DECOMPRESS-2
Outcomes of Decompressive Surgery for Patients With Severe Cerebral Venous Thrombosis: DECOMPRESS2 Observational Study
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 | Control | Intervention | HR / OR / RR | P-value |
|---|---|---|---|---|---|
| Death or severe disability (mRS 5–6) at 12 months | Primary | 39% | |||
| Functional independence (mRS 0–2) at 12 months | Secondary | 34% | |||
| Complete recovery (mRS 0–1) | Secondary | 16.1% | |||
| Cumulative mortality at 12 months | Secondary | 34% | |||
| Seizures | Adverse | 10% (discharge), 13–16% during follow-up | |||
| New bleeding | Adverse | 14% | |||
| Pulmonary infection | Adverse | 23% | |||
| Pulmonary embolism | Adverse | 5% | |||
| Reoperation | Adverse | 15% | |||
| Cranioplasty | Adverse | 26% (total) |
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.