Managing malignant middle cerebral artery infarction with open scalp incision and partial hemispherectomy: illustrative case

Abstract

Background: Malignant middle cerebral artery (MCA) infarctions result in cerebral edema that can lead to brain herniation and death. Standard management includes decompressive hemicraniectomy (DHC) and comprehensive neurocritical care. Some patients may continue to decline despite these measures. Reopening of the scalp incision may allow for additional decompression and provide mortality benefit.

Observations: A 47-year-old man developed malignant right MCA territory infarction following intravenous thrombolysis and unsuccessful mechanical thrombectomy. Despite aggressive hyperosmolar therapy and a large DHC, the patient continued to exhibit clinical decline and radiological progression of cerebral edema. In response, the scalp incision was reopened to facilitate maximal external cerebral herniation, a strategy the authors believe was critical in managing the brain swelling. The patient was maintained on prophylactic antibiotics during this period, given the increased infection risk associated with exposed brain surface and potential CSF leakage. Following the resolution of cerebral swelling, a right partial hemispherectomy was performed to excise the infarcted hemisphere. Notably, the patient achieved significant functional recovery following the intervention and an extended period of rehabilitation.

Lessons: This case highlights the complexities encountered in the surgical management of malignant cerebral infarction, particularly when standard decompressive measures fail. https://thejns.org/doi/10.3171/CASE2523.

Keywords: decompressive hemicraniectomy; hemispherectomy; ischemic brain edema; malignant MCA infarction; open scalp incision.

FIG. 1.

A–D: Poststroke day 1. Noncontrast axial CT images of the head showing large right hemispheric hypodensity consistent with evolving infarction, extensive cytotoxic edema, right-to-left midline shift of 9 mm, right lateral ventricle compression, and left lateral ventricular entrapment. E–H: Poststroke day 4. Noncontrast axial CT images of the head showing right DHC, evolving large right hemispheric infarction, extensive cytotoxic edema, transcalvarial herniation, developing leftward midline shift measuring 10 mm, and new right uncal herniation. I and J: Three-dimensional reconstruction of original right DHC.

FIG. 2.

Poststroke day 5. Noncontrast axial CT images of the head showing hemorrhagic conversion, prominent cytotoxic edema, and transcalvarial herniation.

FIG. 3.

Poststroke day 15. Noncontrast axial CT images of the head posthemispherectomy, showing right hemispheric hemorrhage, within resection cavity, rightward midline shift of 7 mm with transcalvarial herniation, and right middle cranial fossa subdural/extradural fluid collection.

FIG. 4.

Poststroke day 37. Noncontrast axial CT images of the head showing decreasing right hemispheric edema, resolution of transcalvarial herniation, and decreased right subdural fluid collection.

FIG. 5.

Exposed necrotic brain tissue herniating through open scalp incision.