Neurocritical Care

, Volume 8, Issue 2, pp 286–289 | Cite as

Decompressive Hemicraniectomy and Durotomy for Malignant Middle Cerebral Artery Infarction

  • Raphael A. Carandang
  • Derk W. KriegerEmail author


The high early case fatality among patients with massive hemispheric strokes calls for effective treatments. Release of the restriction created by the dura mater and bony skull to allow the infarcted brain tissue to swell has been successfully adopted by some while considered controversial by others. A recent pooled analysis provides estimates for the efficacy of decompressive surgery. Further analyses of current trial data suggest that in particular patient age and timing of surgery determine outcome. Nonetheless, in order to guide the management of individual patients, carefully adjusted medical care, ongoing futility analysis, and simultaneous caregiver meetings should be conducted to reach a joint decision addressing any ethical concerns. In conclusion, decompressive surgery increases the probability of survival but produces patients with moderate or moderately severe disability (albeit not severe disability). Currently, the decision to perform decompressive surgery should remain an individual one in each and every patient.


Malignant MCA infarction Decompressive hemicraniectomy 


  1. 1.
    Hacke W et al. Malignant middle cerebral artery territory infarction. Arch Neurol 1996;53:309–15.PubMedGoogle Scholar
  2. 2.
    Berrouschot J et al. Mortality of space-occupying (malignant) middle cerebral artery infarction under conservative intensive care. Intensive Care Med 1998;24:620–3.PubMedCrossRefGoogle Scholar
  3. 3.
    Frank J. Large hemispheric infarction, deterioration, and intracranial pressure. Neurology 1995;45:1286–90.PubMedGoogle Scholar
  4. 4.
    Rutkow I. Trephination: How did they do it? Arch Surg 2000;135:1119.PubMedCrossRefGoogle Scholar
  5. 5.
    Smith ER, Carter BS, Ogilvy CS. Proposed use of prophylactic decompressive craniectomy in poor-grade aneurismal subarachnoid hemorrhage patients presenting with associated large sylvian hematomas. Neurosurgery 2002;51(1):117–24.PubMedCrossRefGoogle Scholar
  6. 6.
    Forsting M et al. Decompressive hemicraniectomy for cerebral infarction: an experimental study in rats. Stroke 1995;26:259–64.PubMedGoogle Scholar
  7. 7.
    Doerfler A et al. Decompressive craniectomy in a rat model of “malignant” cerebral hemispheric stroke: experimental support for an aggressive therapeutic approach. J Neurosurg 1996;85:853–9.PubMedGoogle Scholar
  8. 8.
    Delashaw JB et al. Treatment of right hemispheric cerebral infarction by hemicraniectomy. Stroke 1990;21:874–81.PubMedGoogle Scholar
  9. 9.
    Carter BS et al. One-year outcome after decompressive surgery for massive nondominant hemispheric infarction. Neurosurgery 1997;40:1168–76.PubMedCrossRefGoogle Scholar
  10. 10.
    Schwab S et al. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 1998;29:1888–93.PubMedGoogle Scholar
  11. 11.
    Frank JI. Hemicraniectomy and durotomy upon deterioration from infarction related swelling trial (HeaDDFIRST). Neurology 2003;60(suppl 1):A426.Google Scholar
  12. 12.
    Vahedi K et al. for DESTINY, DECIMAL and HAMLET investigators. Early decompressive hemicraniectomy surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomized controlled trials. Lancet Neurol 2007;6:315–22.Google Scholar
  13. 13.
    Juttler E et al. Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY) – a randomized controlled trial. Stroke 2007;38:2518–25.PubMedCrossRefGoogle Scholar
  14. 14.
    Vahedi K et al. A sequential design, multicenter, randomized, controlled trial of early decompressive craniectomy for malignant middle cerebral infarction (DECIMAL trial). Stroke 2007;38:2506–17.PubMedCrossRefGoogle Scholar
  15. 15.
    Hofmeijer J et al. Hemicraniectomy after middle cerebral artery infarction with life-threatening edema trial (HAMLET). Protocol for a randomized controlled trial of Decompressive surgery for space occupying hemispheric infarction. Trials 2006;7:29.PubMedCrossRefGoogle Scholar
  16. 16.
    Gupta R, Connolly ES, Mayer S, Elkind MS. Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review. Stroke 2004;35(2):539–43.PubMedCrossRefGoogle Scholar
  17. 17.
    Curry WT Jr, Sethi MK, Ogilvy CS, Carter BS. Factors associated with outcome after hemicraniectomy for large middle cerebral artery territory infarction. Neurosurgery 2005;56(4):681–92.PubMedCrossRefGoogle Scholar
  18. 18.
    Foerch C, Lang JM, Krause J, Raabe A, Sitzer M, Seifert V, Steinmetz H, Kessler KR. Functional impairment, disability, and quality of life outcome after decompressive hemicraniectomy in malignant middle cerebral artery infarction. J Neurosurgery 2004;101(2):248–54.CrossRefGoogle Scholar
  19. 19.
    Pillai A, Menon SK, Kumar S, Rajeev K, Kumar A, Panikar D. 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
  20. 20.
    Chen CC, Cho DY, Tsai SC. Outcome of and prognostic factors for decompressive hemicraniectomy in malignant middle cerebral artery infarction. J Clin Neurosci 2007;14(4):317–21.PubMedCrossRefGoogle Scholar
  21. 21.
    Walz B, Zimmermann C, Bottger S, Haberl R. Prognosis of patients after hemicraniectomy in malignant middle cerebral artery infarction. J Neurol 2002;249:1183–90.PubMedCrossRefGoogle Scholar
  22. 22.
    Kastrau F et al. Recovery from aphasia after hemicraniectomy for infarction of the speech-dominant hemisphere. Stroke 2005;36(4):825–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Mayer S. Hemicraniectomy. A second chance on life for patients with space-occupying MCA infarction. Stroke 2007;38:2410–2.PubMedCrossRefGoogle Scholar

Copyright information

© Humana Press Inc. 2007

Authors and Affiliations

  1. 1.Stroke Service Cleveland Clinic FoundationClevelandUSA
  2. 2.Massachusetts General HospitalBostonUSA

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