Malignant middle cerebral artery (MCA) infarcts occur in a small subset of patients with ischaemic strokes and lead to high levels of disability and mortality. Over the last 10 years, surgical interventions, in the form of decompressive craniectomies, have become more popular. There is insufficient evidence to support current medical treatments including mannitol, glycerol, steroids, hypertonic saline, and therapeutic hypothermia. Several randomised controlled trials of early decompressive craniectomies in younger patients have shown a significant improvement in functional outcomes and mortality. Questions still need answering regarding the timing of this surgery, long-term survival benefits, and age thresholds. In this review article we will discuss the evidence and uncertainties surrounding the management of malignant MCA infarcts.
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