Hemicraniectomy and durotomy for malignant middle cerebral artery infarction

Decompressive hemicraniectomy with durotomy is a life-saving procedure for patients who have large middle cerebral artery or carotid terminus strokes at high risk for malignant cerebral edema. Although randomized clinical trial data are not yet available, there are several case series that attempt to address issues of patient selection and timing of the procedure in the context of survival and functional outcomes. Patients who have an increased number of medical comorbidities, especially older age, are less likely to benefit from the procedure, but patients who have even large dominant hemispheric infarctions may do relatively well in certain circumstances.