Yes! This patient is young (age < 60) and sustained a large MCA infarct that occupies ≥ 50% of that territory. This is a malignant MCA infarct. (There are a variety of other definitions for "malignant MCA infarct," including > 145mL core infarct, > 67, or 75% of the MCA territory.) The problem isn't with intracranial hypertension per se; it's more about the pressure vector from one hemisphere to the other. This pathology is a good example of how you can get herniation without elevated ICPs. Hyperosmolar therapy can be pretty good for managing ICPs; it's not that great for herniation from focal lesions like this.
Malignant MCA infarcts account for about 10% of ischemic strokes. Unfortunately, mortality of these malignant infarcts is anywhere between 40-80% without surgical intervention. There are a few risk scores out there that are supposed to help predict the likelihood of progression to a malignant infarct. They're not great; don't rely on them.
So, we do know that a decompressive hemicraniectomy (DHC) can help address the herniation and give the brain more room to continue swelling. (The cytotoxic edema from infarcts generally peaks between post-stroke days 3 to 5.) With such a dire pathology, we have to ask ourselves, though, does surgery actually help in the long run? And when should we go for it? Fortunately, we do have randomized trial data that helped answer these questions. There were several pertinent RCTs, all done in the 2000s and 2010s: DESTINY I and II, DECIMAL, HAMLET, HeADDFIRST, HeMMI, Slezins et al., and Zhao et al. Five of these trials included patients older than 60.
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