DESTINY II Trial: Hemicraniectomy in Older Patients With Malignant MCA Stroke
In patients aged 61 or older with malignant MCA infarction, does early decompressive hemicraniectomy within 48 hours improve survival and functional outcome compared with conservative intensive care?
Juttler et al. (NEJM 2014) · doi:10.1056/NEJMoa1311367 · 112 patients
Population
Included
- Age 61 years or older
- Malignant MCA infarction with clinical and imaging criteria for expected fatal brain swelling
- Surgery within 48 hours of stroke onset
- Pre-stroke mRS 0-1
Demographics
- 61 years of age or older
Clinical
- Clinical symptoms of acute unilateral middle-cerebral-artery infarction with an onset of symptoms less than 48 hours before the initiation of treatment
- Scores higher than 14 (nondominant hemisphere) or higher than 19 (dominant hemisphere) with reduced levels of consciousness on the NIHSS
Imaging
- Infarction of at least two thirds of the middle-cerebral-artery territory, including the basal ganglia, on brain imaging
Excluded
- Age younger than 61 years
- Pre-existing disability (mRS 2 or higher)
- Posterior circulation or bilateral infarcts
- Hemorrhagic transformation before randomization
- Major comorbidities limiting life expectancy
Pre-stroke function
- A preexisting score of more than 1 on the modified Rankin scale
- A preexisting score of less than 95 on the Barthel index
Neurological / clinical
- Absence of pupillary reflexes
- A score of less than 6 on the Glasgow Coma Scale
Imaging / lesion
- Hemorrhages or other associated brain lesions
Other
- Contraindications to surgery
- An estimated life expectancy of less than 3 years
Source: Juttler et al., N Engl J Med 2014· Retrieved 2026-06-09
Primary Outcome — Survival Without Severe Disability (mRS 0-4) at 6 Months
112 patients aged 61-82; early hemicraniectomy vs conservative intensive care
Primary endpoint met — but no patient achieved good functional outcome
0% of patients in either group achieved mRS 0-2 (independent function). Virtually all surgical survivors who met the primary endpoint had mRS 4 (severe disability, dependent for most bodily needs). Surgery reduces the chance of dying from 70% to 33% — it does not restore function.
Survival Without Being Bedbound or Dead (mRS 0-4) at 6 Months
Study Arms
- Agent
- Decompressive hemicraniectomy
- Route
- Surgical
- Duration
- Initiated within 48 hours after onset of symptoms and not later than 6 hours after randomization
- Co-interventions
- Conducted in the ICU with the same conservative protocol available to both groups: basic ICU therapy for stroke; osmotherapy with mannitol, glycerol, or hypertonic hydroxyethyl starch; sedation; intubation and mechanical ventilation; hyperventilation; and buffer solutions.
Large hemicraniectomy with a bone-flap diameter of at least 12 cm, combined with duraplasty. Performed in addition to ICU conservative care.
- Agent
- Conservative medical management
- Route
- Intensive care unit
- Co-interventions
- Same ICU conservative protocol as the surgical group.
Consensus conservative protocol used by all centers, without decompressive surgery: basic ICU therapy for stroke; osmotherapy with mannitol, glycerol, or hypertonic hydroxyethyl starch; sedation; intubation and mechanical ventilation; hyperventilation; and buffer solutions.
Trial Design
Type
- Randomized controlled trial in older adults
- Hemicraniectomy vs conservative intensive care treatment
- Malignant MCA infarction with treatment within 48 hours
- Primary endpoint: survival without severe disability (mRS 0-4) at 6 months
Timeline
Germany; patients aged 61-82 years
N
112
Enrollment
112 patients aged 61-82 at multiple German centers (planned 188; stopped early for enrollment difficulty). Open-label randomized trial with blinded outcome assessment. Surgery within 48 hours of stroke onset. Published NEJM 2014.
Bedside Pearl
DESTINY II is a positive trial for survival and surgery is a legitimate option, but it must be offered with the right framing. Tell the family: 'Surgery reduces the chance of dying from 70% to 33%. But 0% of patients who had surgery regained the ability to care for themselves. Nearly all surgical survivors needed help for most bodily needs (mRS 4).' Do not show this trial to a family as evidence that their loved one will do well. Show it as evidence that surgery shifts the outcome from death to severe disability. The family and patient (if able) must decide whether that shift is consistent with their values.
Trial lineage
Hemicraniectomy for malignant MCA infarction
Three near-simultaneous European RCTs (DECIMAL, DESTINY, HAMLET) established that decompressive hemicraniectomy reduces mortality in younger patients with space-occupying MCA infarction. The pooled analysis underpins the AHA/ASA Class I recommendation in patients up to 60 years. DESTINY II later extended the question to patients over 60, where survival is preserved but most survivors have moderate-to-severe disability.
- 2007DECIMAL TrialNEUTRAL
- 2007DESTINY TrialNEUTRAL
- 2009HAMLET TrialNEUTRAL
- 2014DESTINY II Trial· this pagePOSITIVE