Decompressive Surgery for Malignant Cerebral Infarction

Malignant cerebral infarction denotes an extensive ischaemic insult, most often of the middle cerebral artery territory, leading to rapid development of cerebral oedema, refractory intracranial hypertension and risk of transtentorial herniation. Without intervention, mortality approaches 70% within the first week. Decompressive surgery, encompassing hemicraniectomy and duraplasty, relieves intracranial pressure by removing a section of the skull and opening the dura mater. Randomised trials have demonstrated that early intervention—in selected patients under 60 years of age and within 48 hours of radiological confirmation—can halve mortality and increase the proportion of survivors with moderate disability. Key determinants of outcome include age, baseline neurological deficit, infarct volume and timing of surgery. Surgical technique varies in bone‐flap dimensions and dural expansion, but all aim to accommodate swelling brain tissue and prevent secondary ischaemic injury. Postoperative care relies on meticulous neurocritical management of fluid balance, cerebral perfusion and prevention of complications such as haemorrhage or infection. Current clinical guidelines advocate a multidisciplinary approach for patient selection, weighing potential benefits against the likely functional status and quality of life. While the procedure has become established in high‐income settings, ongoing research is expanding indications, refining surgical parameters and exploring biomarkers to guide personalised decision‐making.

Research from Nature Portfolio

No recent Nature Portfolio content available.

Research from all publishers

Recent analyses have revisited technical and outcome questions in large hemispheric infarction. A multicentre registry study found that extending hemicraniectomy beyond a 14 cm diameter did not confer additional survival benefit or improved long-term functional status compared with the standard craniectomy size, suggesting that age and infarct volume remain the primary predictors of outcome rather than flap dimensions. A comprehensive review of decompressive craniectomy in acute ischaemic stroke collated evidence across patient groups and age ranges, reaffirming the life-saving role of early surgery while emphasising the need for shared decision-making regarding acceptable disability and the timing of intervention. For early identification of patients at highest risk of malignant brain oedema, a simple prognostic score combining clinical severity (NIH Stroke Scale), radiological extent (ASPECTS), collateral circulation and revascularisation outcome showed robust prediction of oedema progression and may facilitate triage for decompression.

Decompressive Surgery for Malignant Cerebral Infarction publication trend

The graph below shows the total number of articles in decompressive surgery for malignant cerebral infarction across all publications each year (not limited to Nature Index journals).

Technical terms

Malignant cerebral infarction: A large territory ischaemic stroke leading to rapid cerebral swelling and risk of herniation.

Decompressive craniectomy (hemicraniectomy): Surgical removal of part of the skull and dural expansion to relieve raised intracranial pressure.

Intracranial hypertension: Elevated pressure within the cranial vault, often due to cerebral oedema, which can impair cerebral perfusion.

Modified Rankin Scale (mRS): A widely used ordinal scale for assessing global disability and functional outcome after stroke.

References

1. Large diameter hemicraniectomy does not improve long-term outcome in malignant infarction. Journal of Neurology (2023).
2. Decompressive craniectomy for acute ischemic stroke. Critical Care (2019).
3. A simple prediction score system for malignant brain edema progression in large hemispheric infarction. PLOS ONE (2017).
4. Preliminary Results of Randomized Controlled Study on Decompressive Craniectomy in Treatment of Malignant Middle Cerebral Artery Stroke. Medicina (2012).