[Hemicraniectomy in acute brain infarction]

Area of Science:

• Neurosurgery
• Neurology
• Critical Care Medicine

Context:

• Massive hemispheric brain infarctions pose a high mortality risk due to cerebral edema and increased intracranial pressure.
• Decompressive craniectomy (DC) is a surgical procedure to alleviate these pressures by removing a portion of the skull.
• This review focuses on the utility of hemicraniectomy, a specific type of DC, particularly for massive cerebral infarctions.

Purpose:

• To review the existing literature on hemicraniectomy for massive cerebral infarctions.
• To discuss the effectiveness and indications of hemicraniectomy in managing severe stroke.
• To identify remaining questions regarding surgical timing, patient selection, and long-term outcomes.

Summary:

• A literature search identified 39 studies on decompressive craniotomy for cerebral infarction between 1990 and 2006.
• Pooled analysis of three recent randomized studies (93 patients < 60 years) with middle cerebral artery territory infarction showed significantly lower one-year mortality and better functional outcomes (mRS < 3) with hemicraniectomy compared to medical management alone.
• Hemicraniectomy performed within 48 hours of stroke onset demonstrated improved survival rates.

Impact:

• Hemicraniectomy can significantly reduce mortality in patients with massive supratentorial brain infarction.
• The procedure offers improved functional outcomes for younger patients (< 60 years) with large territorial infarcts.
• Further research is required to optimize surgical timing, determine the role of hemispheric dominance, define infarct extent, and evaluate risks versus benefits in older populations.