Decompressive hemicraniectomy for malignant hemispheric infarction

Opinion statement

Malignant middle cerebral artery infarction is associated with up to 80% mortality due to ischemic edema and brain herniation. No medical therapy has proven its efficacy in efficiently and durably reducing brain edema and improving patients’ outcome. Decompressive surgery by a large hemicraniectomy with durotomy has been suggested as a life-saving emergency procedure. However, because of the lack of established prognostic criteria, the fear of severe and “unacceptable” residual disability in surviving patients, and the impossibility of considering the opinion of the patient at the time of decision, there was no consensus regarding this surgery. Recently the results of a pooled analysis of three European randomized trials (DECIMAL, DESTINY, and HAMLET) of early (≤ 48 hours) decompressive large hemicraniectomy in patients less than 60 years of age showed that, compared with medical therapy alone, there was a 50% (95% CI, 33%–67%) absolute risk reduction (ARR) of death, with more patients surviving with a slight to moderate disability (modified Rankin score of 2 or 3) (ARR of 23% [95% CI, 5%–41%]) or with a slight to moderately severe disability (modified Rankin score of 2, 3, or 4) (ARR of 51% [95% CI, 34%–69%]). About 5% of all patients in each therapeutic group were left with a severe residual disability (Rankin 5). These data indicate that early decompressive hemicraniectomy should be considered and fully discussed with the relatives of selected patients with a malignant hemispheric infarction.