Acute occlusion of the middle cerebral artery is an important cause of ischemic stroke. The resulting brain infarction is often very large, leading to massive brain oedema and intracranial hypertension. Despite intensive medical treatment, the mortality rate due to herniation and cerebral circulatory arrest remains very high. A Norwegian left-handed male, 28 years of age, developed signs of impending herniation following an acute right-side middle cerebral artery occlusion. When admitted to neurosurgical care 54 hours after the stroke, he was soporous, had a left-side hemiparalysis, conjugated deviation of the gaze and a mydriatic pupil on the right side. The intracranial pressure level was between 30 and 40 mm Hg. Following a right-side hemicraniectomy, the intracranial pressure fell to levels around 20 mm Hg. The bone flap was replaced four months later. One year after the stroke, the patient is fully independent of others, despite a left-side hemianopia and hemiparesis. Hemicraniectomy may be indicated in selected patients with impending herniation due to brain infarction. Intracranial pressure recordings are useful as an adjunct in the management of these patients. Our report seems to be the first account of decompressive hemicraniectomy performed in Norway for acute massive brain infarction.
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