Trends and predictors of decompressive craniectomy in acute ischemic stroke, 2011-2020

•Rates of decompressive craniectomy in acute ischemic stroke have been increasing over time.•Increasing rates of endovascular therapy in acute ischemic stroke does not seem to be preventing the occurrence of decompressive craniectomy.•The main predictors of decompressive craniectomy are age, hospital stroke volume, hospital teaching status, and transfer status; endovascular therapy does not predict decompressive craniectomy. Rates of decompressive craniectomy (DC) in acute ischemic stroke (AIS) have been reported to decline over time, attributed to an increase in endovascular therapy (EVT) preventing the development of malignant cerebral edema. We sought to characterize trends in DC in AIS between 2011 and 2020. We performed a retrospective observational study of U.S. AIS hospitalizations using the National Inpatient Sample, 2011 to 2020. We calculated rates of DC per 10,000 AIS among all AIS hospitalizations, as well as AIS hospitalizations undergoing invasive mechanical ventilation (IMV). A logistic regression to determine predictors of DC was performed. Of ∼4.4 million AIS hospitalizations, 0.5 % underwent DC; of ∼300,000 AIS with IMV, 5.8 % underwent DC. From 2011 to 2020, the rate of DC increased from 37.4 to 59.1 per 10,000 AIS (p < 0.001). The rate of DC in patients undergoing IMV remained stable at ∼550 per 10,000 (p = 0.088). The most important factors predicting DC were age (OR 4.88, 95 % CI 4.53–5.25), hospital stroke volume (OR 2.61, 95 % CI 2.17–3.14), hospital teaching status (OR 1.54, 95 % CI 1.36–1.75), and transfer status (OR 1.53, 95 % CI 1.41–1.66); EVT status did not predict DC. The rate of DC in AIS has increased between 2011 and 2020. Our findings are contrary to prior reports of decreasing DC rates over time. Increasing EVT rates do not seem to be preventing the occurrence of DC. Future research should focus on the decision-making process for both clinicians and surrogates regarding DC with consideration of long-term outcomes.