In 2006, results from randomised controlled trials were published regarding decompressive surgery for the treatment of spaceoccupying ‘malignant’ middle cerebral artery (MCA) infarctions. Each of these studies and the pooled analysis provided evidence for a benefit of early hemicraniectomy with respect to mortality after three months. This article focuses on hemicraniectomy as the current treatment of choice for malignant ischaemic brain infarction.

Complete MCA territory infarctions, occasionally with additional ischaemia of the anterior and posterior cerebral artery (ACA and PCA, respectively), are found in 1–10% of patients with supratentorial infarcts.¹ The term ‘malignant MCA infarction’ was introduced based on the commonly associated serious brain swelling, which usually manifests itself between the second and fifth day after stroke onset.² These massive cerebral infarctions are life-threatening events with a uniform natural course and an extremely poor prognosis.³ The mass effect leads to an increased intracranial pressure (ICP) with further destruction of formerly healthy brain tissue, resulting in midline shifting and possible transtentorial or uncal herniation in the majority of patients (see Figure 1).^1,3 A rapid neurological deterioration with a case fatality rate of up to 80% despite maximal treatment was seen in about two-thirds of these patients.^4,5 Several medical treatment strategies, such as osmotic therapy, steroids, hyperventilation, barbiturates and buffers, have been proposed to reduce cerebral oedema formation and raised ICP, but so far none of these therapeutic strategies has been supported by adequate evidence of efficacy from experimental studies or randomised clinical trials and several reports suggest that these approaches are not only ineffective, but even detrimental.^6,7

Hemicraniectomy
Findings from Experimental and Observational Studies Hemicraniectomy for the treatment of space-occupying stroke is by no means new and dates back to as early as 1935.⁸ Results from animal studies revealed that decompressive surgery was significantly associated with a reduction in mortality and infarct size and, moreover, improved regional blood flow and functional outcome.^9–11 These experimental findings are supported by data from clinical reports; meanwhile, there are many data available in the literature on hemicraniectomy for the treatment of malignant MCA infarction – between 1935 and 2007, 93 case reports and series of patients with malignant brain infarctions were published including a cumulative total of 1,834 patients. However, most of the reports were retrospective, including only few patients.^12,13 Before 2006, there were only a few prospective trials comparing decompressive surgery with conservative treatment, some of which used historical control groups, and most control groups consisted of patients who were older, suffered from more severe co-morbidity and were frequently affected by infarctions of the dominant hemisphere.^14–17

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