Malignant hemispheric infarction: diagnosis and management by hemicraniectomy.

Abstract

A previously healthy, right-handed 43-year-old man was found lying on the floor in his apartment. His relatives had been unable to contact him for more than a day. On admission, he was somnolent but attempted to obey commands and had a right-sided hemiplegia, dense sensory loss, severe word-finding difficulty, and anisocoria with miosis and ptosis in left eye (National Institutes of Health Stroke Scale, 21). Emergent computerized tomographic scan revealed an extensive left-hemispheric infarction (Figure [A]). Computerized tomographic angiography showed a left carotid dissection. The neurosurgeon recommended medical management; hypertonic saline was initiated. Fifteen hours after admission, his level of consciousness had deteriorated (Glasgow coma score, 10), his left pupil was enlarged and fixed, and increased midline shift was visible on computerized tomography (Figure [B]). The patient was referred to decompressive hemicraniectomy (DHC), which was performed 20 hours after admission. By 72 hours, the patient was more alert and his left pupil was reactive (still enlarged). Because of ventilatory problems, he required intermediate care for subsequent 2 weeks. After tracheostomy removal 18 days after admission, the patient was alert but hemiplegic and hemianopic, obeying commands, and able to communicate with single words and short phrases. He was discharged to a rehabilitation hospital 10 days later and thereafter to a supported residential home. Six years later, he was able to walk with a cane, go shopping unaided, communicate reasonably, and read short sentences with difficulty. His right …