed in select patients with malignant infarction (MCI), reduces mortality. However, there is conflicting evidence surrounding the use of DHC in improving disability outcomes in this patient population. This is in part due to differing definitions of functional recovery in prior studies. The purpose of this study is to characterize a cohort of patients with ischemic stroke who underwent DHC and compare the outcomes data with pooled data from three major trials published for DHC (DECIMAL, DESTINY, and HAMLET).Methods:This was a retrospective, observational cohort study of consecutive patients who underwent DHC as part of best clinical care during 2015-2020. We report our cohort using descriptive statistics.Results:Of the 44 patients underwent DHC at our institution, 33 were included for analysis after applying the inclusion and exclusion criteria based on the three major trials. Our DHC cohort tended to have higher rates of comorbidities including hypertension and diabetes (Table 1).A greater number of our DHC patients had unfavorable modified Rankin Scale (mRS) scores of 4 or 5 at 6-month follow-up compared to those who underwent DHC or received conservative therapy at 12-month follow-up in the three prospective trials (Figure 1).Conclusion:DHC in patient cohorts with significant comorbid data is associated with reduced mortality but a worsened functional outcome in survivors. The treating practitioner should consider this procedure only in the context of a lengthy discussion regarding the patient’s baseline functional and health status as well as competing benefits and risks associated with this procedure.

Introduction:The carotid web is a compelling potential mechanism of embolic ischemic stroke. In this study, we perform a systematic review and meta-analysis to determine the prevalence of ipsilesional carotid webs in patients with acute ischemic stroke.Methods:We performed a systematic review of prospective and retrospective observational studies enrolling consecutive patients with acute ischemic stroke. We included only studies in which high quality imaging of the cervical vessels was performed and in which the presence or absence of carotid web was adjudicated based on established criteria. The prevalence of carotid web was calculated in each study and pooled prevalence calculated via a random effects model. We also calculated relative risks of carotid web ipsilateral versus contralateral to stroke in the same pool of patients and performed sensitivity analyses including patients with cryptogenic stroke, patients less than 60 and patients with cryptogenic stroke <60.Results:A systematic review yielded 3,814 patients from 11 studies of whom 1,127 had cryptogenic stroke. We identified 4 studies in which we could derive data on patients <60 with cryptogenic stroke, a total of 332 patients. The relative risk of carotid web ipsilateral versus contralateral to ischemic stroke was 2.6 (95%: 1.6-4.3, p<0.01) in all patients with acute ischemic stroke and 3.0 (95% CI: 1.6-5.8, p<0.01) in patient less than 60 with cryptogenic stroke (Figure A-C). The pooled prevalence of ipsilateral carotid web in patients <60 with cryptogenic stroke was 13% (95% CI: 7%-22%; I2= 66.1%) (Figure D).Discussion:Carotid webs are more common in young patients with ESUS than in other stroke subtypes. Future studies concerning the diagnosis and secondary prevention of stroke associated with carotid web should focus on this population.