Place de la chirurgie dans le traitement des accidents ischémiques cérébraux

Malignant middle cerebral artery (MCA) infarction is a devastating condition that leads to early death in nearly 80% of cases; the cause is a rapid rise of intracranial pressure, resulting in temporal herniation despite maximum medical management of the ischemic brain edema. Hemicraniectomy with durotomy has been proposed as an emergency decompression therapy to prevent brain herniation in concerned patients but this procedure remains controversial until the results of currently ongoing randomized controlled trials are made available. These trials aim to assess not only disability but also long term quality of life after hemicraniectomy for malignant MCA infarction. In space occupying cerebellar infarction, ischemic edema may lead to brainstem and basal cistern compression and subsequent supratentorial hydrocephalus and clinical deterioration and death. External ventricular derivation may rapidly normalize the intraventricular pressure in such patients. However the exact timing of the ventricular derivation remains controversial, as well as whether suboccipital craniectomy should be performed in patients with clinical deterioration due to brainstem compression. However, it should be noticed that in the absence of associated severe brainstem infarction, clinical outcome after cereballer infarction is usually good, justifying the decision of invasive surgical procedure in cases of deterioration due to the ischemic brain edema.