• Suresh Subramaniam and Michael D Hill.
• Department of Clinical Neurosciences, Medicine, Community Health Sciences, University of Calgary, Alberta, Canada.
• Neurologist. 2009 Jul 1;15(4):178-84.

BackgroundMalignant middle cerebral artery (MCA) infarction is a devastating disease affecting a minority of stroke victims. The mortality rate from malignant MCA infarction managed with conservative medical treatment is estimated at 80%. Standard medical management includes physiologic support, osmotherapy, intubation and mechanical ventilation, and intracranial pressure monitoring. Decompressive hemicraniectomy has been viewed with skepticism because of lack of evidence from randomized controlled trials.MethodsNarrative review of recent surgical evidence in favor of hemicraniectomy.ResultsCurrent evidence from randomized controlled trials and a recent pooled analysis, show clear benefit from hemicraniectomy with improved survival and better functional outcomes.DiscussionHemicraniectomy for malignant MCA infarction is a life saving procedure. Further data on quality of life outcomes and patient and caregiver burden are required. Until that time, selection of patients for hemicraniectomy still requires an individual approach.

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