Patients with middle cerebral artery (MCA) infarction who meet the criteria below should be considered for decompressive hemicraniectomy. Patients should be referred to neurosurgery within 24 hours of stroke onset and treated within 48 hours of stroke onset.
- pre-stroke modified Rankin Scale score of less than 2;
- clinical deficits indicating infarction in the territory of the MCA;
- NIHSS > 15
- A decrease in the level of consciousness to a score of 1 or more on item 1a of the NIHSS
- Signs on CT of an infarct of at least 50% of the MCA territory with or without additional infarction in the territory of the ACA or PCA on the same side, or infarct volume greater than 145 cubic centimetres on diffusion-weighted MRI.
AHA Guidelines Feb 2018 [USA]
- Although the optimal trigger for decompressive craniectomy
is unknown, it is reasonable to use a decrease in level of
consciousness attributed to brain swelling as selection criteria.
- In patients =60 years of age with unilateral MCA infarctions who
deteriorate neurologically within 48 hours despite medical therapy,
decompressive craniectomy with dural expansion is reasonable because
it reduces mortality by close to 50%, with 55% of the surgical survivors
achieving moderate disability (able to walk) or better (mRS score 2 or 3)
and 18% achieving independence (mRS score 2) at 12 months.
- In patients >60 years of age with unilateral MCA infarctions
who deteriorate neurologically within 48 hours despite medical
therapy, decompressive craniectomy with dural expansion may be
considered because it reduces mortality by close to 50%, with 11%
of the surgical survivors achieving moderate disability (able to walk
[mRS score 3]) and none achieving independence (mRS score =2)
at 12 months.
- Use of osmotic therapy for patients with clinical deterioration from
cerebral swelling associated with cerebral infarction is reasonable.
- Use of brief moderate hyperventilation (Pco2 target 30-34
mm Hg) is a reasonable treatment for patients with acute severe
neurological decline from brain swelling as a bridge to more
- Because of a lack of evidence of efficacy and the potential to
increase the risk of infectious complications, corticosteroids (in
conventional or large doses) should not be administered for the
treatment of cerebral edema and increased intracranial pressure
complicating ischemic stroke.