COVID-19 and Decompressive Hemicraniectomy for Acute Ischemic Stroke

Liang, John W.; Reynolds, Alexandra S.; Reilly, Kaitlin; Lay, Cappi; Kellner, Christopher P.; Shigematsu, Tomoyoshi; Gilligan, Jeffrey; Majidi, Shahram; Al-Mufti, Fawaz; Bederson, Joshua B.; Mocco, J.; Dhamoon, Mandip S.; Dangayach, Neha S.

Young patients with malignant cerebral edema have been shown to benefit from early decompressive hemicraniectomy. The impact of concomitant infection with coronavirus disease 2019 (COVID-19) and how this should weigh in on the decision for surgery is unclear. METHODS: We retrospectively reviewed all COVID-19–positive patients admitted to the neuroscience intensive care unit for malignant edema monitoring. Patients with >50% of middle cerebral artery involvement on computed tomography imaging were considered at risk for malignant edema. RESULTS: Seven patients were admitted for monitoring of whom 4 died. Cause of death was related to COVID-19 complications, and these were either seen both very early and several days into the intensive care unit course after the typical window of malignant cerebral swelling. Three cases underwent surgery, and 1 patient died postoperatively from cardiac failure. A good outcome was attained in the other 2 cases. CONCLUSIONS: COVID-19–positive patients with large hemispheric stroke can have a good outcome with decompressive hemicraniectomy. A positive test for COVID-19 should not be used in isolation to exclude patients from a potentially lifesaving procedure.