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Decompressive hemicraniectomy for space-occupying cerebral infarction.

The development of a space-occupying hemispheric infarction occurs in a subset of patients with ischaemic cerebrovascular stroke. It is a life-threatening condition with a high mortality rate of up to 80% with medical therapy alone. Previous retrospective and uncontrolled case series have suggested that decompressive hemicraniectomy can significantly reduce mortality to 20-30% compared to conservative treatment. This evidence has now been confirmed by the data of prospective randomised studies. The data also indicate that the reduction of mortality is not accompanied by an increase in the number of completely disabled patients. However, the number of disabled patients depending on the assistance of others increases significantly, and the patients and their caregivers need to be comprehensively informed about the long-term consequences prior to surgery. Furthermore, questions concerning the optimal time point for decompression and the upper age limit at which patients still benefit from surgery remain unanswered. Thus the indication for surgery is to a great extent still dependent on the individual situation of the patient and the experience of the treating physicians. This review covers the indications, the surgical technique, the prognostic factors and the clinical outcome with this procedure based on the data of retrospective series and the results of the recently published prospective randomised trials.