From the Guidelines
Hemicraniectomy for massive stroke should be considered for patients with malignant middle cerebral artery (MCA) infarction who are deteriorating neurologically despite maximal medical management, with the primary criteria including age over 18 years, large hemispheric infarction involving at least 50% of the MCA territory, and evidence of significant edema and mass effect 1. The decision to perform hemicraniectomy should be based on a thorough evaluation of the patient's condition, including the size and location of the infarct, the presence of significant edema and mass effect, and the patient's overall medical condition.
- Key considerations include:
- Age: patients over 18 years old 1
- Infarct size: greater than 50% of the MCA territory on visual inspection, or an ischemic lesion volume greater than 150 cm3 1
- Presence of significant edema and mass effect 1
- Patient's overall medical condition, including the presence of severe comorbidities and pre-stroke functional status 1 The procedure involves removing a large bone flap to allow the swollen brain to expand outside the confines of the skull, thereby preventing herniation and secondary brain injury from increased intracranial pressure, and can reduce mortality from approximately 80% to 30% in appropriately selected patients, though survivors may still have significant disability 1. The decision to perform hemicraniectomy should involve discussion with the patient's family regarding potential outcomes and quality of life considerations, as many survivors will have permanent neurological deficits despite the life-saving intervention 1.
- Additional considerations include:
- Glasgow Coma Scale >6
- Absence of fixed bilateral pupillary abnormalities
- No significant contralateral infarction
- No severe comorbidities that limit life expectancy
- Pre-stroke modified Rankin Scale score of 0-2 (functionally independent) 1 It is essential to note that the benefit of hemicraniectomy in older patients is less certain, and the procedure may result in survival with moderate or severe disability 1.
- The most recent and highest quality study recommends hemicraniectomy for patients with malignant MCA infarction who are deteriorating neurologically despite maximal medical management, with a significant reduction in mortality and improvement in functional outcomes 1.
From the Research
Criteria for Hemicraniectomy
The criteria for hemicraniectomy in patients with massive stroke include:
- Age: relatively young, in the first five decades of life 2
- Infarction of a majority of the middle cerebral artery (MCA) territory in either hemisphere 2
- Decompression should be performed prior to progression to coma or two dilated, fixed pupils 2
- Lethargy combined with midline shift and uncal herniation on neuroimaging is an appropriate trigger to consider and discuss surgical intervention 2
Patient Selection
Patient selection for hemicraniectomy is crucial, and the following factors should be considered:
- The patient's ability to suffer moderate to mild permanent deficits, and the possibility of worse 2
- The importance of aphasia and the acceptable degree of disability in survivors of malignant middle cerebral artery infarction 3
- The best timing for decompressive hemicraniectomy 3
Surgical Procedure
The surgical procedure for hemicraniectomy involves:
- An extensive decompression, targeting a bone flap measuring 14 cm from front to back, and extending 1 to 2 cm lateral to the midline sagittal suture to the floor of the middle cranial fossa at the level of the coronal suture 2
- An augmentation duraplasty is mandatory 2
Benefits and Outcomes
The benefits and outcomes of hemicraniectomy for massive stroke include: