Early Decompressive Hemicraniectomy in Older Patients With Nondominant Hemispheric Infarction Improves Outcome

The Case:A 70 year-old right-handed woman with a massive right MCA infarction and 3 mm midline shift is seen within 17 hours of onset. The Questions: The Controversy:Early decompressive hemicraniectomy in older patients with non-dominant hemispheric infarction improves outcome.To answer the questions regarding the efficacy of hemicraniectomy in older patients with malignant middle cerebral artery infarctions, several facts and open questions must be considered. First, the natural course of complete middle cerebral artery infarctions is associated with early death in 70% to 80% of cases. This “malignant” and deadly course can also be seen in older patients. Second, in case of survival, recovery with a complete functional independent outcome is almost impossible.1 Third, there is no proven standard medical or conservative critical care management. Standard care is largely ineffective and probably not better than palliative care.1,2 Osmotherapy, hyperventilation, buffers, barbiturates, and hypothermia are unproven, ineffective, or even detrimental.2 Fourth, the efficacy …