Perceptions of decompressive craniectomy following endovascular thrombectomy in the Middle East and North Africa: A multi-specialty cross-sectional survey of attitudes, reported practices, and barriers.

Decompressive craniectomy (DC) can be a life-saving rescue therapy for malignant cerebral edema after endovascular thrombectomy (EVT), yet DC practices following EVT have not previously been examined across the Middle East and North Africa (MENA). We conducted a web-based, bilingual (English/Arabic) cross-sectional survey of physicians involved in acute stroke care across 15 MENA countries (January-March 2025) using a 22-item instrument that underwent expert content-validity review (S-CVI/UA = 0.86) and cognitive-interview pilot testing, to describe self-reported attitudes, perceived practices, and barriers regarding DC after EVT, and to determine whether key findings remained consistent among clinicians with the most direct relevant experience. Of 440 physicians invited, 179 responded; five respondents from zero-EVT-volume institutions were excluded, yielding an analytic cohort of 174 (response rate 41%) from 13 countries, of whom 49% (n = 85) were neurosurgeons. Eighty-four percent of respondents endorsed DC over medical management in selected patients, but only 51% perceived DC was performed in a timely manner "always/often." The mean physician-estimated, recall-based consent rate was 52% (SD 19%), with a Gulf Cooperation Council versus North African difference (59% vs. 44%, p < 0.001) that persisted when restricted to clinicians with direct family-meeting or operative involvement. Leading perceived barriers were patient/family preferences (79%), surgical resource constraints (55%), and delayed detection (30%). These findings, which reflect physician perceptions rather than institutionally verified practice, support development of culturally adapted consent pathways, standardized DC candidacy algorithms, regionalized stroke networks, and a prospective MENA stroke registry to confirm whether these perception-based signals correspond to actual clinical practice and outcomes.