What are the surgical management options for a patient with a malignant infarct?

Surgical Management of Malignant Infarct

Decompressive craniectomy with dural expansion should be performed within 48 hours of stroke onset in patients ≤60 years with malignant middle cerebral artery infarction who deteriorate neurologically despite medical therapy, as this reduces mortality by approximately 50% and improves functional outcomes. 1, 2

Patient Selection Criteria

Supratentorial (MCA) Infarction

• Age ≤60 years is the primary selection criterion, with strong evidence supporting surgery in this population 1, 3
• Patients >60 years have uncertain benefit: only 11% achieve moderate disability and none achieve independence at 12 months, though mortality is still reduced 4
• Clinical deterioration with impaired or progressively declining consciousness despite medical management is required 3
• CT hypodensity involving ≥50% of MCA territory detected within 12 hours of onset 3
• Mass effect with midline shift, compression of frontal horn, shift of septum pellucidum, and pineal gland displacement 3
• Hyperdense MCA sign indicating proximal vessel occlusion 3

Cerebellar Infarction

• Suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically from cerebellar stroke 1
• Ventriculostomy alone is contraindicated - it must be accompanied by decompressive suboccipital craniectomy to avoid upward cerebellar herniation 1
• Surgery after cerebellar infarct leads to acceptable functional outcome in most patients 1

Surgical Technique Specifications

For Supratentorial Infarction

• Fronto-parieto-temporo-occipital craniectomy with bone flap diameter ≥12 cm extending up to the midline 2, 3
• Durotomy with enlargement duroplasty is essential 2, 3
• Do NOT remove ischemic brain tissue during the initial surgery 2, 3
• Place an intracranial pressure monitor for postoperative management 2, 3

For Cerebellar Infarction

• Suboccipital craniectomy with dural expansion 1
• Simultaneous ventriculostomy if obstructive hydrocephalus is present 1

Timing of Intervention

Surgery must be performed within 48 hours of stroke onset, before severe neurological deterioration occurs 1, 2, 3. Earlier intervention is associated with better outcomes 3. Delaying until brainstem compression signs develop results in poorer outcomes 3.

Bridging Medical Management

While awaiting surgery or in patients not yet meeting surgical criteria:

• Elevate head of bed 20-30 degrees to optimize venous drainage 2
• Maintain cerebral perfusion pressure >60 mmHg using volume replacement and/or vasopressors 2
• Osmotic therapy with mannitol 0.25-0.5 g/kg IV over 20 minutes every 6 hours (maximum 2 g/kg) 2
• Hypertonic saline is an effective alternative, particularly for clinical transtentorial herniation 2
• Avoid antihypertensive agents causing cerebral vasodilation 2
• Restrict free water and minimize glucose administration 2
• Treat hyperthermia, hypoxemia, and hypercarbia aggressively 2

Important caveat: Medical management alone has not been proven efficacious for malignant MCA infarction and should not delay definitive surgical intervention 3. Osmotherapy efficacy is controversial and should only serve as a bridge to surgery 3, 5.

Expected Outcomes

For Patients ≤60 Years

• Mortality reduction from 80% to approximately 20-30% 6, 5, 7
• 55% achieve moderate disability or better (mRS ≤3) at 12 months 2, 4
• 18% achieve independence at 12 months 2, 4
• One-third will be severely disabled and fully dependent on care even after surgery 1, 4

For Patients >60 Years

• Mortality is reduced but functional outcomes are worse 4, 8
• Only 11% achieve moderate disability and none achieve independence at 12 months 4
• There is significant uncertainty about efficacy in this age group 1

For Cerebellar Infarction

• Most patients achieve acceptable functional outcome after surgery 1

Postoperative Management

• Monitor for wound dehiscence, particularly near the posterior aspect of the craniectomy flap 2
• Many patients require tracheostomy and gastrostomy for initial management 2, 3
• Close observation in dedicated stroke or neurocritical care units is essential, as 25% experience clinical deterioration after initial assessment 2
• Depression affects nearly half of survivors and requires monitoring 4

Critical Pitfalls to Avoid

• Do not perform ventriculostomy alone for cerebellar infarction - this can cause upward herniation and must be accompanied by suboccipital craniectomy 1
• Do not delay surgery beyond 48 hours waiting for further deterioration 1, 2, 3
• Do not use routine intracranial pressure monitoring or CSF diversion for supratentorial infarcts 1
• Do not rely on medical management alone - it has not been proven effective for malignant infarction 3
• Ensure bone flap is ≥12 cm - smaller craniectomies are inadequate 2, 3