Issues And Strategies Of Surgical Treament For Massive Cerebral Infarction

Massive cerebral infarction (MCI), mostly caused by occlusion of either the internal carotid artery or the proximal middle cerebral artery (MCA), accounts for 10% of all ischaemic infarcts approximately. The characteristic of MCI is the relentless formation of early cytotoxic and late vasogenic and subsequent space-occupying edema. Owing to the rigid nature of the skull, escalating brain edema leads to an increase in intracranial pressure (ICP) which, in turn, causes reduction in cerebral perfusion pressure (CPP) and cerebral blood flow (CBF). These effects contribute to development of additional brain edema. Forming a’vicious circle’that can lead to brain herniation and death. Various treatment strategies have been proposed to limit brain tissue shifts and to reduce ICP, but their use is controversial. Even under standard and under intensive medical care, the mortality rate is as high as 80%, and most survivors are left severely disabled. In contrast, Decompressive hemicraniectomy (DHC) is an effective surgical therapy to reduce mortality and improve functional outcome. Findings of three randomized, controlled clinical trials (DECIMAL, DESTINY, HAMLET) and their meta-analysis showed that early surgical decompression not only reduced the number of case fatalities but also increased the incidence of favorable outcomes. Although many patients have a good outcome after DHC, the issue of DHC-related disability raises important ethical issues. Therefore, we should screen the eligible patients first. At the same time, strict operation timing and suitable operation procedure is the key points to elevate the effect. This review aimed to provide an overview of the current surgical treatment issues and strategies of MCI.