A patient with a malignant MCA territory infarct was transferred to the ICU with a decreased level of consciousness. CT head revealed significant midline shift. The neurosurgeon was consulted and the patient underwent decompressive hemicraniectomy. Part of his skull on the right was removed to allow the brain to swell, avoiding further damage due to increased intracranial pressure. The arrow on the picture above indicates brain swelling beyond the craniectomy defect.

In summary, decompressive craniectomy was found to improve mortality but not the neurological outcome. Younger patients (< 50 years) have better outcomes with the surgery. Craniectomy is also more beneficial when performed early (<48 hours from stroke onset).