We aim to determine the incidence of decompressive hemicraniectomy (DHC) in the modern era of mechanical thrombectomy techniques and improved revascularization outcomes.

We performed a retrospective analysis of 512 patients admitted with acute ischemic strokes with anterior circulation large-vessel occlusion that were treated by mechanical thrombectomy from 2010–2019. The primary endpoint was the need for surgical decompression. Secondary endpoints were infarct size, hemorrhagic conversion, and functional outcome at hospital discharge.

Of the 512 patients, 18 (3.5%) underwent DHC at a median 2.0 days from stroke onset. The DHC group was significantly younger than the non-DHC group (P < 0.001), had worse reperfusion rates (P = 0.024) and larger infarct size (P < 0.001). Hemorrhagic conversion was more frequent in the DHC group but did not reach statistical significance (P = 0.08). From 2010–2015, 196 patients underwent a mechanical thrombectomy, 13 of whom (6.6%) required a DHC, while 316 patients underwent mechanical thrombectomy from 2016–2019 and only 5 patients required a DHC (1.6%; P = 0.002). Younger age (P < 0.001), urinary tract infection (P < 0.001) and increasing infarct size were significantly associated with needing a DHC. When controlling for other risk factors, higher thrombolysis in cerebral infarction score significantly reduced the need for decompressive hemicraniectomy (P = 0.004).

This is one of the largest single-center experiences demonstrating that improved recanalization decreased the need for DHC without increasing the risk of hemorrhagic conversion.