LAUSR

The term “malignant” is commonly used for large spaceoccupying middle cerebral artery (MCA) infarcts. They comprise 1–10% of all supratentorial strokes, may be more common in females and typically present at a younger age compared to other forms of ischemic stroke [1]. In the infarcted brain regions, a profound brain edema develops resulting in midline shift, compression of the basal cisterns and increased intracranial pressure (ICP). Using best medical management, mortality exceeds 80% in most clinical series. Decompressive craniectomy (DC), i.e., removal of a large bone flap over the infarcted area combined with duraplasty, alleviates the increase in ICP and may prevent brain herniation. Thus, DC is commonly life-saving in selected malignant MCA infarct cases. However, in view of the devastating underlying brain injury and fear of intolerable neurological deficits in DC survivors, this surgery was only infrequently performed before the 1990s. Then, the influential mid-2000s randomized controlled trials (RCTs) DECIMAL, DESTINY and HAMLET were able to show that DC markedly reduced mortality without increasing the risk of leaving the survivor in a most severely disabled state in patients younger than 60 years old and surgically treated within 48 h of stroke onset [2]. The case fatality reduction by DC was estimated to be ca. 50–75%, and these RCTs substantially changed neurosurgical practice. To date, an ever increasing number of publications have documented the role of DC in malignant MCA infarct patients, addressing not only the potential clinical benefits but also complications and important ethical and quality of life concerns [3]. However, there are some remaining clinical questions regarding malignant MCA infarcts that have been insufficiently addressed in the literature.