ORACLE Stroke Study: Opinion Regarding Acceptable Outcome Following Decompressive Hemicraniectomy for Ischemic Stroke

Abstract

Background: There continues to be considerable interest in the use of decompressive hemicraniectomy in the management of malignant cerebral artery infarction; however, concerns remain about long-term outcome.

Objective: To assess opinion on consent and acceptable outcome among a wide range of healthcare workers.

Methods: Seven hundred seventy-three healthcare workers at the 2 major public neurosurgical centers in Western Australia participated. Participants were asked to record their opinion on consent and acceptable outcome based on the modified Rankin Score (mRS). The evidence for clinical efficacy of the procedure was presented, and participants were then asked to reconsider their initial responses.

Results: Of the 773 participants included in the study, 407 (52.7%) initially felt that they would provide consent for a decompressive craniectomy as a lifesaving procedure, but only a minority of them considered an mRS score of 4 or 5 an acceptable outcome (for mRS score ≤4, n = 67, 8.7%; for mRS score = 4, n = 57, 7.4%). After the introduction of the concept of the disability paradox and the evidence for the clinical efficacy of decompressive craniectomy, more participants were unwilling to accept decompressive craniectomy (18.1% vs 37.8%), but at the same time, more were willing to accept an mRS score ≤4 as an acceptable outcome (for mRS score ≤4, n = 92, 11.9%; for mRS score = 4, n = 79, 10.2%).

Conclusion: Most participants felt survival with dependency to be unacceptable. However, many would be willing to provide consent for surgery in the hopes that they may survive with some degree of independence.

Abbreviations: DESTINY, Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral ArterymRS, modified Rankin Scale.