Decompressive hemicraniectomy in a 19-month-old female after malignant cerebral infarction

Malignant cerebral infarction is a life-threatening condition with case fatality rates of approximately 80% in adults with malignant infarction of the middle cerebral artery. No medical treatment has been proven effective for this condition. Decompressive hemicraniectomy within 48 h of massive cerebral infarction significantly reduces mortality and improves outcome in adults 18-60 years of age. However, there is very limited data available about the role of decompressive hemicraniectomy in children with acute malignant cerebral infarction. We present the case of a 19-month-old female who presented with progressive encephalopathy and right hemiparesis. Computed tomography and magnetic resonance imaging of the brain showed massive cerebral infarction in the distribution of the left carotid artery with midline shift and impeding brain stem herniation. She underwent emergent decompressive hemicraniectomy with duraplasty and placement of an intracranial pressure monitor. Intracranial pressure was controlled with sedation and the patient was extubated on postoperative day 4. Extensive stroke workup was negative. Cranioplasty was performed at 3 months post-op. At the 6-month follow-up, she had an excellent recovery (modified Rankin scale of 1). Decompressive hemicraniectomy should be considered for the treatment of cerebral edema in children with malignant cerebral infarction. This may improve mortality and functional outcome compared to medical therapy alone. Due to the rare occurrence of stroke in children, more reports of decompressive hemicraniectomy are encouraged.