1. health and fitness
2. disease

REVIEW ARTICLE
Decompressive Hemicraniectomy for Malignant Middle Cerebral
Artery Infarction
An Update
Suresh Subramaniam, MD, MSc, and Michael D. Hill, MD, MSc, FRCPC
Background: Malignant middle cerebral artery (MCA) infarction is a devastating disease affecting a minority of stroke victims. The mortality rate from
malignant MCA infarction managed with conservative medical treatment is
estimated at 80%. Standard medical management includes physiologic support,
osmotherapy, intubation and mechanical ventilation, and intracranial pressure
monitoring. Decompressive hemicraniectomy has been viewed with skepticism
because of lack of evidence from randomized controlled trials.
Methods: Narrative review of recent surgical evidence in favor of hemicraniectomy.
Results: Current evidence from randomized controlled trials and a recent
pooled analysis, show clear benefit from hemicraniectomy with improved
survival and better functional outcomes.
Discussion: Hemicraniectomy for malignant MCA infarction is a life saving
procedure. Further data on quality of life outcomes and patient and caregiver
burden are required. Until that time, selection of patients for hemicraniectomy still requires an individual approach.
Key Words: hemicraniectomy, malignant infarction
(The Neurologist 2009;15: 178 –184)
M
alignant middle cerebral artery (MCA) infarction is a term
used to describe complete MCA territory infarction with
significant space occupying effect and herniation of brain tissue.1
The incidence of malignant MCA infarction is estimated to be less
than 1% of all strokes. The mortality with conservative forms of
medical treatment is approximately 80% and coma terminates in
brain death within 2 to 5 days of onset.1 Death usually occurs from
progressive swelling of the ischemic brain tissue, brain tissue shifts,
focal increase in intracranial pressure (ICP), and the extension of
ischemia to adjacent vascular territories. Survivors of this kind of
stroke are disabled with poor quality of life.2,3
Until recently, several case studies and nonrandomized studies
had suggested that decompressive hemicraniectomy with durotomy or
duraplasty could improve survival in malignant MCA infarction but not
functional outcomes.2–5 Numerous developments have occurred in the
understanding of the pathophysiology of malignant MCA infarction
resulting in improvements in medical and surgical management of such
patients. Recent completion of the 3 European hemicraniectomy randomized controlled trials have shed light on the functional quality of life
of these patients for the first time.6,7 A recent pooled analysis provides
evidence for a favorable functional outcome for patients with malignant
From the Calgary Stroke Program, Department of Clinical Neurosciences, Medicine, Community Health Sciences, University of Calgary, Calgary, Alberta,
Canada.
Reprints: Michael D. Hill, MD, MSc, FRCPC, Calgary Stroke Program, Hotchkiss
Brain Institute, Department of Clinical Neurosciences, University of Calgary,
Foothills Hospitals, Rm 1242A, 1403 29th St. NW, Calgary, Alberta, T2N
2T9 Canada. E-mail: [email protected].
Copyright © 2009 by Lippincott Williams & Wilkins
ISSN: 1074-7931/09/1504-0178
DOI: 10.1097/NRL.0b013e3181963d19
178 | www.theneurologist.org
MCA infarction undergoing hemicraniectomy. This article provides a
review of the latest updates that have taken place in the surgical
management of malignant MCA infarction, highlighting the current
evidence for survival benefit and favorable outcome, from recent
randomized controlled trials.
CLINICAL COURSE OF MASSIVE
CEREBRAL INFARCTION
The most common underlying vascular lesion in malignant
MCA infarction is carotid-T or carotid-L occlusion that involves the
terminal internal carotid artery (ICA), A1-ACA, and M1-MCA or
just the ICA terminus and the M1-MCA (carotid-L occlusion). This
produces ischemia of the MCA and variously the ACA, anterior
choroidal artery, and if a fetal-type posterior cerebral artery (PCA)
circulation is present, in the PCA territories.1 Most often, patients
with malignant MCA infarction have head turning and gaze deviation secondary to involvement of frontal eye fields, gross higher
cortical dysfunction with global aphasia in dominant hemisphere
involvement or severe hemispatial neglect in nondominant hemisphere involvement, flaccid hemiplegia, and hemianesthesia.8
The most common underlying vascular lesion in
malignant MCA infarction is carotid-T or carotid-L
occlusion.
In addition to the neurologic symptoms from hemispheric infarction, the additional manifestations evolving from malignant MCA
infarction are largely because of focal edema and displacement of the
brain, rather than a global increase in ICP. This is a critical pathophysiologic point, in that, an external ventricular drain is not a solution to a
worsening focal ICP problem. Cerebral autoregulation is impaired in
areas around the infarction because of focal increase in ICP greater than
20 mmHg.9 Patients at risk for focal increase in ICP are mainly those
with greater than 50% infarction of the MCA territory.10 Patients who
deteriorate following malignant MCA infarction have symptoms of
nausea, vomiting, headache, increasing somnolence, and respiratory
compromise as early as 3 hours after the stroke onset and this usually
heralds mass effect from brain edema. Mass effect is an expected
complication, particularly in young patients with malignant MCA
infarction because they have not suffered the atrophy that becomes
permissive in allowing older patients to tolerate focal infarct-related
edema. Young patients with massive infarction may suffer sudden
herniation as early as 1 to 5 days after admission.11 Mass effect can
progress rapidly over minutes to hours to cause herniation of brain tissue
through dural spaces and may produce subfalcine, uncal, transtentorial and
tonsillar herniation, often terminating in rapid death.12 Patients with maligThe Neurologist • Volume 15, Number 4, July 2009
The Neurologist • Volume 15, Number 4, July 2009
Decompressive Hemicraniectomy
nant MCA infarction require careful physiological support in an intensive
care unit with high-observation nursing because of the potential for rapid
deterioration and the need for airway management.
The additional manifestations evolving from
malignant MCA infarction are largely because of
focal edema and displacement of the brain, rather
than a global increase in ICP.
IDENTIFICATION OF PATIENTS
FOR HEMICRANIECTOMY
Early and prompt identification of patients at risk for developing malignant MCA infarction syndrome is crucial for patient
selection for decompressive hemicraniectomy. Neuroimaging provides an invaluable tool for identifying these patients at risk for
developing brain edema. Neurologic deterioration often correlates
with horizontal displacement of the anterior septum and pineal gland
as seen on CT scan. The presence of low-density infarction that
occupies more than 50% of the MCA territory on CT scan is a
reliable predictor of impending brain edema formation following a
large hemispheric infarction. Early (less than 6 hours) CT scan
changes of greater than 50% MCA infarction or local brain edema
producing effacement of sulci or compression of the lateral ventricle
have been associated with fatal outcomes. These CT scan changes
have 94% specificity and 61% sensitivity.13 Early radiologic signs
visualized on CT scan that are predictive of malignant MCA transformation include anteroseptal shift of greater than 5 mm, pineal
shift greater than 2 mm, hydrocephalus, temporal lobe infarction,
and the presence of other vascular territory infarction (ACA and/or
PCA territories).14 Pineal gland shift measurements are sometimes
predictive of neurologic deterioration. A pineal shift of 2.5 to 4 mm
is associated with drowsiness, 6 to 9 mm with stupor, and greater
than 9 mm with coma. Patients with a baseline National Institutes of
Health Stroke Scale (NIHSS) score greater than or equal to 20 in
patients with dominant hemisphere infarctions, or greater than or
equal to 15 points with nondominant hemispheric infarction within
6 hours of symptom onset accompanied by more than 50% hypodensity on CT scan are at high risk for developing fatal brain
edema.15 Terminal internal carotid artery (carotid-T or carotid-L)
occlusion demonstrated on angiography, is a better predictor than
CT scan cortical hypodensity in patients with malignant MCA
infarction. The absence of collateral supply, recanalization, and ICA
occlusion are the predictors of death in patients with malignant
MCA infarction.1
Early (less than 6 hours) CT scan changes of
greater than 50% MCA infarction or local brain
edema producing effacement of sulci or compression
of the lateral ventricle have been associated with
fatal outcomes.
© 2009 Lippincott Williams & Wilkins
FIGURE 1. Three-dimensional rendered image of a patient
depicting the boundaries on different regions of the cranium
for optimal resection of the bone flap in decompressive
hemicraniectomy and durotomy (Courtesy of Ross Mitchell’s
Laboratory, University of Calgary, Calgary, Alberta, Canada).
DESCRIPTION OF SURGICAL TECHNIQUE FOR
HEMICRANIECTOMY AND DURAPLASTY
Hemicraniectomy surgery was first performed as a treatment for acute subdural hematoma.16 Hemicraniectomy involves
removal of bone from 1 side of the skull measuring roughly 13
cm in the antero-posterior dimension, and from the floor of the
middle cranial fossa to at least 9 cm superiorly, and simultaneously performing a generous dural opening. The minimal
adequate decompression is defined by the following bony boundaries (Fig. 1):
1.
2.
3.
4.
Anterior, frontal to midpupillary line.
Posterior, approximately 4 cm to the external auditory canal.
Superior, to the superior sagital sinus.
Inferior, to the floor of the middle cranial fossa.
Bone removed during a hemicraniectomy can be saved in
the peritoneum or in a bone bank in antibiotic solution at 80°C.
Bone is replaced after the swelling has subsided in 2 to 8 weeks,
but typically closer to 4 weeks. Cruciate or circumferential
durotomy must be performed over the entire region of bony
decompression to insure that nothing resists the expanding brain
from being able to herniate outward. Dural grafting is performed
with loose closure of the dura with allograft or pericranium. In
general, no brain resection or ventriculostomy is required (see
following comments on temporal lobe infarction). This complete
procedure opens a new pathway of least resistance for the
swelling brain ipsilateral to the lesion. Removal of a large part of
the skull theoretically reduces the ICP, ongoing ischemia, and
prevents swollen brain tissue from displacing adjacent healthy
tissue. The size of the bone flap determines the magnitude of
decompression achieved and significantly increases when the
diameter exceeds 12 cm. Sometimes, a repeat hemicraniectomy
may be required for clinical and/or radiographic evidence of
persisting herniation.
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Subramaniam and Hill
CURRENT EVIDENCE FOR
DECOMPRESSIVE HEMICRANIECTOMY
Until recently, there were no randomized controlled clinical
trials performed in malignant MCA infarction patients undergoing
decompressive hemicraniectomy. A majority of the evidence was
obtained from uncontrolled case series and retrospective studies
purporting that hemicraniectomy was a life-saving procedure.2,4,5
Previous studies did not consider quality of life and social disability
measures as outcomes, and as a result, it was unclear whether
decompressive hemicraniectomy was improving survival of the
malignant MCA patients at the cost of dependent functional outcomes with poor quality of life.3,17 It was only recently that 1 North
American randomized controlled trial (HeADDFIRST) and 3 European randomized controlled trials 关decompressive craniectomy in
malignant MCA infarction (DECIMAL), decompressive surgery for
the treatment of malignant infarction of the middle cerebral artery
(DESTINY), hemicraniectomy after middle cerebral artery infarction with life-threatening Edema trial (HAMLET)兴 provided an
invaluable data on the functional outcomes of patients with malignant MCA infarction undergoing hemicraniectomy.6,7,18,19 A recent
pooled analysis of the 3 European randomized controlled trials by
Vahedi et al proved that hemicraniectomy is a life-saving procedure
and can result in a favorable functional outcome when offered early
to younger patients (less than 60 years of age).20 It is important to
remember that, in all these trials, clinical management was likely
unblinded to treatment modality (despite attempts to preserve blinding), raising the issue of bias toward hemicraniectomy. It is entirely
possible that bias among investigators could have influenced
decisions not to pursue aggressive care and withhold treatment in
the medically managed group, thus leading to differences in outcomes favoring hemicraniectomy. Unfortunately, this issue is not
resolvable.
A pooled analysis of the 3 European randomized
controlled trials proved that hemicraniectomy is a lifesaving procedure and can result in a favorable functional
outcome when offered early to younger patients.
DECIMAL is a French trial that assessed the efficacy of early
decompressive hemicraniectomy on functional outcomes.7 Enrollment in DECIMAL was terminated prematurely because of improved survival with hemicraniectomy. Patients between 18 and 55
years of age were included within 24 hours of a malignant MCA
infarction with NIHSS score of greater than or equal to 16, CT scan
of the head involving more than 50% of the MCA territory, and a
diffusion-weighted imaging (DWI) infarct volume of greater than or
equal to 145 cm3. Thirty-eight patients were randomized to receive
standard medical therapy alone or standard medical therapy with
decompressive hemicraniectomy and durotomy. For the surgical
group of patients, hemicraniectomy had to be done no later than 6
hours after randomization and up to 30 hours after the onset of
symptoms. The primary outcome was a favorable functional outcome defined by patient survival with a modified Rankin score
(mRS) less than or equal to 3 at 6 months. The mRS is a 7-point
functional disability scale, where 0 means no neurologic symptoms
at all, 6 means death. A score of 3 implies that a patient is able to
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The Neurologist • Volume 15, Number 4, July 2009
walk independently but requires help with some activities of daily
living. Secondary end points were survival, mRS, Barthel Index greater
than 85, NIHSS, and Stroke Impact Scale (SIS) at 12 months. The
proportion of patients with a mRS less than or equal to 3 at the 6-month
follow-up was 25% in the surgical group and 5.6% in the medical
treatment group. Fifty percent in the surgical group had a mRS less than
or equal to 3 compared with 22.2% in the medical group at 1-year
follow-up. The primary outcome was not significant between the
medical and surgical groups. The secondary outcomes were significantly different between the medical and surgical groups at 6 and 12
months when analyzed on the basis of nondichotomized mRS. The
dramatic life-saving effect of hemicraniectomy was evident with an
absolute-risk reduction of 52.8% in mortality in the surgical group
compared with the medical group. At the end of the follow-up, 67%
of the survivors in the surgical group and 50% in the medical group
were at home. In the predefined subgroup analysis, DWI infarct
volume at the beginning of enrolment in the medical group correlated with the mRS at 6 months. In the surgical group, there was a
trend toward worse outcomes in patients with higher infarct volumes
at the time of enrollment and younger age correlated with better
functional outcomes at 6 months. There was no significant difference between dominant and nondominant hemisphere infarction outcomes
at the end of 1-year follow-up. Interviews at the end of 1-year showed that
hemicraniectomy patients were satisfied with their quality of life. The
DECIMAL trial thus showed that, among patients with malignant MCA
infarction, early decompressive hemicraniectomy when offered to younger
patients led to better functional outcome and survival compared with
medical management alone.
DESTINY is a German trial that randomized 32 patients with
malignant MCA infarction to decompressive hemicraniectomy plus
medical management or medical management alone.6 Patients aged
18 to 60 years with NIHSS score greater than 18 for nondominant
hemisphere and greater than 20 for dominant hemisphere, CT scan
showing infarction of at least two-thirds of the MCA territory, and
onset of symptoms ⬎12 and ⬍36 hours before hemicraniectomy
were enrolled. The NIHSS score in the medical treatment group was
higher than the surgical group at baseline. The primary outcome was
the 30-day mortality and secondary outcomes looked at functional
recovery at 6 and 12 months. In the hemicraniectomy group, 88% of
the patients survived compared with 47% in the medical group after
30 days. Survival after 6 and 12 months was 82% in the surgical
group and 47% in the medical group. Analysis of functional outcomes at 6 and 12 months showed positive results in favor of
hemicraniectomy. Forty-seven percent in the surgical group versus
27% in the medical group reached an mRS of 0 to 3; 77% in the
surgical group reached mRS of 0 to 4 versus 33% in medical group.
Eighty-two percent in the surgical group and 47% in the medical
group were alive. In an interview with patients and their caregivers,
there was 100% satisfaction with the hemicraniectomy procedure in
the surgical group. The trial was not blinded and there were 2 major
protocol violations but the overall result suggested that hemicraniectomy led to improved survival and better functional outcomes.
The HAMLET trial is an ongoing study with 112 patients
aged between 18 and 60 years with a malignant MCA infarction
randomized to hemicraniectomy with medical treatment versus best
medical treatment.19 The enrolment included patients with CT scan
showing greater than two-thirds involvement of the MCA territory,
NIHSS score ⬎16 for nondominant hemisphere, and NIHSS score
⬎21 for dominant hemispheric infarcts in a treatment window of 96
hours. The primary outcome was functional outcome as determined
by the mRS at 1-year dichotomized as good (mRS 0 –3) and poor
(mRS 4 to dead). Secondary outcomes were mRS of 0 to 2 at 12
months, NIHSS score, Barthel’s index, depression scores, visual
analog scales, and quality of life assessment tools at 1 and 3 years.
© 2009 Lippincott Williams & Wilkins
The Neurologist • Volume 15, Number 4, July 2009
The hemicraniectomy and durotomy on deterioration from infarction related swelling trial (HeADDFIRST) was the first North
American trial to randomize 26 patients between the ages 18 to 75 with
a NIHSS score ⬎18, premorbid mRS ⬍2, and CT evidence of a
massive (⬎180 mL) MCA infarction plus or minus ACA or PCA
infarction.18 All patients initially received standard medical therapy and
were subsequently randomized to hemicraniectomy plus standard medical therapy or standard medical therapy alone. This randomization was
based on midline shift within 96 hours defined as ⬎7-mm anteroseptal
or ⬎4-mm pineal shift. Primary outcomes measures were mortality,
functional outcome, quality of life, caregiver burden, patient perceptions of survivorship, and acute health care utilization measured 21, 90, and
180 days after stroke onset. Mortality was 40% in the medical group
versus 23% in surgical group at 21 days. The trial showed an early
benefit in favor of surgery at 21 days but failed to show any sustained
benefit at 3 and 6 months or improved functional outcomes at 6
months. HeADDFIRST remains published only in the abstract form.
The robust amount of information favoring hemicraniectomy
for improved survival and functional outcomes from the DECIMAL
and DESTINY trials led to the investigators of these trials combining their data with HAMLET to perform a pooled analysis. In the
pooled analysis, the inclusion criteria were the following: patients
aged 18 to 60 years with malignant MCA infarction, NIHSS score
⬎15, decrease in the level of consciousness to a score of 1 or greater
on item 1a of NIHSS, greater than 50% involvement of the MCA on
CT scan, DWI infarct volume ⬎145 cm3, inclusion within 45 hours
after onset of symptoms, and an informed consent by the patient or
a legal representative.20 The authors looked at the dichotomized
mRS (0 – 4 as favorable and 5 to death as unfavorable) as the
primary outcome measure. Secondary analyses included an alternative dichotomized mRS (0 –3 as favorable and 4 to death as unfavorable) and case fatality at 1 year. Ninety-three patients were
included, of whom 51 were randomized to hemicraniectomy and 42
to conservative medical management. The results showed a dramatic
increase in the primary outcome for the hemicraniectomy group. Seventy-five percent in the hemicraniectomy groups had a mRS ⱕ 4
compared with 24% in the medical group (ARR ⫽ 51%). This
resulted in a number needed to treat (NNT) of 2 for prevention of
mRS 5 or death and 4 for prevention of mRS 4 to death. The
mortality at 1 year was 71% for medical group versus 21% for
surgical group resulting in an absolute benefit of 50% which translates to a NNT of 2 to prevent 1 death. There was no significant
heterogeneity between the 3 trials in the pooled analyses. A subgroup analysis was done according to age (less than or greater than
50), timing of randomization (less than or greater than 24 hours),
and presence of aphasia. Hemicraniectomy was beneficial in all the
subgroups. Quality of life measures could not be looked at because
the individual trials (DECIMAL, DESTINY, HAMLET) were incomplete at the time of the pooled analyses. These data have not yet
been published but will provide a critical counterbalance to the
question of whether a life-saving procedure is considered worthwhile by the patient and family. On comparison of functional
outcomes among survivors, 75% of patients who received medical
therapy had a favorable outcome (mRS ⱕ3) at 1 year compared with
55% who underwent hemicraniectomy.21 It can be argued that
medical therapy leads to death or survival with a good favorable
outcome whereas hemicraniectomy produces more survivors who
are moderate to severely disabled. However, in a malignant MCA
infarction trial, where the mortality of the medically treated group is
80%, it may be inadequate to compare outcomes only in survivors.
Hemicraniectomy increases the likelihood of achieving a mRS ⱕ3
by 23% at the expense of a 29%-increased chance of sustaining a
moderate to severe disability. Hence, the decision to proceed with
hemicraniectomy has to be made on an individual basis.
© 2009 Lippincott Williams & Wilkins
Decompressive Hemicraniectomy
A number needed to treat (NNT) of 2 for
prevention of mRS 5 or death and 4 for prevention
of mRS 4 to death.
Hemicraniectomy increases the likelihood of
achieving a mRS ⱕ3 by 23% at the expense of a
29%-increased chance of sustaining a moderate to
severe disability.
OUR RECOMMENDATION ON OFFERING
HEMICRANIECTOMY TO MALIGNANT
MCA PATIENTS
Given the data from DECIMAL, DESTINY, and the pooled
analyses in favor of hemicraniectomy for malignant MCA infarction, the next challenge would be whether we can apply the evidence. A number of questions arise when one considers hemicraniectomy for malignant MCA infarction. The key questions to
consider when dealing with a decision to proceed with hemicraniectomy are age, patient selection, timing of surgery, and presence of
a dominant hemispheric infarction.
Impact of Age on Outcomes in Patients
Undergoing Hemicraniectomy
Age is a powerful predictor of functional outcome in patients
undergoing hemicraniectomy.4,22 Based on the results from the
pooled analyses, it is clear that hemicraniectomy is beneficial when
offered to younger patients (in this case results dichotomized at 50
years).20 When drawing a conclusion regarding age from the trials,
1 important distinction between the European and the North American trials is that the upper limit for age was 60 years for DECIMAL,
DESTINY, and HAMLET and 75 years for HeADDFIRST. Thus
the dilemma of offering hemicraniectomy remains when encountering an older patient (⬎60 years). Previously, it was thought that
older patients performed worse than younger patients because of the
fact that older patient more often had associated comorbidities
contributing to a poor outcome.4 Only 27 patients in the pooled
analysis were 50 years of age or older. Given the survival benefit of
hemicraniectomy for younger patients, more data are needed to
determine whether hemicraniectomy is an appropriate treatment
option for patients aged 60 to 80 years.
Patient Selection for Hemicraniectomy
Hemicraniectomy is usually considered when there are unequivocal clinical and neuroimaging signs of impending brain
edema, clinical deterioration is occurring (eg, reduced level of
consciousness), and in some centers when medical measures such as
hypertonic saline or osmotic agents have failed. It is imperative to
recognize the patients at risk for forming brain edema and herniation, so that timely hemicraniectomy can be offered. However, the
major difficulty lies in identifying the patients at risk for brain
edema formation. Clinically, younger age, NIHSS score ⬎15, nausea, vomiting within the first 24 hours and signs of herniation are
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Subramaniam and Hill
The Neurologist • Volume 15, Number 4, July 2009
FIGURE 2. Proposed management algorithm of
high-risk group of patients with malignant MCA
infarction.
known clinical predictors for brain edema after MCA infarction.23
The presence of these signs justifies the need for repeating (every
12 hours) neuroimaging to offer early hemicraniectomy. There
were substantial differences between DECIMAL, DESTINY,
and HAMLET with respect to imaging modalities and timing.
DECIMAL was the only trial to incorporate DWI infarct volume an
inclusion criterion. Patients were enrolled in DECIMAL only if they
had a DWI infarct volume of ⬎145 cm3. DWI infarct volume
correlated well with outcomes in the medical group and patients
with ⬎200 cm3 DWI volume did not survive without hemicraniectomy. Performing an MRI in acute strokes may not be practical in
some centers. DESTINY and HAMLET enrolled patients with more
than 50% involvement of the MCA territory. Unfortunately, no
specific CT scan markers for malignant MCA transformation were
identified in DESTINY. There is definitely a need for future randomized controlled studies to evaluate radiologic markers as predictors of brain edema formation following MCA infarction. To
identify the high-risk group of malignant MCA infarction patients
potentially eligible for decompressive hemicraniectomy, we propose
a management algorithm as outlined in Figure 2.
Hemicraniectomy is usually considered when there
are unequivocal clinical and neuroimaging signs of
impending brain edema, clinical deterioration is
occurring and in some centers when medical
measures such as hypertonic saline or osmotic
agents have failed.
182 | www.theneurologist.org
Timing of Hemicraniectomy
The optimal timing of hemicraniectomy for malignant MCA
infarction remains unknown. Previous case series have reported that
early hemicraniectomy for malignant MCA infarction improves survival and outcomes.4 It has been argued that early hemicraniectomy
prevents irreversible damage to adjacent brain tissue. Controversy
exists over whether hemicraniectomy should be offered to malignant
MCA patients at the time of diagnosis as opposed to patients who are
symptomatic from brain edema and practices vary widely among
centers. Some patients may respond well to medical management for
raised ICP and brain edema, and it may be unnecessary to subject these
patients to hemicraniectomy. On the other hand, waiting for early
deterioration signs to occur might delay management. The timing of
hemicraniectomy was limited to less than 48 hours after the stroke onset
in DECIMAL and DESTINY, and was less than 96 hours for HAMLET. In the pooled analyses, there was no difference in outcome if
hemicraniectomy was performed in the first 24 hours compared with
later time window up to 48 hours.20 It remains to be seen whether
hemicraniectomy has any benefit on survival and outcome after 48
hours of stroke onset. HAMLET is the only study that addresses the
time window for randomization up to 96 hours and the full results of
this trial are eagerly awaited.19
Hemicraniectomy can, however, be a planned procedure. In
our view, it is relevant to identify the patients early, serially image
them and plan for the procedure. Clinically, the useful observation is
an early change in the level of consciousness. Note that coma in
large hemispheric infarction is most commonly related to subfalcine
herniation rather than rostral-caudal degeneration. Anatomy is relevant here; if there is a large degree of temporal lobe infarction, very
early hemicraniectomy is preferred to prevent uncal herniation.
Early hemicraniectomy may both theoretically protect brain by
preserving local capillary level perfusion pressures and prevent the
need for intubation, for airway compromise and the evolution of
complications such as aspiration pneumonia. For patients requiring
© 2009 Lippincott Williams & Wilkins
The Neurologist • Volume 15, Number 4, July 2009
hemicraniectomy beyond 48 hours, surgical decisions must be made
on an individual basis. In general, the careful clinician should not be
surprised by the need for hemicraniectomy and should proceed in an
anticipatory fashion.
One possibly common approach to hemicraniectomy is to use
medical therapy first. This would include intensive care support,
intubation with careful physiological control, use of osmotic agents,
hypertonic saline, and in some centers hypothermia as a general
measure to reduce intracranial pressure. However, earlier hemicraniectomy has the potential to avoid the complications of such care
which include pneumonia, deep venous thrombosis, malnutrition,
and others. It is our view, that if a hemicraniectomy is desirable, that
it should be done early, before aggressive medical measures are
needed and thereby avoid the complications of prolonged intubation.
Decompressive Hemicraniectomy
Other Considerations—Social Support
and Anatomy
Other considerations at the time of hemicraniectomy include,
we believe, some assessment of social support. This procedure does
not occur in a sphere isolated to the patient. A hemicraniectomy
commits the patient and his/her family to 4 to 6 months of inpatient
rehabilitation and 6 months or more of outpatient rehabilitation,
physical changes to the home which will include costs for renovations, and increased costs for devices (eg, wheelchairs, transportation, etc.). It is very challenging to make a comprehensive assessment of these social factors when decisions about surgery need to be
made in the relative urgency of an acute stroke situation.
A hemicraniectomy commits the patient and his/her
It is our view, that if a hemicraniectomy is desirable,
family to 4 to 6 months of inpatient rehabilitation
that it should be done early, before aggressive
and 6 months or more of outpatient rehabilitation.
medical measures are needed and thereby avoid the
complications of prolonged intubation.
Hemicraniectomy for Dominant
Hemispheric Infarction
Performing hemicraniectomy in patients who have suffered large
dominant hemisphere infarction has been viewed with skepticism.2,4
However, in the long term, aphasia may be less disabling than severe
hemispatial neglect.24 Moreover, functional MRI studies have demonstrated that most functional recovery from aphasia is because of cortical
reorganization in the nondominant (usually right) hemisphere.25 Significant improvement in aphasia can occur after hemicraniectomy
because of cortical reorganization of adjacent areas of normal brain
tissue that surrounds the language areas.26 In the DECIMAL trial, there
was no significant difference in outcome after 1 year between dominant
and nondominant hemispheric strokes. All 10 survivors of hemicraniectomy in DECIMAL acknowledged that ‘life is worth living’ following the procedure and 6 of 10 survivors were aphasic. In the pooled
analyses performed by Vahedi et al, hemicraniectomy was beneficial in
improving survival and functional outcomes regardless of the presence
or absence of aphasia at baseline.
There are subtleties here, however, that we must consider.
The major outcome of the pooled analysis was mRS 0 to 4 versus 5
to 6. At such a dichotomy of the mRS, higher cortical function
(aphasia or hemispatial neglect) does not influence the outcome.
Finer grades of outcome assessment, including quality of life assessments, are needed to help us determine if the differences in
outcome depend upon the hemisphere involved. In general, the
current evidence supports considering hemicraniectomy of both
dominant and nondominant hemispheric infarction.
The anatomy of infarction is important. Involvement of the
MCA territory only likely provides the best prognosis. If the ACA
territory is additionally involved, outcomes may be markedly different because of an involvement of the medial frontal lobes.
Personality change, abullia and dysexecutive syndromes are symptoms which interact substantially with the capacity of family supports to function well, and can result in very poor long term
outcomes. If the PCA territory is additionally involved, vision and
reading add additional disability; in western society, which is so
visually dependent (eg, driving, computers, reading, television),
vision impairment may also lead to poorer long term outcomes.
Additionally, PCA involvement may lead to substantial temporal
lobe infarction with subsequent uncal herniation, something which
anatomically is not well relieved by the more superior hemicraniectomy with duroplasty procedure. If life preservation is the goal,
temporal lobectomy or infarct-ectomy may be required in cases
where large temporal lobe infarction is present. In the pooled
analyses, the anatomy of infarction was not assessed as a predictor
of outcome, but certainly may have played a role in the selection of
patients for trial entry. Our view is that a judgment must be made by
the attending physician on the amount and localization of tissue
involved before offering this procedure.
Involvement of the MCA territory only likely provides
the best prognosis.
CONCLUSIONS
The current evidence supports considering
hemicraniectomy of both dominant and
nondominant hemispheric infarction.
© 2009 Lippincott Williams & Wilkins
It is now clear that hemicraniectomy is both a life-saving and
disability-reducing procedure in malignant MCA infarction. However, more data are still required to address unresolved issues.
Hemicraniectomy and duroplasty should be considered in all patients with large hemispheric infarction but should not be offered to
all. A careful assessment of the interplay of factors including age,
comorbid illness, radiologic size, and anatomy of the infarct with
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Subramaniam and Hill
predicted brain modalities affected, and social situation is required.
Dominant hemisphere infarction is not an automatic contraindication to this procedure. In those patients for whom hemicraniectomy
is indicated, we favor early and planned surgery.
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© 2009 Lippincott Williams & Wilkins