Malignant cerebral swelling following cranioplasty

•Massive cerebral swelling following cranioplasty has recently been reported.•This may relate to failure of autoregulation.•Six cases amongst a cohort of 528 patients are reported.•This would give an incidence of 1.1%.

Over the past few years there have been a number of case reports and small cohort studies that have described so called “malignant” cerebral swelling following an uneventful cranioplasty procedure. The pathophysiology remains to be established however it has been suggested that it may be related to a combination of failure of autoregulation and the use of closed vacuum suction drainage. The current study presents three further patients who had had a decompressive hemicraniectomy for ischaemic stroke. If decompressive craniectomy is utilised in the management of neurological emergencies, close attention and wider reporting of this type of complication is required not only to focus attention on possible management strategies, but also to determine which patients are at most risk of this devastating complication.