Hemicraniectomy in Malignant Middle Cerebral Artery Infarction

The concept of decompressive surgery for treatment of elevated intracranial pressure has been developed already in the beginning of the 20th century.1 The rationale of this treatment modality consists of opening of the skull and removal of a bone flap to allow the edematous brain to swell outward, thereby preventing intracranial tissue shifts and life-threatening downward herniation. The use of decompressive hemicraniectomy (DHC) in the context of ischemic brain edema had been reported already in 1956.2 Since that time, DHC has been increasingly studied in the setting of different conditions, including traumatic brain injury, subarachnoid hemorrhage, and malignant middle cerebral artery (MCA) infarction. Depending on the location of the affected area, different surgical decompression techniques have been developed. In the presence of diffuse brain edema without a midline shift, as commonly seen in traumatic brain injury, bilateral (eg, bifrontal) craniectomy has been advocated. Hemicraniectomy, or removal of a frontotemporoparietal bone flap, is suitable in patients with unilateral hemisphere swelling as seen after ischemic stroke.3 Accumulating experience with DHC over the years has led to increasing refinement of the surgical technique. The size of the removed bone fragment has been recognized as a factor of crucial importance for generation of a sufficient decompressive effect.4 Hemicraniectomy with a diameter of 10 cm, especially in combination with sharp trepanation edges, has been associated with an increased incidence of shearing injury to the herniated brain.4 Furthermore, dural opening, usually followed by insertion of a dural graft (duraplasty), has meanwhile become an integral part of the decompressive surgery technique.3