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(Stroke. 2003;34:1899.)
© 2003 American Heart Association, Inc.

Original Contributions

Editorial Comment—Can We Predict Massive Space-Occupying Edema in Large Hemispheric Infarctions?

Department of Neurology and Neurological Sciences, Stanford University Medical Center, Stanford Stroke Center, Palo Alto, California

An extract of the first 250 words of the full text is provided, because this article has no abstract.

Approximately 10% of large hemispheric infarctions are associated with massive, so-called malignant, space-occupying cerebral edema resulting in neurological deterioration due to brain tissue shifts, leading to herniation and often death. Increase in intracranial pressure is a late phenomenon that typically does not occur until after clinical signs of herniation have developed.¹ Space-occupying edema is the leading cause of death within the first week of stroke. Mortality rates derived from intensive care unit–based series are as high as 79% despite aggressive medical therapy, and survivors have a poor neurological outcome.² These data should be interpreted with caution because of possible selection bias.

There is currently no universally accepted treatment modality for patients who deteriorate as a result of space-occupying hemispheric infarction.³ Hemicraniectomy with dural patch enlargement has been proposed as a life-saving measure and might be the most promising therapeutic option. The goal of surgery is to reverse mass effect and brain tissue shifts, decrease increased intracranial pressure, improve cerebral perfusion pressure, and prevent secondary neural injury. Laboratory studies of hemicraniectomy for large hemispheric infarction in rats have shown a decrease in mortality and, when performed very early, reduction in infarct volume as well as improved neurological outcome.⁴ Data in humans have been largely derived from case series and 2 open, nonrandomized, controlled studies. In 1 study 32 patients with clinical deterioration, midline shift, and uncal herniation or obliteration of the cisterns underwent hemicraniectomy, and 21 controls received medical treatment alone.⁵ Mean time between symptom onset and surgery was 39 hours. . . . [Full Text of this Article]