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Outcome Following Decompressive Hemicraniectomy for Malignant Cerebral Infarction: Ethical Considerations.

Over the past 2 decades, there has been a resurgence of interest in the use of decompressive craniectomy for a variety of neurological emergencies, including severe traumatic brain injury, stroke, subarachnoid hemorrhage, severe intracranial infection, dural sinus thrombosis, and inflammatory conditions.1 The rationale for surgical intervention is that, by providing extra space into which the injured brain can expand, intracranial pressure can be reduced, thereby preventing life-threatening herniation of the cerebellar tonsils and improving cerebral perfusion.2,3 The surgical procedure is technically straightforward, and numerous studies have demonstrated that in the context of life-threatening cerebral swelling, mortality can be reduced, and many patients go on to make a good long-term recovery.4,5

Unfortunately, this is not always the case, and many patients survive only to be left with severe neurological disability.6,7 Indeed, for many years, the concern among clinicians has been that surgical intervention would convert death into survival with a level of disability that patients and their families may feel to be unacceptable.8,9

Recently, 2 meta-analyses have been published of the 6 randomized controlled trials comparing decompressive hemicraniectomy with standard medical therapy in patients who develop malignant cerebral swelling after middle cerebral artery stroke.10,11 Both analyses would seem to provide unequivocal evidence that use of the procedure can reduce mortality; however, there remains controversy regarding long-term outcome, patient selection, and some of the ethical issues that require consideration.

### What Is the Aim of Decompressive Hemicraniectomy?

Traditionally, the stroke literature has assessed outcome on the modified Rankin Scale (mRS) score and used a dichotomy between favorable (mRS score 0–3) and unfavorable (mRS score 4–6). That implies that clinicians attempt to provide patients with a favorable outcome where, on the mRS score, the …