Decompressive hemicraniectomy for malignant MCA territory infarction

A number of patients with ischemic cerebrovascular stroke suffer a progressive deterioration secondary to massive cerebral ischemia, oedema, and increased intracranial pressure (ICP). The evolution is often fatal. Stroke is the second leading cause of death worldwide. Life-threatening, complete middle cerebral artery (MCA) infarction occurs in up to 10% of all stroke patients, and this may be characterized as massive hemispheric or malignant space-occupying supratentorial infracts.^35,50 Malignant, space-occupying supratentorial ischemic stroke is characterized by mortality up to 80%, several reports indicated a beneficial effect of hemicraniectomy in this situation, converting the closed, rigid cranial vault into a semi open. The main cause of death encountered in these patients is severe postischemic brain oedema leading to raised ICP, clinical deterioration, coma, and death.^20,44 The result is dramatic decrease in ICP and a reversal of the clinical and radiological signs of herniation. For these reasons, decompressive craniectomy has been increasingly proposed as a life-saving measure in patients with large, space-occupying hemispheric infarction. Recent successes with intra-venous ⁽⁵²⁾ and intra-arterial⁽¹¹⁾ thrombolytic therapy have resulted in an increased awareness of stroke as a medical emergency. ⁵² Thus, increasing numbers of patients are being evaluated in the early hours following the ictal event. In the process of gaining more experience in the early management of patients with acute ischemic stroke, it has become clear that in a number of these patients a progressive and often fatal deterioration secondary to mass effect from the oedematous, infarcted tissue occurs. An increasing body of experimental and clinical evidence suggests that some of these patients may benefit from undergoing a decompressive craniectomy but the timing and indications for this potential lifesaving procedure are still debated. Early hemicraniectomy based on radiographic and clinical criteria, but before signs of brainstem herniation, has been proposed as a means of improving outcomes. The objectives of the review are to help better define the selection criteria for performing the surgery in case of supratentorial infarctions, to asses the immediate outcome in terms of time conscious recovery and survival and to assess long term outcome using standard and functional assessment scales.