Hemicraniectomy is a life-saving procedure in patients with massive cerebral infarctions. At this time, it is not very clear which age group of patients have a better functional outcome. Younger patients with massive cerebral infarctions should be monitored carefully for brain edema and strongly considered for hemicraniectomy. We require a better understanding of the pathophysiology of massive cerebral infarctions in this group of patients.

No therapy has been proven optimal for massive cerebral infarctions. It is difficult to form a coherent inference from case series and retrospective studies because selection bias prevents valid conclusions. The key pathophysiologic concept is that focal increases in ICP are different from global increases. Although surgical decompressive craniectomy can save lives and appears more promising than moderate hypothermia, it remains unclear whether these management strategies are appropriate, given the expected severe disability. Quality-of-life and social-disability measures might be the most important outcomes for future randomized clinical trials. Finally, randomized trials are difficult to execute for both strategies because massive cerebral infarction occurs relatively rarely and expertise in its treatment, with either hypothermia or surgical management, is in the development stage.

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