Hemicraniectomy for malignant middle cerebral artery territory infarction: an updated review

A decompressive hemicraniectomy is frequently performed for patients with malignant middle cerebral artery territory infarction (MMI) to reduce the intracranial hypertension, which may otherwise result in transtentorial herniation. However, certain clinically significant issues - diagnostic criteria, predictors of the MMI clinical course, benefit of surgery in certain populations, timing of surgery - are unresolved. In this article, we provide an updated review on the diagnosis and management of MMI. An extensive search of the PubMed, EMBASE, and Cochrane was conducted using varying combinations of the search terms, "hemicraniectomy," "decompressive craniectomy," "malignant middle cerebral artery territory infarction," "massive middle cerebral artery territory infarction," "massive ischemic stroke," "decompressive surgery," and "neurosurgery for ischemic stroke." Several large, randomized trials within the past decade have firmly established the benefit of decompressive hemicraniectomy (DHC) as a treatment of MMI. Further studies since then have not only better characterized the diagnosis and predictors of MMI, but have also shown that this benefit extends to patients with additional clinical and demographic characteristics. Future randomized studies should continue to evaluate the benefit of a DHC in other subgroups, and assess neurocognitive and psychosocial secondary outcomes.