• malignant cerebral infarction = extensive infarction with large space-occupying edema
    • occurs in up to 10% of patients with supratentorial infarcts 
    • it is traditionally associated with a high mortality rate (up to 80%)  [Hacke, 1996]
  • occurs mainly in cases of ICA and MCA occlusions or with posterior circulation strokes (mainly cerebellar infarctions)
  • it is characterized by a development of edema within 24 h, clinical deterioration usually in < 72h, sometimes later (e.g., in case of collateral circulation failure and development of infarction in the penumbra
  • early surgical decompression reduces mortality and increases the number of younger patients with a favorable outcome according to randomized controlled trials (RCTs)

Predictors of malignant infarction

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Clinical features

  • the initial severe neurological deficit with hemiplegia, deviation of eyes and head, high NIHSS, nausea, vomitus
  • posterior circulation infarction is associated with altered consciousness, oculomotor dysfunction, altered brainstem reflexes, ataxia, and dysmetria
  • progressive impairment of consciousness and conus symptoms due to craniocaudal deterioration
  • Cushing’s triad is present in advanced stages of intracranial hypertension
    • hypertension
    • bradycardia
    • respiratory disorders
      • hypo-, hyperventilation
      • Cheyne-Stokes breathing   Cheyne-stokes breathing
      • apneic pauses
  • cardiovascular lability
  • cerebellar infarctions are associated with an increased risk of brainstem compression and hydrocephalus development

Diagnostic evaluation

Imaging methods

  • look for expansive behavior of ischemia and a midline shift on CT
  • repeat brain CT within the first 48h in high-risk patients [AHA/ASA 2014 I/C]
  • use MRI for early detection of large DWI lesions
    • prediction of fulminant course within 6 h: DWI lesion > 80-89 mL
    • prediction of fulminant course beyond 14 h: DWI lesion > 145 mL
Malignant ischemia

Malignant infarction in MCA and ACA territory
Malignant infarction in MCA territory
Cerebellar malignant infarction causing hydrocephalus

Blood tests

  • tests should exclude extracerebral causes of clinical deterioration
  • a basic metabolic panel including hepatic enzymes
  • minerals, including phosphate
  • coagulation and blood count
  • toxicology and ASTRUP should be considered in the presence of impaired consciousness not fully explained by structural changes on CT

Other methods

  • EEG excludes nonconvulsive status epilepticus (unless NCCT correlates with the severe clinical condition)
  • TCD / TCCD can be used to monitor blood flow
  • ICP monitoring

Differencial diagnosis

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Medical therapy

  • routine intensive care for acute stroke patients see here
  • consider transport to a hospital capable of performing acute decompressive craniectomy
  • antiedema therapy
    • osmotic therapy Mannitol / NaCl 10% (AHA/ASA 2019 IIa/C-LD)
    • there are no data on the benefit of hypothermia, barbiturates, and corticosteroids in stroke patients and they are therefore not recommended
    • therapy should be initiated only in patients with developing edema; prophylactic administration of osmotherapy is not recommended
  • the effect of conservative treatment in malignant ischemia is usually insufficient and not clearly demonstrated


  • preferred in younger patients
  • don’t wait for the effect of drug therapy  with developing malignant ischemia (as it has only minimal impact)
Cerebellar infarction
  • ventriculostomy in case of obstructive hydrocephalus due to expansive cerebellar infarction (with or without craniectomy) (AHA/ASA 2019 I/C-LD) 
  • suboccipital craniectomy and resection of the infarcted tissue for expansive cerebral ischemia may be a life-saving procedure (AHA/ASA 2019 I/B-NR)
    • ischemia leads to brainstem and aqueducts compression, so craniectomy can also relieve obstructive hydrocephalus
    • it can be combined with the ventricular drainage
  • imaging criteria
    • compression of the 4th ventricle
    • hydrocephalus
    • basal cisterns/brainstem compression
    • medial cerebellar infarction
Cerebellar ischemia with hydrocephalus managed by with decompressive craniectomy
Suboccipital decompressive craniectomy
Supratentorial infarction (usually MCA territory stroke)
  • decompression releases pressure from the edematous tissue on adjacent tissue ⇒ ↓ ICP and ↑ CPP
  • potentially life-saving procedure (see below for additional indication criteria)
    • age < 60 years – a meta-analysis of the DESTINY, HAMLET a DECIMAL trials demonstrated that decompressive craniectomy within 48 hours in patients aged <60 years results in reduced mortality and improved outcome (AHA/ASA 2019 IIa/A)
    • age > 60 yearsreduced mortality alone was demonstrated in smaller studies [Won Yu, 2012]  and randomized DESTINY II trial
      • n = 112 (surgery 49 vs. control 63), age> 61 years
      • mRS 0-4 39% (surgery) vs. 17% (control), ARR 22, NNT = 5 !!
      • significant reduction of mortality (50%); compared to trials with patients < 60 years of age, there is a significant increase of survivors with very severe deficits and only a minimum of patients with mRS 3 (none 0-2) – questionable cost-effectiveness
  • craniectomy diameter of at least 12 cm
    • 14-15 cm anteroposteriorly
    • 0-12 cm from the base to the vertex
  • concomitant resection of infarcted tissue is rather not recommended
Progressive malignant MCA infarction leading to a decompressive craniectomy (right image)
Decompressive craniectomy

Indication criteria (used in the randomized trials)

  • age 18 – 60 years (younger patients have a better prognosis,  in the age of > 60y, mainly a reduction in mortality can be expected)
  • NIHSS> 15
  • somnolence-sopor
  • ischemia > ½ of the MCA territory according to CT (with or without concurrent infarction in ACA or PCA on the same side)
  • infarct volume > 145 cm3 according to DWI
  • < 45 h (surgery completed < 48 h) from symptom onset

Exclusion criteria

  • non-reactive, dilated pupils
  • pre-morbid mRS ≥ 2 
  • extensive hemorrhagic component (type PH2)
  • survival assumption <3 years due to severe comorbidities
  • coagulopathy
  • contraindications to general anesthesia (GA)

Clinical trials

Early decompressive craniectomy – a meta-analysis of the three European randomized trials
(DECIMAL 38, DESTINY 32, HAMLET 23, total number of patients = 93)  [Vahedi, 2007]
HAMLET trial results (mRS)
Primary and secondary outcome craniectomy control
mRS 0-4 / 1 year 75% 25%
mRS 0-3 / 1 year 43% 21%
survival 78% 29%

DESTINY II [Jüttler, 2014]

  • total n= 112
    • decompressive craniectomy, n =  49
    • control group, n = 63
  • > 61 years of age
  • mRS 0-4 39% (craniectomy) vs 17% (control), ARR 22, NNT = 5
  • significant reduction in mortality, but only a small number of patients with mRS ≤ 3 !!!!
mRS Decompressive craniectomy (%) Control (%)
3 6 4
4 33 14
5 26 12
6 35 70
DESTINY trial results (mRS)

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Malignant cerebral infarction