Decompressive Craniectomy in Ischemic Stroke: Neurosurgical Perspectives on Patient Outcomes and Psychological Impact on Family

Abstract Malignant middle cerebral artery infarction afflicts 1 to 10% of ischemic stroke patients and carries 40 to 80% mortality under best medical therapy. To synthesize neurosurgical evidence, family-centered psychosocial data, and future research priorities concerning decompressive craniectomy (DC) for ischemic stroke. A narrative review of randomized trials, cohort studies, meta-analyses, and caregiver research (1995–2025) was undertaken, adhering to the Indian Journal of Neurosurgery guidelines. Primary endpoints were survival, modified Rankin Scale (mRS) distribution, caregiver psychological burden, and emerging neurorehabilitation insights. Early DC (<48 hours) reduces mortality by 41 to 50% versus medical treatment alone, with a number-needed-to-treat of 2 to 3. Survival gains are offset by higher rates of severe disability (mRS: 4–5) in 27 to 40% of cases. Patients < 60 years demonstrate twice the odds of achieving mRS of 0 to 3 at long-term follow-up compared with older cohorts. Complication rates reach 54%, dominated by hemorrhage, hydrocephalus, and sinking-flap syndrome. Up to 75% of caregivers report clinically significant anxiety or depression, and 17 to 28% develop posttraumatic stress symptoms. Neuroplastic recovery mechanisms—synaptogenesis, peri-infarct network re-engagement, and restored cerebrospinal fluid dynamics after cranioplasty—permit functional gains beyond 6 months, challenging traditional prognostic pessimism. DC transforms a previously fatal event into survivable—but often disabling—outcomes. Shared decision-making must balance survival with quality of life and caregiver well-being. Future work should refine patient selection (especially > 60 years), integrate structured family support, and exploit advanced rehabilitation technologies to convert survival benefits into meaningful functional recovery.