Decompressive Craniectomy in Ischemic Stroke: Neurosurgical Perspectives on Patient Outcomes and Psychological Impact on Family.

BACKGROUND

Malignant middle cerebral artery infarction afflicts 1 to 10% of ischemic stroke patients and carries 40 to 80% mortality under best medical therapy.

OBJECTIVE

To synthesize neurosurgical evidence, family-centered psychosocial data, and future research priorities concerning decompressive craniectomy (DC) for ischemic stroke.

MATERIALS AND

METHODS

A narrative review of randomized trials, cohort studies, meta-analyses, and caregiver research (1995-2025) was undertaken, adhering to the Indian Journal of Neurosurgery guidelines. Primary endpoints were survival, modified Rankin Scale (mRS) distribution, caregiver psychological burden, and emerging neurorehabilitation insights.

RESULTS

Early DC (<48 hours) reduces mortality by 41 to 50% versus medical treatment alone, with a number-needed-to-treat of 2 to 3. Survival gains are offset by higher rates of severe disability (mRS: 4-5) in 27 to 40% of cases. Patients < 60 years demonstrate twice the odds of achieving mRS of 0 to 3 at long-term follow-up compared with older cohorts. Complication rates reach 54%, dominated by hemorrhage, hydrocephalus, and sinking-flap syndrome. Up to 75% of caregivers report clinically significant anxiety or depression, and 17 to 28% develop posttraumatic stress symptoms. Neuroplastic recovery mechanisms-synaptogenesis, peri-infarct network re-engagement, and restored cerebrospinal fluid dynamics after cranioplasty-permit functional gains beyond 6 months, challenging traditional prognostic pessimism.

CONCLUSION

DC transforms a previously fatal event into survivable-but often disabling-outcomes. Shared decision-making must balance survival with quality of life and caregiver well-being. Future work should refine patient selection (especially > 60 years), integrate structured family support, and exploit advanced rehabilitation technologies to convert survival benefits into meaningful functional recovery.