Decompressive craniectomy for Malignant MCA infarction

Reviewed and revised 30 March 2015


  • Decompressive craniectomy is a controversial therapy for malignant middle cerebral artery (MCA) stroke
  • Malignant MCA stroke is indicated by:
    • MCA territory stroke of >50% on CT
    • Perfusion deficit of >66% on CT
    • Infarct volume >82 mL within 6 hours of onset (on MRI)
    • Infarct volume of >145mL within 14 hours of onset (on MRI)


  • Malignant MCA infarction is a devastating event with substantial morbidity and mortality, due to:
    • involvement of a large amount of brain tissue, resulting in cerebral edema and increased intracranial pressure
    • risk of haemorrhagic transformation
    • midline shift resulting in compression of medial cerebral structures
    • potential for transtentorial herniation, with compression of the posterior cerebral artery
    • Poor perfusion of the contralateral cerebral hemisphere due to increased ICP
  • Decompressive craniectomy may have the following effects, which could lead to improved morbidity and mortality:
    • can decrease intracranial pressure by increasing cranial compliance
    • prevent transtentorial herniation
    • improving perfusion in the penumbra of the stroke



  • face validity based on theoretical rationale
  • decreased mortality in age <60 years with <48h onset of malignant MCA stroke
  • Well tolerated even after thrombolysis (though apparently antiplatelet drugs tend to increase the risk of bleeding)
  • Craniectomy and evacuation of clot may be required for haemorrhagic transformation anyway


  • Highly invasive procedure
  • Resource intensive (monetary cost, neurosurgeons, OT, ICU care)
  • Craniectomy has to be large enough to extend past the margins of the infarct
  • Evidence base is limited by small trials and potential for systematic bias (e.g. due to lack of allocation concealment)
  • Should only be considered if age <60 years and <48h since stroke onset


There are 3 important trials that have studied decompressive hemicraniectomy for malignant MCA strokes in patients <60 years of age

DESTINY trial (2007)

  • Prospective, MC RCT from Germany
  • n=32 (projected sample size calculated to be n-188)
  • steering committee terminated the trial early as a statistically significant mortality reduction was found at this stage in comibnation with the results of the other European decompressive craniectomy trials
  • Outcome: 88% vs 47% survival in favour of decompressive craniectomy

DECIMAL trial (2007)

  • Prospective, MC RCT from France
  • n=38
  • data safety monitoring committee terminated the trial because of slow recruitment
  • Outcome: ARR 52.8% in mortality favouring the decompressive craniectomy group (75% vs 22% survival)

HAMLET trial (2009)

  • Prospective, MC RCT from the Netherlands
  • n=64
  • Outcome: ARR 38% in mortality favouring the decompressive craniectomy group

Pooled analysis of DESTINY, DECIMAL and HAMLET (Vahedi et al, 2007)

  • n=93
  • Patients aged <60y with supratentorial infarctions treated with decompressive craniectomy, usually within 48 hours of stroke onset
  • With hemicraniectomy compared with medical management:
    • Reduced mortality (22% versus 71% – pooled analysis; NNT=2)
    • No individual study showed an improvement in the percentage of survivors with good outcomes (mRS score, 0–3)
      • Only shown in a pooled analysis (43% versus 21%).
      • Only 14% of surgical survivors could look after their own affairs without assistance (mRS score, 2)
    • no difference in outcome whether dominant or non-dominant hemispheres are involved

Subsequently, the DESTINY II Trial (2014) studied patients aged >60 years:

  • n = 112 patients >60 years of age (median age was 70)
  • Primary outcome measure was survival without severe disability
    • 38% in the hemicraniectomy group vs 18% in the control group
  • Secondary outcomes:
    • Overall mortality was lower in the surgery group (33% vs 70%)
    • Almost none of the survivors has an outcome as good as an mRS score of 3; almost all post-operative survivors were severely disabled


Decompressive hemicraniectomy

  • can be considered in patients <60 years of age, within 48 hours of stroke onset, although outcomes are still likely to be poor
  • should not be performed in malignant MCA stroke patients aged >60 years as survivors will be severely disabled

References and Links

Journal articles

  • Back L, Nagaraja V, Kapur A, Eslick GD. The role of decompressive hemicraniectomy in extensive middle cerebral artery strokes: a meta-analysis of randomized trials. Intern Med J. 2015 Feb 13. doi: 10.1111/imj.12724. [Epub ahead of print] PubMed PMID: 25684396.
  • Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp HB; HAMLET investigators. 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. Lancet Neurol. 2009 Apr;8(4):326-33. doi: 10.1016/S1474-4422(09)70047-X. Epub 2009 Mar 5. PubMed PMID: 19269254.
  • Jüttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, Witte S, Jenetzky E, Hacke W; DESTINY Study Group. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke. 2007 Sep;38(9):2518-25. Epub 2007 Aug 9. PubMed PMID: 17690310. [Free Full Text]
  • Jüttler E, Unterberg A, Woitzik J, Bösel J, Amiri H, Sakowitz OW, Gondan M, Schiller P, Limprecht R, Luntz S, Schneider H, Pinzer T, Hobohm C, Meixensberger J, Hacke W; DESTINY II Investigators. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med. 2014 Mar 20;370(12):1091-100. doi: 10.1056/NEJMoa1311367. PubMed PMID: 24645942. [Free Full Text]
  • Rahme R, Zuccarello M, Kleindorfer D, Adeoye OM, Ringer AJ. Decompressive hemicraniectomy for malignant middle cerebral artery territory infarction: is life worth living? J Neurosurg. 2012 Oct;117(4):749-54. doi: 10.3171/2012.6.JNS111140. Epub 2012 Aug 24. Review. PubMed PMID: 22920962.
  • Taylor B, Lopresti M, Appelboom G, Sander Connolly E Jr. Hemicraniectomy for malignant middle cerebral artery territory infarction: an updated review. J Neurosurg Sci. 2015 Mar;59(1):73-8. Epub 2014 Nov 25. PubMed PMID: 25423133.
  • Torbey MT, Bösel J, Rhoney DH, Rincon F, Staykov D, Amar AP, Varelas PN, Jüttler E, Olson D, Huttner HB, Zweckberger K, Sheth KN, Dohmen C, Brambrink AM, Mayer SA, Zaidat OO, Hacke W, Schwab S. Evidence-Based Guidelines for the Management of Large Hemispheric Infarction : A Statement for Health Care Professionals from the Neurocritical Care Society and the German Society for Neuro-Intensive Care and Emergency Medicine. Neurocrit Care. 2015 Jan 21. [Epub ahead of print] PubMed PMID: 25605626.
  • Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, Boutron C, Couvreur G, Rouanet F, Touzé E, Guillon B, Carpentier A, Yelnik A, George B, Payen D, Bousser MG; DECIMAL Investigators. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke. 2007 Sep;38(9):2506-17. Epub 2007 Aug 9. PubMed PMID: 17690311.
  • Vahedi K, Hofmeijer J, Juettler E, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. The Lancet Neurology 2007;6:215-22. PMID: 17303527.
  • Yang MH, Lin HY, Fu J, Roodrajeetsing G, Shi SL, Xiao SW. Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: A systematic review and meta-analysis. Surgeon. 2015;13:(4)230-40. [pubmed]

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Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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