Diagnosis and treatment of malignant middle cerebral artery infarction and cerebellar infarction with mass effect. Recommendations of the Spanish Society of Neurology's Stroke Study Group.

AIMS: To update the recommendations of the Spanish Society of Neurology's Stroke Study Group on the diagnosis and treatment of malignant middle cerebral artery (MCA) infarction and malignant cerebellar infarction, including the role of decompressive craniectomy.

DEVELOPMENT: A systematic review of the literature was conducted on PubMed, selecting clinical trials and meta-analyses evaluating malignant infarction as an independent variable. A series of PICO (patient, intervention, comparison, outcome) questions were developed to identify practical aspects of the diagnosis and the medical and surgical treatment of these patients. Based on the results, we developed a series of recommendations in response to each PICO question.

CONCLUSIONS

We propose evidence-based definitions of malignant MCA infarction and malignant cerebellar infarction. Clinical trials of such anti-oedema therapies as osmotherapy and hypothermia have not been shown to reduce rates of mortality or disability. In patients aged < 60 years with malignant MCA infarction, the number needed to treat to avoid a death with decompressive craniectomy is 2, and the number needed to treat to achieve survival with a modified Rankin Scale score ≤ 3 is 4. In patients aged 60-75 years, decompressive craniectomy reduces mortality but is associated with severe sequelae, and therefore is not recommended for routine use. Suboccipital decompressive craniectomy should be considered either as a primary indication or after failure of a ventricular drain, in patients with extensive cerebellar infarction and neurological deterioration due to brainstem compression.