Global Survey: Challenges of Decompressive Craniectomy after Endovascular Thrombectomy

Dear Colleagues

Decompressive craniectomy (DC) as a rescue therapy after endovascular thrombectomy (EVT) presents several challenges that vary across different regions of the world. The availability of neurological and neurosurgical expertise, access to healthcare facilities, and disparities in healthcare infrastructure can significantly influence the outcomes and feasibility of DC. In low- and middle-income countries, limited access to specialized surgical teams and critical care resources may hinder the timely performance of DC, impacting patient survival and recovery rates. In contrast, high-income countries might face challenges related to the optimization of patient selection and balancing the risks of the procedure against potential benefits, particularly in elderly or comorbid populations. Conducting a global survey to gather the opinions of medical staff involved in these procedures is crucial for understanding these regional differences. It can provide insight into the barriers faced, resource limitations, and variations in clinical practice, helping to establish guidelines that are more globally inclusive and equitable.

We would be grateful if you could provide your opinion to foster international collaboration and knowledge exchange, ultimately aiming to improve patient outcomes regardless of geographical location.

Your valuable input is crucial to this effort. It will foster international collaboration and knowledge exchange, ultimately helping us improve patient outcomes regardless of geographical location.The survey will take 3 to 5 minutes.

We look forward to your participation.

Sincerely,

Suyue Pan,Thanh Nguyen,Urs Fischer,Yimin Chen, Mingzhu Feng,Mohammad  Mofatteh et.
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1.First section: Baseline
1.1.Your email:

(only used for administrative tracking purposes)

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1.2.What is your country of practice?
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1.3.What is your role in treating patients?
A.Neurologist
B.Interventionist/Interventional Radiologist/Interventional Neurologist
C.Neurosurgeon
D.ICU Physician
E.Neurocritical Care Physician
F.Internal Medicine Physician
G.Resident or Fellow
H.Other (please specify)
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1.4.What is your gender?
A.Male
B.Female
C.Non-binary
D. Prefer not to disclose
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1.5.How many years of experience do you have in your position listed above?
A.0-5 years
B.6-10 years
C.11-15 years
D.>15 years
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2.Second section: Clinical Practice
2.1.How many endovascular thrombectomy procedures for ischemic stroke were performed at your center in the last 12 months?
A.None
B.Less than 30
C.30 to 100
D.Over 100
E.Not sure
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2.2.What percentage of patients do you estimate receive decompressive craniectomy after endovascular thrombectomy during the last 12 months?
A.Less than 5%
B.5% to 10%
C.Over 10%
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2.3.Does your center have a neurological intensive care unit?
A.Yes
B.No
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2.4.Do you personally perform endovascular thrombectomy?
A.Yes
B.No
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2.5.If a patient with a large stroke is indicated for decompressive craniectomy, what percentage of patients or their deputies/representative agree to do the decompressive craniectomy if you suggest decompressive craniectomy? (fill 0 to 100%) 
(fill 0 to 100)
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2.6.I believe that, in certain situations, decompressive craniectomy is superior to standard medical treatment for patients with ischemic stroke of large infarction.
A.Strongly agree
B.Somewhat agree
C.Neither agree nor disagree
D.Somewhat disagree
E.Strongly disagree
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2.7.I believe that, in certain situations, early decompressive craniectomy before cerebral herniation for patients is indicated with ischemic stroke of large infarction.
A.Strongly agree
B.Somewhat agree
C.Neither agree nor disagree
D.Somewhat disagree
E.Strongly disagree
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2.8.I believe that, in certain situations, some endovascular thrombectomy patients, who are highly likely to progress to herniation, should receive immediately decompressive craniectomy just after endovascular thrombectomy before herniation.
A.Strongly agree
B.Somewhat agree
C.Neither agree nor disagree
D.Somewhat disagree
E.Strongly disagree
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2.9.Has your center ever performed endovascular thrombectomy cases with immediate decompressive craniectomy to prevent hernia?
A.Yes
B.No
C.Not sure
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2.10.I believe that endovascular thrombectomy patients in my current center, who need decompressive craniectomy underwent decompressive craniectomy procedure in time.
A.Always
B.Often
C.Sometimes
D.Rarely
E.Never
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2.11.What are the most common clinical factors considered at your institution when deciding if decompressive craniectomy is necessary as rescue therapy after endovascular thrombectomy in acute ischemic stroke patients? (Select all that apply)[Multiple]
A.Neurological deterioration
B.Development of malignant edema on imaging
C.Increased intracranial pressure refractory to medical management
D.Progressed to a cerebral hernia
E.Age
F.Comorbidities
G.Socioeconomic conditions
H.Other (please specify)
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2.12.What is the typical timeframe at your institution for considering decompressive craniectomy as rescue therapy after endovascular thrombectomy in acute ischemic stroke patients? (Select one)
A.Within 24hours
B.Within 48 hours
C.Within 96 hours
D.Depending on individual patient presentation and clinical deterioration
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2.13.What are the most common clinical factors associated with delayed (e.g., cerebral hernia) decompressive craniectomy as rescue therapy after endovascular thrombectomy in acute ischemic stroke patients? (Select all that apply)[Multiple]
A.Availability of surgical resources
B.Institutional protocols
C.Patient and family preferences
D.Neurosurgeon delayed decisions
E.Supervising doctor delayed detection
F.Others（specified）
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2.14.In your experience, what are the main benefits of using decompressive craniectomy as rescue therapy after endovascular thrombectomy in acute ischemic stroke patients? (Select all that apply)[Multiple]
A.Improved survival rates
B.Reduced risk of herniation and improved neurological outcomes
C.Improving the opportunities to achieve normal functional independence.
D.Other (please specify)
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2.15.In your experience, what are the main challenges associated with using decompressive craniectomy as rescue therapy after endovascular thrombectomy in acute ischemic stroke patients? (Select all that apply)[Multiple]
A.Increased risk of surgical complications
B.Limited window for successful intervention
C.Difficulty in predicting patient response and limited clinical value
D.Hospitalization costs
E.Other (please specify)
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3.Third section: Future Considerations
3.1.Do you believe that additional randomized controlled trials are warranted for decompressive craniectomy in patients with ischemic stroke after endovascular thrombectomy?
A.Definitely yes
B.Probably yes
C.Might or might not
D.Probably not
E.Definitely not
3.2.Please leave any additional comments that you may have here:
Thank you for your time and valuable contribution to this global survey!
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