La mortalidad asociada al infarto cerebral maligno de arteria cerebral media (ACM) se aproxima al 80% con tratamiento médico, pero varios estudios demuestran que la cirugía descompresiva aumenta la supervivencia hasta el 40–50%. Presentamos nuestra experiencia en este tratamiento y una revisión de la literatura.

Se han realizado siete craniectomías descompresivas en cinco pacientes con infarto masivo de ACM de edades entre 33 y 57 años (tres varones y dos mujeres). El GCS pre-cirugía estuvo entre 9–13 puntos, realizándose siempre TAC craneal antes de 12 horas. Dos pacientes presentaron infartos en hemisferio dominante y tres en no dominante. La presión intracraneal (PIC) se monitorizó continuamente en cuatro pacientes. Se realizaron craniectomías amplias con apertura dural y colocación de plastia heteróloga.

La cirugía se realizó en torno a las 47 horas desde el debut clínico. La PIC preoperatoria osciló entre 27 y 50mmHg, siendo menor a 15mmHg tras la cirugía en todos los casos. Dos pacientes (hemisferio no dominante) sobrevivieron con resultados funcionales excelente y bueno (precisó reintervención), estables tras diez y cinco meses. Tres pacientes fallecieron a los cinco, cinco y trece días por hipertensión intracraneal (uno se reintervino). En nuestra experiencia la retirada del hueso resultó más relevante que la apertura dural para controlar la PIC. Las craniectomías amplias podrían evitar la necesidad de reintervención.

La reducción de la mortalidad, una ventana terapéutica amplia (2-3 días) y la baja incidencia de complicaciones confieren a esta técnica un papel relevante en el manejo del infarto de ACM maligno.

Medically managed malignant infarction of the middle cerebral artery (MCA) is associated with an 80% mortality rate. However, several studies report a 40–50% increase in survival rates when decompressive craniectomy is performed. We present our experience with such surgical treatment and a literature review.

Seven decompressive craniectomies were performed on five patients for space-occupying MCA infarctions. Age ranged from 33 to 57 years-old (three males and two females). Preoperative GCS score was 9–13. Cranial CT was performed within the first 12 hours. Intracranial pressure (ICP) was continuously measured in four patients. Two infarcts occurred in the dominant hemisphere and three in the non-dominant side. Wide fronto-parieto-temporal craniectomies were performed. The duramater was opened and a large heterologous dura graft was placed.

Surgery was performed on the second day after the onset of symptoms (median: 47 hours). Preoperative ICP ranged from 27 to 50mmHg (median: 30.5mmHg), with immediate postoperative ICP under 15 mmHg in all patients. Two patients (both non-dominant side) survived with good (after reoperation) and excellent functional outcome. They remain stable after ten and five months of follow-up. Three patients died five, five and thirteen days after admission due to uncontrollable high ICP. In our experience, bone removal itself was more relevant than dural opening for ICP control. Initial wide craniectomies may spare reoperations.

The significant mortality rate reduction, a wide therapeutic window (2–3 days) and a low incidence of intraoperative complications make decompressive craniectomy a relevant treatment in malignant cerebral MCA infarction.