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Decompressive hemicraniectomy for malignant middle cerebral artery territory infarction

Rishi Gupta, MD
Mitchell SV Elkind, MD, MS, FAAN
Section Editor
Scott E Kasner, MD
Deputy Editor
John F Dashe, MD, PhD


Decompressive hemicraniectomy and durotomy is a surgical technique used to relieve the increased intracranial pressure and brain tissue shifts that occur in the setting of large cerebral hemisphere mass or space-occupying lesions. In general, the technique involves removal of bone tissue (skull) and incision of the restrictive dura mater covering the brain, allowing swollen brain tissue to herniate upwards through the surgical defect rather than downwards to compress the brainstem.

Hemicraniectomy has been used to treat brain swelling and mass effect secondary to a middle cerebral artery (MCA) territory infarction, hemispheric encephalitis, and large parenchymal intracerebral hemorrhage in subarachnoid hemorrhage. The procedure was first described in 1905 by Harvey Cushing [1], and was first utilized specifically for massive cerebral infarction in 1956 [2].

This topic will review both the clinical features of malignant (also called massive) MCA territory infarction, and the treatment of this devastating type of stroke with decompressive hemicraniectomy. The acute treatment of large MCA infarction in the first few hours after stroke onset (prior to the development of malignant brain swelling) is similar to other types of acute ischemic stroke, as discussed in detail elsewhere. (See "Initial assessment and management of acute stroke".)


Roughly 10 percent of ischemic strokes are classified as malignant or massive because of the presence of space-occupying cerebral edema that is severe enough to produce elevated intracranial pressure and brain herniation [3,4]. The etiology of the majority of these infarcts is cardioembolic or thrombotic occlusion of the internal carotid artery or the proximal segment (stem, or M1) of the middle cerebral artery (MCA).

On examination, patients with a malignant MCA territory infarction have forced gaze deviation, visual field deficit, hemiplegia, and aphasia or neglect, depending on the hemisphere involved. This combination of neurologic findings yields a National Institutes of Health Stroke Scale (NIHSS) score >15 for a right hemisphere infarction and >20 for a left hemisphere infarction.

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Literature review current through: Nov 2017. | This topic last updated: Mar 14, 2017.
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  1. Cushing H. The establishment of cerebral hernia as a decompressive measure for inaccessible brain tumors; with the description of intermuscular methods of making the bone defect in temporal and occipital regions. Surg Gynecol Obstet 1905; 1:297.
  2. SCARCELLA G. Encephalomalacia simulating the clinical and radiological aspects of brain tumor; a report of 6 cases. J Neurosurg 1956; 13:278.
  3. Moulin DE, Lo R, Chiang J, Barnett HJ. Prognosis in middle cerebral artery occlusion. Stroke 1985; 16:282.
  4. Silver FL, Norris JW, Lewis AJ, Hachinski VC. Early mortality following stroke: a prospective review. Stroke 1984; 15:492.
  5. Hacke W, Schwab S, Horn M, et al. 'Malignant' middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol 1996; 53:309.
  6. Wijdicks EF, Sheth KN, Carter BS, 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; 45:1222.
  7. Cucchiara BL, Kasner SE, Wolk DA, et al. Early impairment in consciousness predicts mortality after hemispheric ischemic stroke. Crit Care Med 2004; 32:241.
  8. Thomalla G, Hartmann F, Juettler E, 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; 68:435.
  9. Krieger DW, Demchuk AM, Kasner SE, et al. Early clinical and radiological predictors of fatal brain swelling in ischemic stroke. Stroke 1999; 30:287.
  10. Kasner SE, Demchuk AM, Berrouschot J, et al. Predictors of fatal brain edema in massive hemispheric ischemic stroke. Stroke 2001; 32:2117.
  11. Williams JL, Furlan AJ. Cerebral vascular physiology in hypertensive disease. Neurosurg Clin N Am 1992; 3:509.
  12. Reith J, Jørgensen HS, Pedersen PM, et al. Body temperature in acute stroke: relation to stroke severity, infarct size, mortality, and outcome. Lancet 1996; 347:422.
  13. Jaramillo A, Góngora-Rivera F, Labreuche J, et al. Predictors for malignant middle cerebral artery infarctions: a postmortem analysis. Neurology 2006; 66:815.
  14. Ng LK, Nimmannitya J. Massive cerebral infarction with severe brain swelling: a clinicopathological study. Stroke 1970; 1:158.
  15. Schwab S, Steiner T, Aschoff A, et al. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 1998; 29:1888.
  16. von Kummer R, Meyding-Lamadé U, Forsting M, et al. Sensitivity and prognostic value of early CT in occlusion of the middle cerebral artery trunk. AJNR Am J Neuroradiol 1994; 15:9.
  17. Barber PA, Demchuk AM, Zhang J, et al. Computed tomographic parameters predicting fatal outcome in large middle cerebral artery infarction. Cerebrovasc Dis 2003; 16:230.
  18. Dohmen C, Bosche B, Graf R, et al. Prediction of malignant course in MCA infarction by PET and microdialysis. Stroke 2003; 34:2152.
  19. Minnerup J, Wersching H, Ringelstein EB, et al. Prediction of malignant middle cerebral artery infarction using computed tomography-based intracranial volume reserve measurements. Stroke 2011; 42:3403.
  20. Bektas H, Wu TC, Kasam M, et al. Increased blood-brain barrier permeability on perfusion CT might predict malignant middle cerebral artery infarction. Stroke 2010; 41:2539.
  21. Dittrich R, Kloska SP, Fischer T, et al. Accuracy of perfusion-CT in predicting malignant middle cerebral artery brain infarction. J Neurol 2008; 255:896.
  22. Oppenheim C, Samson Y, Manaï R, et al. Prediction of malignant middle cerebral artery infarction by diffusion-weighted imaging. Stroke 2000; 31:2175.
  23. Kim JJ, Fischbein NJ, Lu Y, et al. Regional angiographic grading system for collateral flow: correlation with cerebral infarction in patients with middle cerebral artery occlusion. Stroke 2004; 35:1340.
  24. Tan IY, Demchuk AM, Hopyan J, et al. CT angiography clot burden score and collateral score: correlation with clinical and radiologic outcomes in acute middle cerebral artery infarct. AJNR Am J Neuroradiol 2009; 30:525.
  25. Kim H, Jin ST, Kim YW, et al. Predictors of malignant brain edema in middle cerebral artery infarction observed on CT angiography. J Clin Neurosci 2015; 22:554.
  26. Flores A, Rubiera M, Ribó M, et al. Poor Collateral Circulation Assessed by Multiphase Computed Tomographic Angiography Predicts Malignant Middle Cerebral Artery Evolution After Reperfusion Therapies. Stroke 2015; 46:3149.
  27. Firlik AD, Yonas H, Kaufmann AM, et al. Relationship between cerebral blood flow and the development of swelling and life-threatening herniation in acute ischemic stroke. J Neurosurg 1998; 89:243.
  28. Berrouschot J, Barthel H, von Kummer R, et al. 99m technetium-ethyl-cysteinate-dimer single-photon emission CT can predict fatal ischemic brain edema. Stroke 1998; 29:2556.
  29. Büttner T, Weyers S, Postert T, et al. S-100 protein: serum marker of focal brain damage after ischemic territorial MCA infarction. Stroke 1997; 28:1961.
  30. Foerch C, Otto B, Singer OC, et al. Serum S100B predicts a malignant course of infarction in patients with acute middle cerebral artery occlusion. Stroke 2004; 35:2160.
  31. Serena J, Blanco M, Castellanos M, et al. The prediction of malignant cerebral infarction by molecular brain barrier disruption markers. Stroke 2005; 36:1921.
  32. Wijman CA. Editorial comment--Can we predict massive space-occupying edema in large hemispheric infarctions? Stroke 2003; 34:1899.
  33. Honeybul S, Ho KM, Gillett G. Outcome Following Decompressive Hemicraniectomy for Malignant Cerebral Infarction: Ethical Considerations. Stroke 2015; 46:2695.
  34. Cruz-Flores S, Berge E, Whittle IR. Surgical decompression for cerebral oedema in acute ischaemic stroke. Cochrane Database Syst Rev 2012; 1:CD003435.
  35. Vahedi K, Vicaut E, Mateo J, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 2007; 38:2506.
  36. Jüttler E, Schwab S, Schmiedek P, et al. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke 2007; 38:2518.
  37. Geurts M, van der Worp HB, Kappelle LJ, et al. Surgical decompression for space-occupying cerebral infarction: outcomes at 3 years in the randomized HAMLET trial. Stroke 2013; 44:2506.
  38. Jüttler E, Unterberg A, Woitzik J, et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 2014; 370:1091.
  39. Frank JI, Schumm LP, Wroblewski K, et al. Hemicraniectomy and durotomy upon deterioration from infarction-related swelling trial: randomized pilot clinical trial. Stroke 2014; 45:781.
  40. Zhao J, Su YY, Zhang Y, et al. Decompressive hemicraniectomy in malignant middle cerebral artery infarct: a randomized controlled trial enrolling patients up to 80 years old. Neurocrit Care 2012; 17:161.
  41. Slezins J, Keris V, Bricis R, et al. Preliminary results of randomized controlled study on decompressive craniectomy in treatment of malignant middle cerebral artery stroke. Medicina (Kaunas) 2012; 48:521.
  42. Alexander P, Heels-Ansdell D, Siemieniuk R, et al. Hemicraniectomy versus medical treatment with large MCA infarct: a review and meta-analysis. BMJ Open 2016; 6:e014390.
  43. Back L, Nagaraja V, Kapur A, Eslick GD. Role of decompressive hemicraniectomy in extensive middle cerebral artery strokes: a meta-analysis of randomised trials. Intern Med J 2015; 45:711.
  44. Vahedi K, Hofmeijer J, Juettler E, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 2007; 6:215.
  45. Torbey MT, Bösel J, Rhoney DH, et al. Evidence-based guidelines for the management of large hemispheric infarction : a statement for health care professionals from the Neurocritical Care Society and the German Society for Neuro-intensive Care and Emergency Medicine. Neurocrit Care 2015; 22:146.
  46. Forsting M, Reith W, Schäbitz WR, et al. Decompressive craniectomy for cerebral infarction. An experimental study in rats. Stroke 1995; 26:259.
  47. Doerfler A, Engelhorn T, Heiland S, et al. Perfusion- and diffusion-weighted magnetic resonance imaging for monitoring decompressive craniectomy in animals with experimental hemispheric stroke. J Neurosurg 2002; 96:933.
  48. Qureshi AI, Geocadin RG, Suarez JI, Ulatowski JA. Long-term outcome after medical reversal of transtentorial herniation in patients with supratentorial mass lesions. Crit Care Med 2000; 28:1556.
  49. Hofmeijer J, Kappelle LJ, Algra A, et al. Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol 2009; 8:326.
  50. Gupta R, Connolly ES, Mayer S, Elkind MS. Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review. Stroke 2004; 35:539.
  51. Curry WT Jr, Sethi MK, Ogilvy CS, Carter BS. Factors associated with outcome after hemicraniectomy for large middle cerebral artery territory infarction. Neurosurgery 2005; 56:681.
  52. Dasenbrock HH, Robertson FC, Vaitkevicius H, et al. Timing of Decompressive Hemicraniectomy for Stroke: A Nationwide Inpatient Sample Analysis. Stroke 2017; 48:704.
  53. Carter BS, Ogilvy CS, Candia GJ, et al. One-year outcome after decompressive surgery for massive nondominant hemispheric infarction. Neurosurgery 1997; 40:1168.
  54. Kastrau F, Wolter M, Huber W, Block F. Recovery from aphasia after hemicraniectomy for infarction of the speech-dominant hemisphere. Stroke 2005; 36:825.
  55. Solomon NA, Glick HA, Russo CJ, et al. Patient preferences for stroke outcomes. Stroke 1994; 25:1721.
  56. Kalia KK, Yonas H. An aggressive approach to massive middle cerebral artery infarction. Arch Neurol 1993; 50:1293.
  57. Akins PT, Guppy KH. Sinking skin flaps, paradoxical herniation, and external brain tamponade: a review of decompressive craniectomy management. Neurocrit Care 2008; 9:269.
  58. Sarov M, Guichard JP, Chibarro S, et al. Sinking skin flap syndrome and paradoxical herniation after hemicraniectomy for malignant hemispheric infarction. Stroke 2010; 41:560.
  59. Rahme R, Zuccarello M, Kleindorfer D, et al. Decompressive hemicraniectomy for malignant middle cerebral artery territory infarction: is life worth living? J Neurosurg 2012; 117:749.