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(Stroke. 2003;34:2304.)
© 2003 American Heart Association, Inc.

Controversies in Stroke

Surgical Decompression of Patients With Large Middle Cerebral Artery Infarcts Is Effective

From the Department of Neurology, University of Heidelberg, Germany.

Correspondence to Dr. Werner Hacke, Department of Neurology, University of Heidelberg, IM Neuenheimer Feld 400, 69120 Heidelberg, Germany. E-mail werner_hacke@med.uni-heidelberg.de

Key Words: critical care • decompression, surgical • infarction, middle cerebral artery

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

The Syndrome and Its "Natural" Course

Early mortality after acute ischemic stroke is most frequently caused by space-occupying ischemic brain edema. In case of complete middle cerebral artery territory (MCA) infarction, including the basal ganglia, a large space-occupying postischemic edema that finally leads to herniation and brain death may occur. These patients present with almost complete hemiplegia, head- and eye-turning progressive deterioration of consciousness over the first 24 to 48 hours, and a reduced ventilatory drive. Prognosis of large MCA or hemispheric infarctions is poor: in prospective case series, 80% died from herniation despite maximum conservative therapy.¹

The Failure of Medical Intervention

General measures of treatment of increased intracranial pressure (ICP) after acute ischemic stroke include elevation of the head to a 30-degree angle to improve venous drainage and avoidance of both hyperthermia and hyperglycemia. As part of the specific anti-edematous pharmacological treatment, osmotherapy using glycerol, mannitol, or hyperosmolar saline solutions is used to reduce brain edema. All substances work by means of lowering ICP, but only for a limited time. The same is true for barbiturates, which may reduce critically elevated ICP reading massively, but only for a short period.^2,3

Decompressive Surgery

Decompressive surgery for malignant MCA infarction is not a new invention. Actually, the first studies date back as early as 1935. Over the past decades, several case reports and smaller retrospective case series have suggested that decompressive surgery is a possible treatment option for massive hemispheric stroke. However, no controlled data were available to support its superiority. The rationale of decompressive surgery is to allow extracranial expansion of the edematous . . . [Full Text of this Article]

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