What are the criteria for considering decompressive craniectomy in a patient under 60 with a malignant Middle Cerebral Artery (MCA) infarct and signs of increased intracranial pressure?

Decompressive Craniectomy for Malignant MCA Infarct: Selection Criteria

For patients under 60 years with malignant MCA infarction and signs of increased intracranial pressure, decompressive craniectomy should be performed within 48 hours of stroke onset when specific clinical and radiographic criteria are met, as this reduces mortality from 80% to approximately 20-30% and improves functional outcomes. 1, 2

Primary Inclusion Criteria (All Must Be Present)

Age ≤60 years is the most critical selection criterion, with strong evidence supporting surgery in this population 3, 1. Patients above 60 have significantly worse outcomes—only 11% achieve moderate disability and none achieve independence at 12 months, though mortality is still reduced 1.

Clinical Criteria:

• Impaired consciousness or progressive reduction in level of consciousness despite medical management 3, 1
• Neurological deterioration within 48 hours of stroke onset 1, 4
• Exclusion of other causes of impaired consciousness including hypoperfusion, hypotension, cerebral reinfarction, or epileptic seizures 3, 4

Radiographic Criteria:

• CT hypodensity involving ≥50% of MCA territory detected within 12 hours of onset 1, 4
• Mass effect on imaging including midline shift, compression of frontal horn, shift of septum pellucidum, and pineal gland displacement 1, 4
• Hyperdense MCA sign indicating proximal vessel occlusion 1, 4

Absolute Contraindications

Do not proceed with surgery if any of the following are present:

• Bilateral, nonreactive, non-drug-induced pupillary dilation associated with coma 3
• All four unfavorable prognostic factors simultaneously present: age ≥50 years, involvement of additional vascular territories, unilateral pupillary dilation, and GCS <8 3
• Severe comorbidity such as severe heart failure, recent myocardial infarction, or incurable neoplasia 3
• Patient refusal documented through current interaction, written advance directives, or proxy communication 3

Critical Timing Requirements

Surgery must be performed within 48 hours of stroke onset, before severe neurological deterioration occurs 1, 4, 2. Earlier intervention within this window is associated with better outcomes 1, 4. Ultra-early intervention (within 6 hours) may provide even greater benefit, with one study showing 8.7% mortality versus 36.7% for surgery after 6 hours 5.

Surgical Specifications

The procedure must include:

• Fronto-parieto-temporo-occipital craniectomy with bone flap diameter ≥12 cm extending up to the midline 3, 1, 4
• Durotomy with enlargement duroplasty 3, 1, 4
• Do NOT remove ischemic brain tissue during initial surgery 3, 1
• Place intracranial pressure monitor for postoperative management 3, 1, 4

Bridging Medical Management (While Preparing for Surgery)

If surgery is delayed, initiate these measures:

• Elevate head of bed 20-30 degrees to optimize venous drainage 1, 6
• Maintain cerebral perfusion pressure >60 mmHg using volume replacement and/or vasopressors 3, 1, 6
• Osmotic therapy with mannitol 20% (0.25-0.5 g/kg IV every 6 hours, maximum 2 g/kg) or hypertonic saline, targeting serum osmolarity 300-310 mOsmol/kg 3, 1
• Profound sedation, intubation, and controlled ventilation with target PaCO2 of 35 mmHg if craniectomy is delayed 3

Important caveat: Osmotherapy and hyperventilation show only transitory effects and may cause rebound phenomena, so they should not be relied upon if surgery is declined 3.

Expected Outcomes for Patients ≤60 Years

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

Critical Pitfalls to Avoid

• Do not delay surgery beyond 48 hours waiting for further deterioration—this significantly worsens outcomes 1, 4, 2
• Do not perform craniectomy with bone flap <12 cm—smaller craniectomies are inadequate 1
• Do not rely on medical management alone—it has not been proven effective for malignant infarction 1, 6
• Do not use corticosteroids—they are contraindicated 3
• Do not administer hypotonic fluids or sedatives (except benzodiazepines for alcohol withdrawal) 3