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Clinical Question

Is hemicraniectomy indicated?

Synthesises 5 trialsspace-occupying MCA infarction across the age spectrum + adjunct edema therapy

Clinical Synthesis

Decompressive hemicraniectomy within 48 hours reduces mortality in space-occupying middle-cerebral-artery infarction; benefit on functional outcome is established in patients ≤60 years, and in patients >60 the trade-off is survival with substantial disability rather than survival with independence.

Bottom line

In patients ≤60 with complete MCA-territory infarction and neurologic decline, decompressive hemicraniectomy within 48 hours reduces mortality and increases the proportion reaching mRS ≤3 (Class I, Level B per AHA/ASA 2014). In patients >60, surgery still reduces mortality (DESTINY-II) but most survivors are mRS 4 to 5; this is a values-based decision that requires explicit family discussion before the OR.

Sources

Hemicraniectomy for malignant MCA infarction· 2014§6.3 Supratentorial Infarction (Surgical Management)· 2026DECIMAL· 2007DESTINY· 2007HAMLET· 2009Early decompressive surgery in malignant infarction of the middle cerebral artery· 2007DESTINY II· 2014CHARM· 2024

Trials in this question· 5

DECIMAL2007
Hemicraniectomy within 30 h cuts mortality 52.8 pp in malignant MCA infarction (age <56).
−52.8 pp mortalityARR 52.8% mortality
DESTINY2007
Decompressive surgery improves survival in malignant MCA infarction (age <61); function not met.
+41 pp survivalARR 41% mortality
HAMLET2009
Hemicraniectomy up to 96 h cuts mortality 38 pp in malignant MCA infarction; no mRS ≤3 benefit.
−38 pp mortalityARR 38% mortality
DESTINY II2014
Hemicraniectomy in patients 61–82 with malignant MCA infarction improves survival at the cost of severe disability.
+20 pp survival+20% survival
CHARM2024
IV glibenclamide did not improve mRS in large hemispheric infarct; trial underpowered after COVID stop.
NScOR 1.17 (0.80–1.71)

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