**6. Decompressive hemicraniectomy for malignant middle cerebral artery territory infarct**

Patients who suffer from middle cerebral artery infarction can have a mortality rate secondary to elevated intracranial pressure. Neurosurgeons often perform decompressive craniectomies when such situations arise. Multiple studies were conducted over the years to determine the efficacy of this practice. There were three randomized controlled landmark studies and a meta-analysis of these studies that aimed to address this issue.

The first trial was the "Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY)" that was published in 2007 [70]. The second trial was the "Sequential-Design, Multicenter, Randomized, Controlled Trial of Early Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarction (DECIMAL Trial)" that was published in 2007 [71]. The third trial was the "Hemicraniectomy after middle cerebral artery infarction with life-threatening Edema trial (HAMLET)" published in 2009 [72].

In 2007 a meta-analysis of the above three randomized controlled studies was conducted while the above studies were ongoing [73]. The aim of the study was to determine whether performing decompressive hemicraniectomy in patients who had suffered malignant middle cerebral artery territory infarct had good long-term outcomes [73]. The study showed that more patients in the hemicraniectomy group had an mRS of less than equal to 4 in comparison to the control group [73]. The study also showed that survival rate in the hemicraniectomy group was higher than in the control group [73]. This meta-analysis favored decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction who underwent surgery within 48 hours of stroke onset in order to reduce mortality and improve mRS score in survivors [73].
