Malignant middle cerebral artery syndrome and decompressive hemicraniectomy after ischaemic stroke.

Malignant middle cerebral artery (MCA) syndrome is one of the most devastating stroke syndromes, occurring in approximately 10% of ischaemic strokes and resulting in high morbidity and mortality (up to 80% if untreated). These outcomes reflect the large volume of infarction and consequent oedema and raised intracranial pressure resulting from a large vessel occlusion. Pharmacological treatment of this syndrome has limited efficacy and surgical management with decompressive hemicraniectomy (DHC) is the mainstay to reduce mortality. Decisions regarding such neurosurgical interventions are nuanced and require a multidisciplinary approach. This review considers the pathophysiology and natural history of malignant MCA stroke, the indications for DHC, technical considerations of craniectomy and cranioplasty, and the importance of clear communication in shared decision-making with patients, families and across specialities.