Decompressive hemicraniectomy and durotomy for malignant middle cerebral artery infarction.
The high early case fatality among patients with massive hemispheric strokes calls for effective treatments. Release of the restriction created by the dura mater and bony skull to allow the infarcted brain tissue to swell has been successfully adopted by some while considered controversial by others. A recent pooled analysis provides estimates for the efficacy of decompressive surgery. Further analyses of current trial data suggest that in particular patient age and timing of surgery determine outcome. Nonetheless, in order to guide the management of individual patients, carefully adjusted medical care, ongoing futility analysis, and simultaneous caregiver meetings should be conducted to reach a joint decision addressing any ethical concerns. In conclusion, decompressive surgery increases the probability of survival but produces patients with moderate or moderately severe disability (albeit not severe disability). Currently, the decision to perform decompressive surgery should remain an individual one in each and every patient.
Stroke Service Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA.
Raphael A
RA
Carandang
Derk W
DW
Krieger
D002544:Cerebral Infarction / Q000473:pathology / Q000601:surgery*; D019299:Decompression, Surgical / Q000379:methods*; D004388:Dura Mater / Q000601:surgery*; D005260:Female; D007839:Functional Laterality; D006801:Humans; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000473:pathology*; D013064:Speech Disorders / Q000209:etiology