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Hemicraniectomy: a second chance on life for patients with space-occupying MCA infarction.

See related articles, pages 2506–2517 and 2518–2525. 

So-called “malignant” middle cerebral artery (MCA) territory infarction is the most devastating form of ischemic stroke. With conventional medical therapy, including endotracheal intubation, blood pressure control, osmotherapy, hyperventilation, and barbiturate anesthesia for refractory intracranial hypertension, mortality rates of up to 80% have been reported.1–3 Death or neurological devastation results from progressive swelling of the infarct, brain tissue shifts, compartmentalized elevation of intracranial pressure, and the extention of ischemia to adjoining vascular territories.

Decompressive hemicraniectomy and duroplasty for malignant MCA territory infarction is intended to prevent the death spiral by normalizing intracranial pressure, restoring compromised flow in the penumbra and adjacent vascular territories, and restoring the midline position of the brain stem and diecephalon. The procedure is not new, but was performed rarely for MCA infarction before the 1990s, primarily because of concerns that it would result in survival with overwhelming neurological impairment and handicap. With improvements in postoperative critical care, however, there has been a resurgence of interest in hemicraniectomy over the past 10 years. Several case series and nonrandomized case-control studies have suggested that hemicraniectomy can improve survival,4,5 but the evidence has been far from definitive, particularly regarding the extent of residual handicap in those who survive the procedure. Given the lack of evidence from clinical trials to date, hemicraniectomy has remained one of the most controversial and hotly debated topics in stroke care. Is it “radical surgery” that only leads to more pain and suffering, or a beneficial procedure that can give some patients a second chance on life?

In this issue of Stroke , the results of 2 of the 5 recently organized trials designed to evaluate the efficacy of hemicraniectomy for MCA infarction—the DESTINY and DECIMAL trials—are reported.6,7 But before we look into the results …