DESTINY Trial: Decompressive Surgery for Malignant MCA Infarction
In patients aged 18-60 with malignant MCA infarction, does early decompressive hemicraniectomy reduce mortality and improve functional outcomes compared with conservative management?
Juttler et al. (Stroke 2007) · 32 patients
Population
Included
- Age 18-60 years
- Clinical and imaging criteria for malignant MCA infarction
- Randomization within 36 hours of symptom onset
- NIHSS greater than 18 for non-dominant hemisphere or greater than 20 for dominant hemisphere
Age
- Age 18 to 60 years
Clinical
- Clinical signs of infarction of the MCA territory with an NIHSS score >18 for lesions of the nondominant hemisphere and >20 for lesions of the dominant hemisphere
- Decrease in the level of consciousness to a score of >=1 on item 1a of the NIHSS
Imaging
- Computed tomography-documented unilateral MCA infarction, including at least 2/3 of the territory and including at least part of the basal ganglia, with or without additional ipsilateral infarction of the anterior or posterior cerebral artery
Timing
- Onset of symptoms >12 and <36 hours before a possible surgical intervention
- Possibility to start treatment/surgery within 6 hours after randomization
Consent
- Written, informed consent by the patient or legal representative
Excluded
- Age greater than 60 years
- Significant pre-existing disability
- Signs of herniation before randomization
- Bilateral infarcts or brainstem involvement
- Major organ failure or terminal illness
Key exclusions
- Prestroke mRS score >=2
- Prestroke score on the Barthel Index <95
- Score on the Glasgow Coma Scale <6
- Both pupils fixed and dilated
- Any other coincidental brain lesion that might affect outcome
- Space-occupying hemorrhagic transformation of the infarct
- Life expectancy <3 years
- Other serious illness that might affect outcome
- Known coagulopathy or systemic bleeding disorder
- Contraindication for anesthesia
- Pregnancy
Source: Juttler et al., Stroke 2007· Retrieved 2026-06-09
Mortality Outcome — 30-Day and 6-Month Survival
32 patients; early hemicraniectomy vs conservative therapy
30-Day and 6-Month Survival
Primary endpoint mRS 0-3 at 6 months was not statistically significant (P=0.23) due to small sample size of 32 patients. Mortality reduction is the secondary endpoint that reached significance.
Study Arms
- Agent
- Decompressive hemicraniectomy with augmented duraplasty
- Duration
- Onset of symptoms >12 and <36 h before surgery; treatment started within 6 h after randomization. Surgery-arm mean onset-to-treatment 24.4 h (range 13.5 to 36.0)
- Co-interventions
- Conservative treatment per the shared consensus protocol (osmotherapy, intubation/ventilation, ICP monitoring, sedation, blood-pressure and glucose targets); all patients ventilated and treated in an ICU
Reversed question-mark skin incision based at the ear; removal of a bone flap diameter >12 cm including frontal, parietal, temporal, and parts of the occipital squama; additional temporal bone removed so the floor of the middle cerebral fossa can be explored; dura opened and an augmented dural patch inserted (homologous periost and/or temporal fascia); no resection of infarcted tissue; ICP sensor inserted. Cranioplasty in survivors after 6 to 8 weeks.
- Agent
- Conservative medical management
- Co-interventions
- Same consensus conservative-treatment protocol in both arms; all patients ventilated and managed in an ICU
Osmotherapy for signs of space-occupying edema: mannitol (0.5 g/kg, 4x/day; max 250 mL), glycerol (10%, 4x/day), or hydroxyethyl starch (6% in 0.9% NaCl, 100 to 250 mL every 8 h; max 750 mL); target serum osmolality 315 to 320 mOsm. Intubation/ventilation for GCS <8 or respiratory insufficiency. Hyperventilation as last resort (target PCO2 28 to 32 mm Hg). Invasive ICP monitoring ipsilaterally. Sedation with propofol; barbiturates discouraged. BP targets: formerly hypertensive 180/100 to 105, formerly normotensive 160 to 180/90 to 100 mm Hg. Normothermia (treat at >37.5 C). Glucose target 80 to 110 mg/dL. Normovolemia, avoiding hyponatremia. DVT prophylaxis with weight-adjusted LMWH. No seizure prophylaxis.
Trial Design
Type
- Prospective multicenter randomized controlled trial
- Hemicraniectomy vs conservative therapy
- Sequential design with 30-day mortality assessed first
- Primary functional endpoint based on mRS 0-3 at 6 months
Timeline
Germany; stopped after pooled European data emerged
N
32
Enrollment
32 patients at multiple German centers (planned 60; stopped early for pooled analysis). Prospective sequential design. Patients aged 18-60 with malignant MCA infarction. Randomization within 36 hours of onset. Published Stroke 2007.
Bedside Pearl
DESTINY confirms the pattern from DECIMAL: hemicraniectomy prevents death in malignant MCA infarction in patients under 61 years, but does not reliably restore functional independence. For family counseling, lead with the survival benefit, then explicitly state that most survivors will have severe to moderate disability and will not return to independent living. Use the pooled analysis (DECIMAL, DESTINY, HAMLET within 48 hours) for the most precise risk-benefit estimate.
See also
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 Trial· this pageNEUTRAL
- 2009HAMLET TrialNEUTRAL
- 2014DESTINY II TrialPOSITIVE