Malignant MCA Stroke: an Update on Surgical Decompression and Future Directions

  • Carolina B. Maciel
  • Kevin N. ShethEmail author
Cardiovascular Disease and Stroke (S Prabhakaran, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Cardiovascular Disease and Stroke


Despite a decline over the past decade in overall stroke mortality, hemispheric strokes retain a strikingly high mortality due to their potential for malignant edema and herniation. The pathogenesis of ischemic cerebral edema is steered by disruption of ionic homeostasis in the neurogliovascular unit. Significant effort has been made to identify potential medical therapies targeting edema formation with promising results. To date, decompressive craniectomy remains the therapy with the most robust impact on mortality. Historically, patient selection for surgical treatment of malignant supratentorial strokes has focused on a strict age cutoff and hemispheric dominance. Recent evidence supports a significant mortality benefit in elderly population, although the impact in morbidity is modest. Careful patient selection for surgical treatment in conjunction with comprehensive neurocritical care and inclusion of family in the educated decision making process remain the mainstay of care for such shattering disease.


Decompressive hemicraniectomy Decompressive craniectomy Malignant ischemic stroke Middle cerebral artery stroke Space occupying stroke Hemispheric stroke Infarction Edema Malignant edema Surgical decompression 



The authors thank the infographic designer Sergio Peçanha for his excellent work with the graphic display of neurological outcomes in this paper.

Compliance with Ethics Guidelines

Conflict of Interest

CB Maciel declares no conflicts of interest.

KN Sheth has received research grants from Remedy Pharmaceuticals, Inc as the national co-PI for the Glyburide Advantage in Malignant Edema and Stroke-Remedy Pharmaceuticals (GAMES-RP) study and is the co-chair for the AHA Guidelines on Large Hemispheric Infarction.

Human and Animal Rights and Informed Consent

All studies by KN Sheth involving animal and/or human subjects were performed after approval by the appropriate institutional review boards. When required, written informed consent was obtained from all participants.


Papers of particular interest, published in the last 3 years, have been highlighted as: • Of importance •• Of major importance

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Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of NeurologyYale-New Haven Hospital, Yale School of MedicineNew HavenUSA
  2. 2.Neurocritical Care Fellow, Department of Neurology, Division of Neurocritical Care and Emergency NeurologyYale School of Medicine and Yale-New Haven HospitalNew HavenUSA
  3. 3.Yale School of Medicine and Yale-New Haven HospitalNew HavenUSA

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