Severe Brain Injury, Stroke, and Hemicraniectomy

brain surgery, neurosurgery
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Most strokes are small strokes and cause insignificant brain swelling. Large strokes, however, may cause significant swelling that can rapidly worsen, leading to a permanent state of unresponsiveness or even death. For example, when a large vessel stroke affects the blood flow through the main middle cerebral artery, almost an entire side of the brain is completely deprived of blood, causing the rapid death and swelling of nearly half of the brain.

Because the brain is encased by the walls of the bony skull, this swelling leads to an increase in intracranial pressure (ICP) ​and results in an enlarged area of brain damage. In the long run, the increased ICP prevents blood from flowing into most of the brain, resulting in a rapid progression to brain death. In the majority of cases, the best way to relieve the deadly ICP is through a life-saving surgery called a hemicraniectomy.

What is a hemicraniectomy?

A hemicraniectomy is one of the most effective ways of relieving massive brain swelling. This surgical procedure, which is performed in the operating room under anesthesia, consists of temporarily removing a portion of the skull (sometimes up to one-half or more) in order to allow the swollen brain to expand beyond the confines of the skull bone, without causing further elevations in brain pressure. The part of the skull bone that is removed is typically frozen until the swelling has resolved, at which point it can be sutured back onto its original place.

Should every large stroke be treated with a hemicraniectomy?

No. Although many physicians advocate for hemicraniectomy in cases of severe brain swelling, others feel that in spite of the proven benefits of this procedure in terms of survival, hemicraniectomy does not guarantee a meaningful restoration of quality of life for patients.

This is especially true for large strokes, for people who are medically frail, and for people of advanced age. Thus, a great deal of controversy surrounds the impact that this procedure has on the lives patients and their families.

Who decides whether my loved one will get a hemicraniectomy?

The decision of whether a given patient should undergo hemicraniectomy is only reached after the risks and benefits of the surgery have been thoroughly communicated to the family, and after the family agrees to go ahead with the procedure. Therefore, unless a hemicraniectomy is performed emergently, the family's opinion about whether or not the procedure should be performed, is thought to be as important as that of the medical team. Many families in this situation are fortunate to know a patient's wishes based on discussions that happened before their stroke. For instance, a patient might have spoken to a parent, or a sibling about their wish to be let go in peace if they ever faced extensive brain injury and life-long disability. In such cases, it is always wise to honor the patient's wishes.

Should I agree to a hemicraniectomy for my loved one?

If you are faced with the need to provide medical consent for a hemicraniectomy for someone you know, it might be helpful to consider the following issues:

  • What is the likelihood that your loved one will recover meaningful brain function if a hemicraniectomy is performed?
  • If the surgery is performed and your loved one survives the stroke, is there a meaningful chance that he/she will be able to eat or breath on his/her own? If not, did he/she ever express his/her feelings about being completely dependent on tube feedings and/or mechanical ventilation?
  • Does my loved one have a living will that explains what interventions he/she would be willing to tolerate under the present circumstances?


Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A, Amelink JG, Schmiedeck P, Schwab S, Rothwell PM, Bousser M-G, van der Worp HB, Hacke W; for the DECIMAL, DESTINY, and HAMLET investigators.

Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomized controlled trials. Lancet Neurol. 2007; 6: 315–322.

Stephan A. Mayer, MD, FCCM; Hemicraniectomy A Second Chance on Life for Patients With Space-Occupying MCA Infarction; Stroke. 2007;38:2410.

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