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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

Abstract

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.

Keywords

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

Notes

Acknowledgments

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.

References

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

  1. 1.
    Mozaffarian D, et al. Heart Disease and stroke statistics-2015 update: a report from the American Heart Association. Circulation. 2014.Google Scholar
  2. 2.
    Heinsius T, Bogousslavsky J, Van Melle G. Large infarcts in the middle cerebral artery territory. Etiology and outcome patterns. Neurology. 1998;50(2):341–50.PubMedCrossRefGoogle Scholar
  3. 3.
    Shimoyama T et al. The DASH score: a simple score to assess risk for development of malignant middle cerebral artery infarction. J Neurol Sci. 2014;338(1–2):102–6.PubMedCrossRefGoogle Scholar
  4. 4.
    Huttner HB, Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol. 2009;8(10):949–58.PubMedCrossRefGoogle Scholar
  5. 5.
    Hacke W et al. ‘Malignant’ middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol. 1996;53(4):309–15.PubMedCrossRefGoogle Scholar
  6. 6.
    Beck C et al. A simple brain atrophy measure improves the prediction of malignant middle cerebral artery infarction by acute DWI lesion volume. J Neurol. 2014;261(6):1097–103.PubMedCrossRefGoogle Scholar
  7. 7.
    Scarcella G. Encephalomalacia simulating the clinical and radiological aspects of brain tumor; a report of 6 cases. J Neurosurg. 1956;13(4):278–92.PubMedCrossRefGoogle Scholar
  8. 8.
    Schwab S et al. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke. 1998;29(9):1888–93.PubMedCrossRefGoogle Scholar
  9. 9.
    Delashaw JB et al. Treatment of right hemispheric cerebral infarction by hemicraniectomy. Stroke. 1990;21(6):874–81.PubMedCrossRefGoogle Scholar
  10. 10.
    Young PH, Smith Jr KR, Dunn RC. Surgical decompression after cerebral hemispheric stroke: indications and patient selection. South Med J. 1982;75(4):473–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Wirtz CR et al. Hemicraniectomy with dural augmentation in medically uncontrollable hemispheric infarction. Neurosurg Focus. 1997;2(5):E3. discussion 1 p following.PubMedCrossRefGoogle Scholar
  12. 12.
    Juttler E et al. Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY): a randomized, controlled trial. Stroke. 2007;38(9):2518–25.PubMedCrossRefGoogle Scholar
  13. 13.
    Hofmeijer J et al. Hemicraniectomy after middle cerebral artery infarction with life-threatening Edema trial (HAMLET). Protocol for a randomised controlled trial of decompressive surgery in space-occupying hemispheric infarction. Trials. 2006;7:29.PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Vahedi K et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke. 2007;38(9):2506–17.PubMedCrossRefGoogle Scholar
  15. 15.
    Holtkamp M et al. Hemicraniectomy in elderly patients with space occupying media infarction: improved survival but poor functional outcome. J Neurol Neurosurg Psychiatry. 2001;70(2):226–8.PubMedCentralPubMedCrossRefGoogle Scholar
  16. 16.
    Simard JM et al. Brain oedema in focal ischaemia: molecular pathophysiology and theoretical implications. Lancet Neurol. 2007;6(3):258–68.PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Walcott BP, Kahle KT, Simard JM. Novel treatment targets for cerebral edema. Neurotherapeutics. 2012;9(1):65–72.PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Menzies SA. Contributions of ions and albumin to the formation and resolution of ischemic brain edema. J Neurosurg. 1993;78(2):257–66.PubMedCrossRefGoogle Scholar
  19. 19.•
    O’Donnell ME. Blood–brain barrier Na transporters in ischemic stroke. Adv Pharmacol. 2014;71:113–46. Provides a great overview of transporting mechanisms involved in edema formation in acute ischemic stroke.PubMedGoogle Scholar
  20. 20.
    Simard JM et al. Does inhibiting Sur1 complement rt-PA in cerebral ischemia? Ann N Y Acad Sci. 2012;1268:95–107.PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Chechneva OV. Evidence for blood–brain barrier Na-K-Cl cotransport, Na/H exchange and Na-HCO3 cotransport involvement in hyperglycemia exacerbation of cerebral edema formation in ischemic stroke. FASEB J. 2014;27:A222.Google Scholar
  22. 22.
    Simard JM. Glibenclamide in cerebral ischemia and stroke. Neurocrit Care. 2014;20(2):319–33.PubMedCentralPubMedCrossRefGoogle Scholar
  23. 23.
    Hertz L. Antagonists of the Vasopressin V1 Receptor and of the β(1)-adrenoceptor inhibit cytotoxic brain edema in stroke by effects on astrocytes—but the mechanisms differ. Curr Neuropharmacol. 2014;12(4):308–23.PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Huang LQ et al. Hypertonic saline alleviates cerebral edema by inhibiting microglia-derived TNF-alpha and IL-1beta-induced Na-K-Cl cotransporter up-regulation. J Neuroinflammation. 2014;11:102.PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    O’Donnell ME et al. Intravenous HOE-642 reduces brain edema and Na uptake in the rat permanent middle cerebral artery occlusion model of stroke: evidence for participation of the blood–brain barrier Na/H exchanger. J Cereb Blood Flow Metab. 2013;33(2):225–34.PubMedCentralPubMedCrossRefGoogle Scholar
  26. 26.
    Lee JH. Effect of propofol post-treatment on blood–brain barrier integrity and cerebral edema after transient cerebral ischemia in rats. Neurochem Res. 2013;38(11):2276–86.PubMedCrossRefGoogle Scholar
  27. 27.
    Wang R, et al. Intra-artery infusion of recombinant human erythropoietin reduces blood–brain barrier disruption in rats following cerebral ischemia and reperfusion. Int J Neurosci. 2014.Google Scholar
  28. 28.
    Yao X. Reduced brain edema and infarct volume in aquaporin-4 deficient mice after transient focal cerebral ischemia. Neurosci Lett. 2015;584:368–72.PubMedCrossRefGoogle Scholar
  29. 29.
    Hedna VS et al. Treatment of stroke related refractory brain edema using mixed vasopressin antagonism: a case report and review of the literature. BMC Neurol. 2014;14:213.PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Panahpour H, Nekooeian AA, Dehghani GA. Candesartan attenuates ischemic brain edema and protects the blood–brain barrier integrity from ischemia/reperfusion injury in rats. Iran Biomed J. 2014;18(4):232–8.PubMedCentralPubMedGoogle Scholar
  31. 31.
    Arch AE, Sheth KN. Malignant cerebral edema after large anterior circulation infarction: a review. Curr Treat Options Cardiovasc Med. 2014;16(1):275.PubMedCrossRefGoogle Scholar
  32. 32.
    Qureshi AI et al. Timing of neurologic deterioration in massive middle cerebral artery infarction: a multicenter review. Crit Care Med. 2003;31(1):272–7.PubMedCrossRefGoogle Scholar
  33. 33.
    Bosche B et al. Extracellular concentrations of non-transmitter amino acids in peri-infarct tissue of patients predict malignant middle cerebral artery infarction. Stroke. 2003;34(12):2908–13.PubMedCrossRefGoogle Scholar
  34. 34.
    Oppenheim C et al. Prediction of malignant middle cerebral artery infarction by diffusion-weighted imaging. Stroke. 2000;31(9):2175–81.PubMedCrossRefGoogle Scholar
  35. 35.
    Sheth KN. Early transfer of patients with stroke to comprehensive centers is necessary. Stroke. 2014;45(12):3748–9.PubMedCrossRefGoogle Scholar
  36. 36.
    Battey TW et al. Brain edema predicts outcome after nonlacunar ischemic stroke. Stroke. 2014;45(12):3643–8.PubMedCrossRefGoogle Scholar
  37. 37.
    Hofmeijer J et al. Predictors of life-threatening brain edema in middle cerebral artery infarction. Cerebrovasc Dis. 2008;25(1–2):176–84.PubMedCrossRefGoogle Scholar
  38. 38.
    Dohmen C et al. Prediction of malignant course in MCA infarction by PET and microdialysis. Stroke. 2003;34(9):2152–8.PubMedCrossRefGoogle Scholar
  39. 39.
    Kim H, et al. Predictors of malignant brain edema in middle cerebral artery infarction observed on CT angiography. J Clin Neurosci. 2014.Google Scholar
  40. 40.
    Bektas H et al. Increased blood–brain barrier permeability on perfusion CT might predict malignant middle cerebral artery infarction. Stroke. 2010;41(11):2539–44.PubMedCentralPubMedCrossRefGoogle Scholar
  41. 41.
    Thomalla G et al. Prediction of malignant middle cerebral artery infarction by magnetic resonance imaging within 6 hours of symptom onset: a prospective multicenter observational study. Ann Neurol. 2010;68(4):435–45.PubMedCrossRefGoogle Scholar
  42. 42.
    Jaramillo A et al. Predictors for malignant middle cerebral artery infarctions: a postmortem analysis. Neurology. 2006;66(6):815–20.PubMedCrossRefGoogle Scholar
  43. 43.
    Minnerup J et al. Prediction of malignant middle cerebral artery infarction using computed tomography-based intracranial volume reserve measurements. Stroke. 2011;42(12):3403–9.PubMedCrossRefGoogle Scholar
  44. 44.
    Kasner SE et al. Predictors of fatal brain edema in massive hemispheric ischemic stroke. Stroke. 2001;32(9):2117–23.PubMedCrossRefGoogle Scholar
  45. 45.
    Dohmen C et al. Identification and clinical impact of impaired cerebrovascular autoregulation in patients with malignant middle cerebral artery infarction. Stroke. 2007;38(1):56–61.PubMedCrossRefGoogle Scholar
  46. 46.
    Burghaus L et al. Evoked potentials in acute ischemic stroke within the first 24 h: possible predictor of a malignant course. Neurocrit Care. 2008;9(1):13–6.PubMedCrossRefGoogle Scholar
  47. 47.
    MacCallum C et al. Low Alberta Stroke Program Early CT score (ASPECTS) associated with malignant middle cerebral artery infarction. Cerebrovasc Dis. 2014;38(1):39–45.PubMedCrossRefGoogle Scholar
  48. 48.
    Kummer RV. Sensitivity and prognostic value of early CT in occlusion of the middle cerebral artery trunk. Am J Neuroradiol. 1994;15(1):9–15. discussion 16–8.Google Scholar
  49. 49.
    Lee SH. The effect of brain atrophy on outcome after a large cerebral infarction. J Neurol Neurosurg Psychiatry. 2010;81(12):1316–21.PubMedCrossRefGoogle Scholar
  50. 50.
    Dohmen C et al. The severity of ischemia determines and predicts malignant brain edema in patients with large middle cerebral artery infarction. Cerebrovasc Dis. 2012;33(1):1–7.PubMedCrossRefGoogle Scholar
  51. 51.
    Menon BK et al. Anterior temporal artery sign in CT angiography predicts reduced fatal brain edema and mortality in acute M1 middle cerebral artery occlusions. J Neuroimaging. 2012;22(2):145–8.PubMedCrossRefGoogle Scholar
  52. 52.
    Schneweis S et al. Predictive value of neurochemical monitoring in large middle cerebral artery infarction. Stroke. 2001;32(8):1863–7.PubMedCrossRefGoogle Scholar
  53. 53.
    Sykora M et al. Baroreflex sensitivity to predict malignant middle cerebral artery infarction. Stroke. 2012;43(3):714–9.PubMedCrossRefGoogle Scholar
  54. 54.
    Burghaus L et al. Early electroencephalography in acute ischemic stroke: prediction of a malignant course? Clin Neurol Neurosurg. 2007;109(1):45–9.PubMedCrossRefGoogle Scholar
  55. 55.
    Schneider AL. Regional attenuation without delta (RAWOD): a distinctive EEG pattern that can aid in the diagnosis and management of severe acute ischemic stroke. Am J Electroneurodiagnostic Technol. 2005;45(2):102–17.PubMedGoogle Scholar
  56. 56.
    Foerch C et al. Serum S100B predicts a malignant course of infarction in patients with acute middle cerebral artery occlusion. Stroke. 2004;35(9):2160–4.PubMedCrossRefGoogle Scholar
  57. 57.
    Burghaus L et al. Prognostic value of electroencephalography and evoked potentials in the early course of malignant middle cerebral artery infarction. Neurol Sci. 2013;34(5):671–8.PubMedCrossRefGoogle Scholar
  58. 58.••
    Wijdicks EF et al. Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(4):1222–38. Provides an updated and comprehensive guideline for the management of acute ischemic strokes associated with edema and mass effect.PubMedCrossRefGoogle Scholar
  59. 59.
    Simard JM et al. Managing malignant cerebral infarction. Curr Treat Options Neurol. 2011;13(2):217–29.PubMedCentralPubMedCrossRefGoogle Scholar
  60. 60.
    Kirkman MA, Citerio G, Smith M. The intensive care management of acute ischemic stroke: an overview. Intensive Care Med. 2014;40(5):640–53.PubMedCrossRefGoogle Scholar
  61. 61.
    Kaufmann AM, Cardoso ER. Aggravation of vasogenic cerebral edema by multiple-dose mannitol. J Neurosurg. 1992;77(4):584–9.PubMedCrossRefGoogle Scholar
  62. 62.
    Grande PO, Romner B. Osmotherapy in brain edema: a questionable therapy. J Neurosurg Anesthesiol. 2012;24(4):407–12.PubMedCrossRefGoogle Scholar
  63. 63.
    Bardutzky J, Schwab S. Antiedema therapy in ischemic stroke. Stroke. 2007;38(11):3084–94.PubMedCrossRefGoogle Scholar
  64. 64.
    Paczynski RP et al. Multiple-dose mannitol reduces brain water content in a rat model of cortical infarction. Stroke. 1997;28(7):1437–43. discussion 1444.PubMedCrossRefGoogle Scholar
  65. 65.
    Bereczki D. Mannitol for acute stroke. Cochrane Database Syst Rev. 2007;3:CD001153.PubMedGoogle Scholar
  66. 66.
    Sandercock PA, Soane T. Corticosteroids for acute ischaemic stroke. Cochrane Database Syst Rev. 2011;(9):Cd000064.Google Scholar
  67. 67.
    Schwab S. The value of intracranial pressure monitoring in acute hemispheric stroke. Neurology. 1996;47(2):393–8.PubMedCrossRefGoogle Scholar
  68. 68.
    Frank JI. Large hemispheric infarction, deterioration, and intracranial pressure. Neurology. 1995;45(7):1286–90.PubMedCrossRefGoogle Scholar
  69. 69.
    Poca MA et al. Monitoring intracranial pressure in patients with malignant middle cerebral artery infarction: is it useful? J Neurosurg. 2010;112(3):648–57.PubMedCrossRefGoogle Scholar
  70. 70.
    Ropper AH. Brain edema after stroke. Clinical syndrome and intracranial pressure. Archi Neurol (Chicago). 1984;41(1):26–9.CrossRefGoogle Scholar
  71. 71.
    Polderman KH. Mechanisms of action, physiological effects, and complications of hypothermia. Crit Care Med. 2009;37(7 Suppl):S186–202.PubMedCrossRefGoogle Scholar
  72. 72.
    Wan YH et al. Therapeutic hypothermia (Different Depths, Durations, and Rewarming Speeds) for acute ischemic stroke: a meta-analysis. J Stroke Cerebrovasc Dis. 2014;23(10):2736–47.PubMedCrossRefGoogle Scholar
  73. 73.
    van der Worp HB et al. Hypothermia in animal models of acute ischaemic stroke: a systematic review and meta-analysis. Brain. 2007;130(Pt 12):3063–74.PubMedCrossRefGoogle Scholar
  74. 74.
    Hong JM et al. Therapeutic hypothermia after recanalization in patients with acute ischemic stroke. Stroke. 2014;45(1):134–40.PubMedCrossRefGoogle Scholar
  75. 75.
    Neugebauer H et al. DEcompressive surgery Plus hypoTHermia for Space-Occupying Stroke (DEPTH-SOS): a protocol of a multicenter randomized controlled clinical trial and a literature review. Int J Stroke. 2013;8(5):383–7.PubMedCrossRefGoogle Scholar
  76. 76.
    Bendszus M et al. Hemodynamic effects of decompressive craniotomy in MCA infarction: evaluation with perfusion CT. Eur Radiol. 2003;13(8):1895–8.PubMedCrossRefGoogle Scholar
  77. 77.
    Kenning TJ. A comparison of hinge craniotomy and decompressive craniectomy for the treatment of malignant intracranial hypertension: early clinical and radiographic analysis. Neurosurg Focus. 2009;26(6):E6.PubMedCrossRefGoogle Scholar
  78. 78.
    Vahedi K et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol. 2007;6(3):215–22.PubMedCrossRefGoogle Scholar
  79. 79.
    Cruz-Flores S, Berge E, Whittle IR. Surgical decompression for cerebral oedema in acute ischaemic stroke. Cochrane Database Syst Rev. 2012;1:Cd003435.PubMedGoogle Scholar
  80. 80.
    Yu JW et al. Outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 70 years old. J Cerebrovasc Endovasc Neurosurg. 2012;14(2):65–74.PubMedCentralPubMedCrossRefGoogle Scholar
  81. 81.
    Zhao J et al. Decompressive hemicraniectomy in malignant middle cerebral artery infarct: a randomized controlled trial enrolling patients up to 80 years old. Neurocrit Care. 2012;17(2):161–71.PubMedCrossRefGoogle Scholar
  82. 82.••
    Juttler E et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med. 2014;370(12):1091–100. Most current randomized clinical trial of decompressive craniectomy for the treatment of malignant middle cerebral artery strokes in the elderly population.PubMedCrossRefGoogle Scholar
  83. 83.
    Gupta R et al. Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review. Stroke. 2004;35(2):539–43.PubMedCrossRefGoogle Scholar
  84. 84.
    Arac A et al. Assessment of outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 60 years of age. Neurosurg Focus. 2009;26(6), E3.PubMedCrossRefGoogle Scholar
  85. 85.
    Maramattom BV, Bahn MM, Wijdicks EF. Which patient fares worse after early deterioration due to swelling from hemispheric stroke? Neurology. 2004;63(11):2142–5.PubMedCrossRefGoogle Scholar
  86. 86.
    Rahme R et al. How often are patients with ischemic stroke eligible for decompressive hemicraniectomy? Stroke. 2012;43(2):550–2.PubMedCentralPubMedCrossRefGoogle Scholar
  87. 87.
    Lucas C et al. Decompressive surgery for malignant middle cerebral artery infarcts: the results of randomized trials can be reproduced in daily practice. Eur Neurol. 2012;68(3):145–9.PubMedCrossRefGoogle Scholar
  88. 88.
    Neugebauer H, Heuschmann PU, Juttler E. DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY - registry (DESTINY-R): design and protocols. BMC Neurol. 2012;12:115.PubMedCentralPubMedCrossRefGoogle Scholar
  89. 89.
    Flechsenhar J et al. Hemicraniectomy in the management of space-occupying ischemic stroke. J Clin Neurosci. 2013;20(1):6–12.PubMedCrossRefGoogle Scholar
  90. 90.
    Ozdemir O et al. Early decompressive surgery after combined intra-venous thrombolysis and endovascular stroke treatment. Clin Neurol Neurosurg. 2014;122:66–9.PubMedCrossRefGoogle Scholar
  91. 91.
    Sundseth J, et al. Long-term outcome and quality of life after craniectomy in speech-dominant swollen middle cerebral artery infarction. Neurocrit Care. 2014Google Scholar
  92. 92.
    Kastrau F et al. Recovery from aphasia after hemicraniectomy for infarction of the speech-dominant hemisphere. Stroke. 2005;36(4):825–9.PubMedCrossRefGoogle Scholar
  93. 93.
    Wagner S et al. Suboptimum hemicraniectomy as a cause of additional cerebral lesions in patients with malignant infarction of the middle cerebral artery. J Neurosurg. 2001;94(5):693–6.PubMedCrossRefGoogle Scholar
  94. 94.
    Creutzfeldt CJ et al. Seizures after decompressive hemicraniectomy for ischaemic stroke. J Neurol Neurosurg Psychiatry. 2014;85(7):721–5.PubMedCrossRefGoogle Scholar
  95. 95.
    Pillai A et al. Decompressive hemicraniectomy in malignant middle cerebral artery infarction: an analysis of long-term outcome and factors in patient selection. J Neurosurg. 2007;106(1):59–65.PubMedCrossRefGoogle Scholar
  96. 96.
    Ewald C et al. Bone flap necrosis after decompressive hemicraniectomy for malignant middle cerebral artery infarction. Neurocrit Care. 2014;20(1):91–7.PubMedCrossRefGoogle Scholar
  97. 97.
    van Middelaar T, et al. Quality of life after surgical decompression for space-occupying middle cerebral artery infarction: systematic review. Int J Stroke. 2014.Google Scholar
  98. 98.
    Schwarz S, Kuhner C. Prognosis and quality of life after decompressive hemicraniectomy: a nationwide survey in Germany on the attitudes held by doctors and nurses. Nervenarzt. 2012;83(6):731–40.PubMedCrossRefGoogle Scholar
  99. 99.
    Geurts M et al. Surgical decompression for space-occupying cerebral infarction: outcomes at 3 years in the randomized HAMLET trial. Stroke. 2013;44(9):2506–8.PubMedCrossRefGoogle Scholar
  100. 100.
    McKenna A et al. Decompressive hemicraniectomy following malignant middle cerebral artery infarctions: a mixed methods exploration of carer experience and level of burden. Disabil Rehabil. 2013;35(12):995–1005.PubMedCrossRefGoogle Scholar
  101. 101.
    Caso V et al. High diastolic blood pressure is a risk factor for in-hospital mortality in complete MCA stroke patients. Neurol Sci. 2012;33(3):545–9.PubMedCrossRefGoogle Scholar
  102. 102.
    Uhl E et al. Outcome and prognostic factors of hemicraniectomy for space occupying cerebral infarction. J Neurol Neurosurg Psychiatry. 2004;75(2):270–4.PubMedCentralPubMedGoogle Scholar
  103. 103.
    Tu PH et al. Postoperative midline shift as secondary screening for the long-term outcomes of surgical decompression of malignant middle cerebral artery infarcts. J Clin Neurosci. 2012;19(5):661–4.PubMedCrossRefGoogle Scholar

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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