Decompressive craniectomy for malignant middle cerebral artery territory infarction [Neurosurgery Wiki]

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====== Decompressive craniectomy for malignant middle cerebral artery territory infarction ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/10KSIBP312BLu8_U9kcw0-Fi7oOpi7-uMkap4TRqOxJw_Wpg5R/?limit=15&utm_campaign=pubmed-2&fc=20230117095930}}


see also [[Cisternostomy for malignant middle cerebral artery territory infarction]].
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see also [[Decompressive craniectomy for malignant internal carotid artery territory infarction]]
===== Indications =====

Malignant cerebral edema after large hemispheric infarct is a highly morbid condition, and major, randomized trials over the last 2 decades have affirmed the beneficial effect of surgical intervention in the form of decompressive craniectomy. Early (<48 hours) decompressive craniectomy increases good functional outcomes (mRS 0-3) and reduces mortality. Additionally, trials have found the benefit of surgery to persist in those patients more than 60 years, though the apparent benefit is of lesser magnitude.
((Cannarsa GJ, Simard JM. Decompressive Craniectomy for Stroke: Who, When, and How. Neurol Clin. 2022 May;40(2):321-336. doi: 10.1016/j.ncl.2021.11.009. Epub 2022 Mar 31. PMID: 35465878.)).
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[[Meta-analysis]]
((Vahedi K, Hofmeijer J, Juettler E, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol. 2007; 6:215–222))
of 3 randomized controlled trials found that hemicraniectomy within 48 hours after stroke onset resulted in decreased mortality and increased the number of patients with a favorable functional outcome.
Indications: No firm indications. 
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The relation between bone flap size and theoretical maximum supratentorial hemicranium area (DCI) in patients with malignant MCA infarction was associated with prognosis. Further studies are necessary to confirm these findings
((Rodrigues TP, Rodrigues MAS, Bocca LF, Chaddad-Neto FE, Cavalheiro S, Junior EA, Silva GS, Suriano IC, Centeno RS. Decompressive craniectomy index: Does the size of decompressive craniectomy matter in malignant middle cerebral artery infarction? Surg Neurol Int. 2022 Dec 16;13:580. doi: 10.25259/SNI_895_2022. PMID: 36600778; PMCID: PMC9805638.)).
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Decompressive craniectomy is a surgical procedure used to relieve pressure in the brain caused by severe swelling (edema) after a large infarction, especially in the context of malignant middle cerebral artery (MCA) territory infarction. Here are the key indications for considering decompressive craniectomy for this condition:

### 1. **Clinical Indications**
   - **Massive Infarction**: The patient has suffered a large infarction in the MCA territory, typically involving more than 50% of the MCA territory, leading to significant swelling.
   - **Severe Neurological Deficit**: The patient exhibits severe neurological deficits, which may include coma or a significantly reduced level of consciousness, indicative of severe brain injury.
   - **Increased Intracranial Pressure (ICP)**: Persistent elevation in intracranial pressure despite medical management, such as hyperventilation, osmotic agents (e.g., mannitol), and sedation.
   - **Unresponsive to Medical Treatment**: The patient’s condition does not improve with conventional treatments aimed at controlling ICP and managing brain edema.

### 2. **Imaging Indications**
   - **CT or MRI Findings**: Imaging studies reveal extensive brain infarction in the MCA territory with associated brain edema. Typically, the infarct area involves a significant portion of the MCA territory and shows substantial mass effect.

### 3. **Timing**
   - **Early Intervention**: Decompressive craniectomy is usually considered within 48 to 72 hours after symptom onset. Early intervention is critical to improve outcomes and reduce mortality.

### 4. **Age and Functional Status**
   - **Patient’s Age and Functional Status**: The decision to perform a decompressive craniectomy may also depend on the patient's age and pre-stroke functional status. Younger patients with a good pre-stroke functional status may be more likely to benefit from the procedure.

### 5. **Secondary Criteria**
   - **Progressive Deterioration**: Evidence of continued clinical deterioration despite medical management and imaging findings that suggest worsening edema.
   - **Contralateral Brain Compromise**: Significant mass effect leading to compression of the contralateral brain structures.

### 6. **Contraindications**
   - **Limited Potential for Recovery**: Patients with extensive and irreversible brain damage where the potential for functional recovery is minimal may not be ideal candidates for decompressive craniectomy.
   - **Systemic Conditions**: Severe systemic comorbidities or conditions that might contraindicate major surgery.

### Summary
Decompressive craniectomy for malignant MCA infarction is typically indicated when there is extensive infarction, severe neurological impairment, elevated ICP not responsive to conservative management, and imaging that shows significant brain swelling. It is generally considered a last-resort measure to prevent further brain damage and potentially improve outcomes in carefully selected patients.

The decision to proceed with decompressive craniectomy should be made by a multidisciplinary team, including neurosurgeons, neurologists, and critical care specialists, who will assess the individual patient's condition, potential benefits, and risks of the procedure.
===== Guidelines =====

1. age < 70 years

2. more strongly considered in the nondominant hemisphere (usually right)

3. clinical & CT evidence of acute, complete ICA or MCA infarcts and direct signs of impending or
complete severe hemispheric brain swelling (severe post-admission neurologic deterioration is the usual event that triggers surgical intervention)

===== Technique =====

see [[Hemicraniectomy]].

===== Outcome =====

see [[Decompressive craniectomy for malignant middle cerebral artery territory infarction outcome]].

===== Systematic reviews =====

[[Decompressive craniectomy for malignant middle cerebral artery territory infarction systematic reviews]]


===== Case series =====

[[Decompressive craniectomy for malignant middle cerebral artery territory infarction case series]]


===== Case reports =====
A 39-year-old woman in the 24th week of [[pregnancy]] who suffered a right malignant MCA infarction that eventually required DC. The patient delivered a healthy baby and underwent a second surgery for cranioplasty 7 months later. ((Fernández García A, Jiménez Zapata HD, de Lera Alfonso MC, Sánchez Fernández C, Jiménez Arribas P, Rodríguez Arias CA. Decompressive Craniectomy in Pregnant Women. J Neurol Surg A Cent Eur Neurosurg. 2021 Jun 2. doi: 10.1055/s-0041-1726108. Epub ahead of print. PMID: 34077979.)).
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A case of malignant right-sided MCA/PCA infarction in a 62-year-old man who presented with progressive headache following a cycling incident leading to a head injury. Initial CT head demonstrated a small right ASDH. He had no neurological deficit, headache settled on analgesia, and there was no expansion of the SDH on the repeat CT; therefore, he was managed conservatively. He was admitted 6-days later with worsening headaches and hyponatremia. Repeat CT revealed an increase in size of the hematoma and mass effect leading to a mini-craniotomy and evacuation of hematoma. He developed left-sided hemiplegia, slurred speech and hyponatremia, and CT head demonstrated a right-sided MCA/PCA infarction with significant mass effect. He underwent emergent DC and subsequent cranioplasty and ultimately recovered to mRS of 2.

Conclusion: SDH are frequent neurosurgical entities. Malignant MCA/PCA strokes following mini-craniotomies are rare but need to be considered especially during the consent process
((Moughal S, Uberti M, Al-Mousa A, Al-Dwairy S, Shtaya A, Pereira E. Malignant middle cerebral artery infarction following subacute subdural hematoma: A case report and literature review. Surg Neurol Int. 2021 Mar 17;12:105. doi: 10.25259/SNI_838_2020. PMID: 33880210; PMCID: PMC8053464.)).