Introduction

Malignant middle cerebral artery (MCA) infarction is one of the most catastrophic forms of ischemic stroke with no proven treatment. It is defined as a massive cerebral infarction involving a large portion or the complete MCA territory, with significant space-occupying effect. The resulting depression of consciousness terminates in coma and brain death within two to five days in almost 80% of patients treated with conservative medical therapy alone. The survivors of this form of stroke are severely disabled, with poor quality of life. Although the incidence of MCA infarction was previously estimated at 2% to 10% of all ischemic stroke (1), incidence of such severe strokes appears to be decreasing (2) and now likely represents less than 1% of all stroke.

Numerous developments have occurred in the understanding of pathophysiology of malignant MCA infarction, resulting in improvements in the medical and surgical management of such patients. However, most of the literature is based on observational studies and not on randomized, controlled studies. The location of cerebrovascular occlusion, the state of collateral blood flow, and the timing of reperfusion determine the extent of cerebral infarction and, ultimately, whether significant brain swelling occurs. Consequences of mass effect are shifts of vital brain structure tissue and increased intracranial pressure (ICP). Neurologic deterioration is known to correlate with horizontal displacement of the anterior septum and the pineal gland, rather than with ICP elevation. Recent evidence suggests that ICP elevation is most likely an irreversible event that results when mass expansion exceeds intracranial volume. Medical therapy aimed at reducing ICP primarily contracts healthy brain tissue volume and can aggravate pressure differentials, causing devastating shifts in brain tissue (3). Ideal therapy should prevent the formation of brain edema and the subsequent displacement of tissue. Current medical therapies, namely, osmotherapy and hypothermia, largely fail to prevent either. Decompressive hemicraniectomy with duroplasty is a controversial approach by which to reduce the catastrophic mass effect of brain edema and tissue displacement.

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