This protocol targets patients with large cerebral or cerebellar infarction who develop neurological decline driven by brain swelling. For hemicraniectomy consideration, the scenario involves unilateral MCA infarction with neurological deterioration within 48 hours despite medical therapy. For cerebellar infarction, the operative triggers are brainstem compression or an infarct volume of 35 mL or greater.
Management involves osmotic therapy as a bridge to surgical intervention in patients with neurological decline from brain swelling. For cerebellar infarction with obstructive hydrocephalus, a specific surgical drainage procedure is recommended. The full protocol — including precise selection criteria, sequencing, and procedural thresholds — is available below.
DOI: 10.1161/STR.0000000000000513
In patients with large cerebral or cerebellar infarctions and neurological decline from brain swelling, the use of osmotic therapy as a bridge to a surgical intervention is reasonable to improve functional outcome and reduce mortality.
In patients with cerebellar infarction and obstructive hydrocephalus, ventriculostomy is recommended to improve neurological function and decrease mortality.
In patients ≤60 years of age with unilateral MCA infarctions who deteriorate neurologically within 48 hours from brain swelling despite medical therapy, decompressive craniectomy with dural expansion is beneficial to reduce mortality and improve functional outcome.
In patients with cerebellar infarction causing neurological deterioration from brainstem compression or volumes ≥35 mL, decompressive suboccipital craniectomy with dural expansion should be performed to improve outcomes and decrease mortality.
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