Purpose of review: Malignant hemispheric infarction is associated with a high mortality rate, approximately 80%, as a result of the development of intracranial pressure gradients, brain tissue shift, and herniation. By allowing the brain to swell outwards and equalizing pressure gradients, decompressive craniectomy appears to significantly reduce the mortality to approximately 20%. This review takes a comprehensive look at the evidence highlighting the benefits and limits of decompressive craniectomy in malignant cerebral infarction.
Recent findings: Three recent European randomized trials have provided compelling evidence that decompressive hemicraniectomy for large hemispheric infarction is not only lifesaving, but also leads to improved functional outcome in patients 60 years of age or less when treated within 48 h of stroke onset.
Summary: Early decompressive hemicraniectomy (<or=48 h) should be strongly considered in any patient 60 years old or less presenting with malignant hemispheric infarction. Further studies are needed to establish objective neuroimaging criteria for aggressive intervention, and to clarify the role of decompressive surgery in older patients (>60 years old) and perhaps, when delayed beyond 48 h.