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A subset of patients with ischemic cerebrovascular stroke suffer a progressive deterioration secondary to massive cerebral ischemia, edema, and increased intracranial pressure (ICP). The evolution is often fatal. In these patients, a decompressive craniectomy converts the closed, rigid cranial vault into an “open box.” The result is a dramatic decrease in ICP and a reversal of the clinical and radiological signs of herniation. For these reasons, decompressive craniectomy has been increasingly proposed as a life-saving measure in patients with large, space-occupying hemispheric infarction. The authors review the rationale, indications, and clinical experience with this procedure, which has been performed in patients who have had supratentorial ischemic stroke.

Decompressive craniectomy for space-occupying supratentorial infarction: rationale, indications, and outcome