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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: Sep 2016. | This topic last updated: Jun 7, 2016.
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