Hemicraniectomy and Large Dominant Hemisphere Infarctions

Performing hemicraniectomy in patients who have suffered large dominant-hemisphere infarctions is highly controversial. The benefit of hemicraniectomy in dominant-hemisphere infarctions appears less convincing due to the mistaken perception that the procedure might leave patients with severe aphasia and poor quality of life. Functional MRI studies have demonstrated that most functional recovery from aphasia is due to cortical reorganization of the unaffected (right) hemisphere. A significant shift of activation areas into homologous areas of the right hemisphere is seen (32,33). However, conflicting evidence suggests that functionally important cortical reorganization occurs in adjacent areas of normal brain tissue that surrounds language areas (32,34), which might explain the somewhat surprising degree of clinical recovery reported in subsets of patients with dominant-hemisphere infarctions who undergo hemicraniectomy. One study reported mild-to-moderate aphasia outcomes in dominant-hemisphere hemicraniectomy if performed early (31). Another group retrospectively studied 14 patients who were admitted with dominant-hemisphere infarction and were subsequently treated with hemicraniectomy; 13 had significant improvement in communication ability. Younger age group and early decom-pressive hemicraniectomy were identified as main predictors for recovery from aphasia (35 ). Thus, it can be argued that younger patients with dominant-hemisphere infarction might be offered early hemicraniectomy, as their natural history favors a trend toward improved mortality and better recovery. We should not underestimate the extent of functional recovery possible via cortical reorganization to the unaffected nondominant hemisphere.

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