Case Prep: Decompressive Hemicraniectomy for Malignant MCA Infarction

Case / Approach Snapshot

• Anatomy at risk: parent vessels, perforators, branch ostia, collateral circulation, venous drainage, cranial nerves, cisterns, and eloquent territories threatened by temporary occlusion or retraction.
• Operative steps: plan proximal and distal control, expose the corridor, obtain cerebrospinal fluid/brain relaxation, identify parent vessels before the lesion, treat the lesion/device target, and confirm flow and hemostasis before closure; use the detailed operative sequence and approach notes below as the step-by-step source.
• Rescue plans: intraoperative rupture, thromboembolism, branch or perforator compromise, vasospasm, inadequate proximal control, bypass or reconstructive options, anticoagulation/reversal, and postoperative surveillance.
• Figures: review Figures, Imaging & Video and the Curated Image Set; embedded local figures should remain open-access, public-domain, or otherwise reusable with attribution.
• Papers: review High-Yield Literature for seminal sources, modern reviews, and outcome data specific to this page.

One-Liner

[Age]yo [M/F] with malignant [left/right] MCA territory infarction with [progressive edema / midline shift / declining consciousness] planned for decompressive hemicraniectomy.

Figures, Imaging & Video

🎥 Operative video — search operative video on YouTube ▸ · The Neurosurgical Atlas ▸

External sources — operative figures/atlases are copyrighted (linked, not copied). See media-sources.md.

Operative technique & approach

• The Neurosurgical Atlas — search “decompressive hemicraniectomy” (technique + flap size)

Imaging

• Radiopaedia — malignant MCA infarction

Open-access figures

• PubMed Central

High-Yield Literature

• Decompressive Hemicraniectomy in the Treatment of Malignant Middle Cerebral Artery Infarction: A Meta-Analysis — Das S. World neurosurgery 2019. PubMed
• Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial — Jüttler E. Stroke 2007. PubMed
• It is all about timing: decompressive hemicraniectomy for malignant middle-cerebral-artery infarction — Macha K. Arquivos de neuro-psiquiatria 2023. PubMed
• Decompressive hemicraniectomy after malignant middle cerebral artery infarction: does hospital of origin matter? — Smyth D. Internal medicine journal 2018. PubMed
• Decompressive hemicraniectomy versus medical treatment of malignant middle cerebral artery infarction: a systematic review and meta-analysis — Wei H. Bioscience reports 2020. PubMed
• Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: A real-world study — Pilato F. Journal of the neurological sciences 2022. PubMed
• Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial — Hofmeijer J. The Lancet. Neurology 2009. PubMed
• Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: A systematic review and meta-analysis — Yang MH. The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland 2015. PubMed
• Decompressive hemicraniectomy for malignant middle cerebral artery infarction: an update — Subramaniam S. The neurologist 2009. PubMed
• Long-term outcome after decompressive hemicraniectomy for malignant middle cerebral artery infarction — Berger N. Journal of neurology 2023. PubMed

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Figure 1. Trial profile. Source: Early decompressive hemicraniectomy combined with mild hypothermia treatment for malignant middle cerebral artery infarction — Frontiers in Neurology 2026; CC BY.

Figure 2. Distribution of 6-month modified Rankin scale scores in patients receiving DHC alone vs. those receiving DHC combined with mild hypothermia. Source: Early decompressive hemicraniectomy combined with mild hypothermia treatment for malignant middle cerebral artery infarction — Frontiers in Neurology 2026; CC BY.

Figure 1. Case illustration of a 39-year-old male (case 4) who presented with left massive MCA infarction demonstrated on A) plain CT scan which was delineated by MRI diffusion B) and ADC scan C)… Source: Decompressive hemicraniectomy for malignant middle cerebral artery infarction — Neurosciences 2017; CC BY.

Fig. 1. (clockwise from top left) overhead view of a 3D-rendered fully segmented brain before (orange) and after (blue) decompressive hemicraniectomy (DCE); front view of a 3D-rendered fully… Source: How much space is needed for decompressive surgery in malignant middle cerebral artery infarction: Enabling single-stage surgery — Brain & Spine 2023; CC BY-NC-ND.

Fig. 2. Schematic representation of the main surgical steps of a decompressive hemicraniectomy as described by Raabe et al. (Raabe, 2019) Dural incision after bony decompression is not shown…. Source: How much space is needed for decompressive surgery in malignant middle cerebral artery infarction: Enabling single-stage surgery — Brain & Spine 2023; CC BY-NC-ND.

Fig. 4. A.Distribution of the different measured volumes in mL,B.the distribution of bone flap diameters, andC.the modeled swelling above the previous outer skull rim after decompressive… Source: How much space is needed for decompressive surgery in malignant middle cerebral artery infarction: Enabling single-stage surgery — Brain & Spine 2023; CC BY-NC-ND.

Figure 8. Source: A Cohort Study of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction: A Real-World Experience in Clinical Practice — Medicine (Baltimore). 2015 Jun 26;94(25):e1039. doi: 10.1097/MD.0000000000001039; CC BY-NC-ND.

Figure 9. Source: A Cohort Study of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction: A Real-World Experience in Clinical Practice — Medicine (Baltimore). 2015 Jun 26;94(25):e1039. doi: 10.1097/MD.0000000000001039; CC BY-NC-ND.

Figure 10. Source: A Cohort Study of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction: A Real-World Experience in Clinical Practice — Medicine (Baltimore). 2015 Jun 26;94(25):e1039. doi: 10.1097/MD.0000000000001039; CC BY-NC-ND.

History of Present Illness

• Chief complaint: Large MCA stroke with deteriorating consciousness
• Stroke onset time; tPA/thrombectomy given?
• Progression: declining GCS, anisocoria, worsening edema on serial CT
• Evidence-based: DESTINY, DECIMAL, HAMLET trials — decompression within 48h reduces mortality in malignant MCA infarction, especially age < 60
• Premorbid functional status, goals of care (decompression survivors often have significant disability — counsel family)

Imaging Review

CT Head

• MCA territory infarct (> 50% MCA territory, or > 145 cm³ on DWI)
• Cytotoxic edema, sulcal effacement
• Midline shift, uncal herniation, basal cistern effacement
• Hemorrhagic transformation
• Involvement of ACA/PCA territory

Labs

• CBC, BMP, Coags (especially if post-tPA/thrombectomy — correct coagulopathy)
• Type and screen

Neurological Examination

• GCS, pupils, motor (dense contralateral hemiplegia expected), gaze deviation
• Decline in consciousness is the key surgical trigger

Surgical Planning

Case Logistics, OR Needs & Orders

• OR setup: large trauma craniectomy tray, dural expansion graft, bone-flap storage plan, ICP/EVD supplies if needed, and CT/CTA/MRI reviewed for dominant side and infarct extent.
• Special needs: arterial line, sodium/osmotherapy plan, antiplatelet/anticoagulation hold/restart plan, DVT/aspiration precautions, and family counseling about malignant edema trajectory.
• Immediate postop orders: ICU neuro checks, HOB 30, sodium/BP goals, CT timing, helmet precautions, DVT prophylaxis timing, swallow/rehab consults, and cranioplasty follow-up planning.

Diagnosis & Indication

• Working diagnosis: Malignant MCA infarction with mass effect
• Indication: Clinical deterioration (declining GCS), radiographic herniation, age (best outcomes < 60 but individualized), within ~48h of onset, before irreversible brainstem injury
• Goals: Relieve mass effect, prevent fatal herniation (life-saving, not function-restoring)

Position

• Supine, head turned contralateral, shoulder roll, Mayfield or horseshoe

Approach: Large Decompressive Hemicraniectomy

Key Surgical Steps

1. Large reverse question-mark incision (frontotemporoparietal)
2. Large bone flap — must be ≥ 12 cm AP diameter (ideally 14-15 cm) — inadequate size is the most common error and risks venous strangulation at bone edges
3. Extend craniectomy to the floor of the middle fossa (temporal decompression critical — uncal/brainstem)
4. Keep ~2-3 cm from midline (avoid sagittal sinus)
5. Open dura widely — stellate or C-shaped
6. Expansile duraplasty — dural substitute sewn in loosely to augment volume; do NOT close dura tightly
7. Do NOT resect infarcted brain routinely (unless strangulated/necrotic herniating tissue causing closure problems)
8. Bone flap stored (subcutaneous abdominal pocket or bone bank/freezer)
9. Hemostasis, subgaleal drain, scalp closure
10. [± ICP monitor]

Critical Anatomy & Structures at Risk

1. Superior sagittal sinus — keep medial bone edge ~2.5 cm from midline
2. Bridging veins / cortical veins — at bone edge if craniectomy too small → venous infarction/strangulation
3. Middle fossa floor / temporal lobe — decompress to relieve uncal herniation
4. Transverse sinus — posterior-inferior limit

Equipment

• Craniotome, high-speed drill
• Dural substitute (large graft for duraplasty)
• Bone storage materials
• ICP monitor/EVD

Anesthesia

• Arterial line, central line, Foley
• Mannitol/hypertonic saline (bridge to OR)
• Correct any coagulopathy
• Cefazolin 2g

Potential Complications

1. Inadequate decompression (flap too small) → persistent herniation
2. Hemorrhagic transformation of infarct
3. Hydrocephalus
4. Sinking skin flap syndrome (pre-cranioplasty)
5. Infection
6. Survivors with significant disability (counsel family pre-op)

Operative Note Template

Preoperative Diagnosis: Malignant [left/right] MCA territory infarction with cerebral edema, mass effect, and [declining consciousness / herniation]

Postoperative Diagnosis: Same

Procedure: [Left/Right] decompressive hemicraniectomy with expansile duraplasty [and ICP monitor placement]

Surgeon / Assistant: Anesthesia: General endotracheal EBL / Fluids: Implants: Dural substitute; bone flap stored [abdominal pocket / bone bank]; [ICP monitor] Complications: None

Indications: [Age]yo [M/F] with a malignant [left/right] MCA infarction (>50% territory) and clinical/radiographic deterioration (declining GCS, midline shift, cistern effacement). Decompression was offered as a life-saving measure; the family was counseled that survivors may have significant disability and elected to proceed.

Description of Procedure: After consent and time-out, general anesthesia was induced and the patient positioned supine with the head turned contralateral on a shoulder roll. A large reverse-question-mark incision was made and the myocutaneous flap reflected. Burr holes were placed and a large frontotemporoparietal bone flap was elevated with a craniotome; the AP diameter was [__] cm (≥12 cm). The temporal squama was rongeured down to the floor of the middle fossa, and the medial margin kept ~2.5 cm from the midline to protect the superior sagittal sinus and bridging veins.

The dura was opened widely in a stellate fashion, decompressing the swollen, infarcted hemisphere; non-viable infarcted brain was [not resected / debrided only where herniating and necrotic]. An expansile duraplasty was fashioned with a dural substitute sewn in loosely to augment intradural volume. [An ICP monitor was placed.] The bone flap was stored in [a subcutaneous abdominal pocket / the bone bank] for future cranioplasty. Hemostasis was confirmed, a subgaleal drain placed, and the scalp closed loosely in layers. The patient was transferred intubated to the NSICU in critical but stable condition.

Postoperative Plan

• NSICU, neuro checks q1h, ICP management
• HOB 30 degrees, Na 145-155 target if edema
• Serial CT (monitor edema peak days 2-5, hemorrhagic transformation)
• DVT prophylaxis (delayed chemical, esp. post-tPA)
• Seizure prophylaxis per practice
• Cranioplasty in ~6-12 weeks once edema resolved
• Early rehab evaluation, goals-of-care discussions

Chief-Level Case Review

Use these as the senior-level mental model for Decompressive Hemicraniectomy for Malignant MCA Infarction:

• Decision point: The operation is won or lost on control: identify inflow, outflow, perforators, collateral options, and the fastest route to temporary control before exposing the lesion itself.
• Technical lever: Do not accept a cosmetic result over physiology: ICG/Doppler/DSA, branch patency, perforator preservation, and parent-vessel caliber matter more than how the clip or resection bed looks.
• Bailout: Have a rupture or ischemia script ready: lower pressure, suction strategy, temporary occlusion time, heparin/reversal plan, bypass/reconstruction threshold, and postop BP targets.
• Postop watch: Postop danger is delayed: vasospasm, thromboembolism, hyperperfusion, hemorrhage, edema, hydrocephalus, and seizure plans need explicit orders.

Common Pimp Questions

Use these to pressure-test preparation for Decompressive Hemicraniectomy for Malignant MCA Infarction:

1. What is the proximal-control plan before the lesion is manipulated?
2. Which branch, perforator, or venous structure is most likely to be injured in this exposure?
3. What are the intraoperative rupture steps, including temporary clip, suction, BP, and backup clip strategy?
4. What confirms treatment success: ICG, Doppler, puncture/deflation, DSA, or postoperative CTA?
5. What postoperative BP, vasospasm, antiplatelet, or anticoagulation issue changes the orders tonight?

Attending Preference Variables

Items that commonly vary by surgeon or institution:

• Preferred approach side, sylvian split style, and cisternal-opening sequence: [attending-specific]
• Temporary clip threshold, burst-suppression preference, and BP during occlusion: [attending-specific]
• Clip manufacturer/shape sequence and whether Doppler, ICG, puncture, or intraop DSA is routine: [attending-specific]
• Antiplatelet/anticoagulation reversal and restart timing: [attending-specific]