NCCEd: Neurocritical Care Education for Residents

Great job! The early acute stroke management for this patient was straightforward. However, it was key for us to recognize the severity of her infarct and to act quickly after she decompensated the next day. This required knowledge of the clinical trial data, as the usual approach with surgery would've generally been to wait further.

Pearl 1: Early decompressive hemicraniectomy (within 48hrs) improves mortality AND morbidity in malignant MCA infarct patients age < 60.

(Lin and Frontera 2021)

This is based on the meta-analysis of the multiple DHC trials done in the 2000s and 2010s. You can also perform DHC on patients above this age group to improve mortality, though this comes at the cost of increased morbidity.

Suggested Reading from this Case:

• Dasenbrock HH, Robertson FC, Vaitkevicius H, et al. Timing of Decompressive Hemicraniectomy for Stroke. Stroke. 2017;48(3):704-711. doi:10.1161/strokeaha.116.014727
• Lin J, Frontera JA. Decompressive Hemicraniectomy for Large Hemispheric Strokes. Stroke. 2021;52(4):1500-1510. doi:10.1161/strokeaha.120.032359
• Rajwani K, Crocker M, Moynihan B. Decompressive craniectomy for the treatment of malignant middle cerebral artery infarction. British Journal of Neurosurgery. 2017;31(4):401-409. doi:10.1080/02688697.2017.1329518