Background: Massive hemispheric brain infarctions are associated with high mortality, due to cerebral oedema, increased intracranial pressure, distortion of the brain stem and herniation. Decompressive craniectomy involves opening of the dura mater to give more space for the brain. This review describes hemicraniectomy and discusses its usefulness, especially in massive cerebral infarctions.
Material and methods: Literature up to January 2007 was retrieved from Medline with the terms "hemicraniectomy" and "decompressive craniotomy" in combination with "stroke" and "cerebral infarction". 39 studies were found of patients operated with decompressive craniotomy for cerebral infarction in the period 1990-2006.
Results and interpretation: Hemicraniectomy for massive supratentorial brain infarction has been insufficiently documented. Hemicraniectomy performed within 48 hours of stroke onset has recently been compared to medical management alone in three randomized studies. A pooled analysis of patients (93 patients aged < 60 years) with massive infarction in the arteria cerebral media territory, indicated a significantly lower one-year mortality and a significantly larger proportion with a one-year outcome of mRS <3 after hemicraniectomy than after medical management alone. The following key questions still need to be answered: surgical timing, the relevance of hemispheric dominance, the extension of infarcted brain, and whether the reduced mortality justifies the morbidity among survivors (particularly in older age groups). Even though increased survival has now been documented, the decision to perform hemicraniectomy in patients with massive brain infarction must still be made on an individual basis.