Sustained raised intracranial pressure implicated only by pattern reversal visual evoked potentials after cranial vault expansion surgery

Craniosynostosis, the premature fusion of cranial sutures, may be associated with raised intracranial pressure (ICP) with or without a reduced intracranial volume. Regardless of the aetiology, raised ICP may result in optic neuropathy, the timely detection of which can prevent further visual deterioration. Raised ICP is usually treated with craniofacial surgery such as cranial vault expansion. In this case study, we recorded serial pattern reversal visual evoked potentials (pVEPs) and obtained digital optic disc images before and after cranial vault expansion surgery. The amplitude of the pVEPs continued to decrease after cranial vault expansion surgery, prompting further neuroimaging that implicated a blocked ventriculo-peritoneal shunt. Only after shunt revision did the pVEP amplitude increase. Throughout the monitoring period, there was no change in the appearance of either the right or left optic disk, nor a consistent change in visual acuity.

Asymptomatic interval in delayed traumatic intracerebral hemorrhage: report of two cases

Delayed traumatic intracranial hemorrhage (DTICH) is seen mostly in trauma to the occipitoparietal region by countercoup mechanism. It is most encountered within the first posttraumatic 10 days, particularly in the first 3. Herein, two cases of delayed traumatic intracerebral hemorrhage were discussed, first one presented with headache and vomiting who had been asymptomatic for 168 days after head trauma and the other presented with dysarthria and hyperkynesias after 92 days of asymptomatic interval, either being longer than that of the previous cases reported in the literature. Despite a long time elapse, DTICH should be considered in the differential diagnosis in the patients with history of head trauma that manifests at later stages with intracranial pressure elevation symptoms such as headache, vomiting.

Rapid neurological deterioration associated with minor head trauma in chronic hydrocephalus

CASE REPORT

An 8-year-old developmentally normal boy (status: post third ventriculostomy and resection of posterior fossa low-grade glioma 4 years earlier and with known history of ventriculomegaly/arrested hydrocephalus) presented to the emergency room with vomiting and lethargy after a minor head trauma. Computed tomography scan of the head revealed no acute changes since previous studies. However, the patient's neurological status rapidly declined in the emergency room, where an emergency ventriculostomy demonstrated increased intracranial pressure. The patient's clinical condition improved over 24 h: he underwent placement of a ventriculoperitoneal shunt without complications and was discharged intact.

DISCUSSION

The pathogenesis of rapid neurological decline associated with minor head trauma in chronic hydrocephalus is reviewed.

Effects of decompressive craniectomy on brain tissue oxygen in patients with intracranial hypertension

This report examined the intraoperative course of partial pressure of brain tissue oxygen (P(ti)O(2)) and intracranial pressure (ICP) during surgical decompressive craniectomy for medically intractable intracranial hypertension due to diffuse brain swelling in three patients after severe subarachnoid haemorrhage and aneurysm coiling. The mean ICP decreased from 59 mm Hg to 10 mm Hg in a two step fashion, relating to bone flap removal and dural opening. Simultaneously, P(ti)O(2) increased rapidly from 0.8 kPa (6 mm Hg) to 3.07 kPa (23 mm Hg). P(ti)O(2) and ICP remained at non-critical ranges postoperatively. Despite these beneficial effects on ICP and P(ti)O(2), the patients' clinical status remained poor with two in a persistent vegetative state and one dead.

Quantitative analysis of continuous intracranial pressure recordings in symptomatic patients with extracranial shunts

OBJECTIVES

To explore the outcome of management of possible shunt related symptoms using intracranial pressure (ICP) monitoring, and to identify potential methodological limitations with the current strategies of ICP assessment.

METHODS

The distribution of persistent symptoms related to extracranial shunt treatment was compared before and after management of shunt failure in 69 consecutive hydrocephalic cases. Management was heavily based on ICP monitoring (calculation of mean ICP and visual determination of plateau waves). After the end of patient management, all ICP curves were re-evaluated using a quantitative method and software (Sensometrics pressure analyser). The ICP curves were presented as a matrix of numbers of ICP elevations (20 to 35 mm Hg) or depressions (-10 to -5 mm Hg) of different durations (0.5, 1, or 5 minutes). The numbers of ICP elevations/depressions standardised to 10 hours recording time were calculated to allow comparisons of ICP between individuals.

RESULTS

After ICP monitoring and management of the putative shunt related symptoms, the symptoms remained unchanged in as many as 58% of the cases, with the highest percentages in those patients with ICP considered normal or too low at the time of ICP monitoring. The quantitative analysis revealed a high frequency of ICP elevations (20 to 35 mm Hg lasting 0.5 to 1 minute) and ICP depressions (-10 to -5 mm Hg lasting 0.5, 1, or 5 minutes), particularly in patients with ICP considered normal.

CONCLUSIONS

The value of continuous ICP monitoring with ICP analysis using current criteria appears doubtful in the management of possible shunt related symptoms. This may reflect limitations in the strategies of ICP analysis. Calculation of the exact numbers of ICP elevations and depressions may provide a more accurate description of the ICP profile.

Cerebral perfusion pressure and spect in patients after craniocerebral injury with transtentorial herniation

We present a group of 29 consecutive head injured comatose patients with the syndrome of transtentorial herniation. All patients had urgent surgery and then continuous monitoring of ICP, CPP, blood pressure and jugular bulb oximetry was instituted. Two postoperative CT and SPECT examinations were performed in each patient. 15 patients had a normal CPP (> 70 mmHg) throughout the postoperative period, 80% of them had a favourable outcome. On the other hand 14 patients had decreased CPP lasting at least one hour and only 36% of them had a favourable outcome (p < 0.05). Similar relationships were found comparing GOS in patients with normal and increased ICP (> 20 mmHg) and normal and decreased SjO2 (< 55%). All but 3 patients had ischaemia on SPECT. Ischaemia improved on the 2nd SPECT in 11 patients and 10 (91%) of them had a favourable outcome. GOS (mean follow up 9 months) is: 12 patients good, 5 moderately disabled, 2 vegetative, 10 died. We conclude that SPECT is able to disclose even reversible ischaemic changes. In these patients all effort has to be made to keep CPP on normal levels. Improvement in cerebral perfusion is related to a better outcome.

ICP and CBF regulation: a new hypothesis to explain the "windkessel" phenomenon

The brain tamponade represents the final condition of a progressive intracranial pressure (ICP) increase up to values close to arterial blood pressure (BP) producing a reverberating flow pattern in the cerebral arteries with no net flow. This finding implies intracranial volume changes, therefore a full application of the Monro-Kellie doctrine is impossible. To resolve this contradiction, in eight pigs a reversible condition of brain tamponade was produced by infusing saline into a cerebral ventricle. The following parameters were measured: BP in the common carotid artery, ICP by the same needle utilised for the infusion, arterial and venous blood flow velocity (BFV) at, respectively, internal carotid artery (ICA) and sagittal sinus (SS) site by ultrasound technique. When ICP approached carotid BP values, reverberating BFV waves both at ICA and SS site were simultaneously observed. The arterial and venous reverberating waves appeared to be almost exactly superimposable, with a delay of about 40 msec. This synchronism between the pulsatile arterial and venous BFV indicates that the residual pulsation, still occurring at the arterial proximal level, is compensated by a passive compression-distension of the SS with no blood volume (that is net flow) crossing the intracranial vasculature.

ICP and CBF regulation: effect of the decompressive craniectomy

The view of the intracranial system as a rigid and closed box has been criticised by many authors who take into account the possibility of a certain degree of elastic bulk accommodation, mainly in the spinal sac. In nine patients, who underwent decompressive craniectomy for treatment of life-threatening intracranial hypertension, when the clinical conditions improved, just before cranioplasty, the blood flow velocities at middle cerebral artery (MCA) and at superior sagittal sinus (SSS) level were simultaneously recorded. The measurements were repeated after cranioplasty. The blood flow velocity recorded from SSS in craniectomized patients appeared flat, without evident pulsation; after cranioplasty a clear-cut pulsatile wave became again evident. The disappearance of a pulsatile shape in the blood flow velocity recorded from the SSS when the intracranial system was "open" and the reappearance of a pulsatile blood flow waveform after the "closure" of the skull confirm that the venous bed acts as a bulk compensatory system in order to maintain the intracranial volume absolutely constant.

Epidural hematomas in a child with Hutchinson-Gilford progeria syndrome

INTRODUCTION

Hutchinson-Gilford progeria syndrome (HGPS) is a rare genetic disorder. It is characterized by severe growth failure, premature aging, and very early atherosclerosis with coronary artery disease and cerebrovascular disease.

CASE REPORT

A 10-year-old boy with HGPS was admitted to our department because of progressive deterioration after a mild head injury. The CT scans revealed epidural hematoma in posterior fossa and another one in the temporal region on the left side. On admission the child was given an estimated score of 10 on the GCS. Neurological examination revealed right hemiparesis. The boy was operated on, and both hematomas were evacuated. In a few days the neurological symptoms disappeared, and he was discharged from the hospital with only residual, minimal right hemiparesis.

CONCLUSION

Intracranial pathology was certainly caused by the head trauma, but was more severe than would have been expected had the trauma been the sole cause. We suggest that progressive atherosclerosis of intracranial vessels was responsible for formation of the hematomas.

Three-dimensional cranial expansion using distraction osteogenesis for oxycephaly

Oxycephaly is associated with raised intracranial pressure as a result of the fusion of multiple cranial sutures. We have performed an effective and less invasive cranial expansion by means of three-dimensional cranial distraction for the treatment of oxycephaly with suspicion of increased intracranial pressure. We describe two oxycephaly cases and the surgical technique of three-dimensional cranial expansion using distraction osteogenesis.

Sex-related differences in patients with severe head injury: greater susceptibility to brain swelling in female patients 50 years of age and younger

OBJECT

The goal of this study was to study the influence of sex and age on factors affecting patient outcome in severe head injury.

METHODS

Data from the prospectively conducted international trial of tirilazad mesylate in patients with head injury were analyzed retrospectively. Included were 957 patients, 23% of whom were female and all of whom were between the ages of 15 and 79 years. All patients presented with Glasgow Coma Scale (GCS) scores between 3 and 8 and evidence of structural brain damage and/or subarachnoid hemorrhage (SAH) on the initial CT scan. Frequencies of recognized risk factors, including brain swelling, intracranial hypertension, systemic hypotension, advanced age, SAH, and injury severity (based on GCS scores), as well as dichotomized Glasgow Outcome Scale (GOS) scores (good recovery or moderate disability compared with severe disability, persistent vegetative state, or death) obtained 6 months postinjury were compared between male and female patients.

CONCLUSIONS

Overall significantly greater frequencies of brain swelling and intracranial hypertension were found in female compared with male patients (35% compared with 24% [p < 0.0008] and 39 compared with 31% [p < 0.03], respectively). The highest rates were found in female patients younger than 51 years old (38% compared with 24% [p < 0.002] and 40% compared with 30% [p < 0.02], respectively, in male patients younger than 51 years of age). This effect was independent of injury severity (GCS) scores, which were not different in male and female patients. Female patients younger than 50 years tended to have worse outcomes, but the difference was not statistically significant. Thus, female patients who sustain severe head injury, especially (presumably) premenopausal ones aged 50 years and younger, are significantly more likely to experience brain swelling and intracranial hypertension than male patients with a comparable injury severity, suggesting that younger women may benefit from more aggressive monitoring and treatment of intracranial hypertension.

Discrepancies between brain CT imaging and severely raised intracranial pressure proven by ventriculostomy in adults with pneumococcal meningitis

OBJECTIVES

Computed tomography (CT) of the brain is recommended for assessment of intracranial pressure (ICP) of patients with acute bacterial meningitis who are comatose or show focal neurological deficits. The aim of this report is to draw attention to the possibility of a discrepancy between CT findings and ICP values in some patients with pneumococcal meningitis.

METHODS

We describe three adult patients with pneumococcal meningitis who had both successive CT examinations and ICP measurements at the time of clinically evident cerebral herniation (n = 2) and/or prolonged coma (n = 2).

RESULTS

Although measurements with a ventriculostomy catheter indicated that all three patients had severely raised ICP values of 90, 44, and 45 mmHg, repeated cranial CT greatly underestimated true ICP values. Despite clinical evidence of acute cerebral herniation, it was not detected in the contemporary CT findings of two patients. Continuous ICP monitoring in the ICU helped to guide treatment for increased ICP; nevertheless, two patients died.

CONCLUSIONS

The clinician must be aware that cranial CT may fail to rule out the possibility of severely raised ICP or cerebral herniation in a patient with pneumococcal meningitis. Therefore, ICP monitoring of patients with bacterial (especially pneumococcal) meningitis who are in prolonged coma should be considered early and regardless of the cranial CT appearances.

Major clinical and physiological benefits of early high doses of mannitol for intraparenchymal temporal lobe hemorrhages with abnormal pupillary widening: a randomized trial

OBJECTIVE

We evaluated long-term clinical outcomes and postoperative physiological findings in acutely comatose patients with nonmissile surgical intraparenchymal temporal lobe hemorrhages and abnormal pupillary widening who received early preoperative high-dose mannitol (HDM) versus conventional dose mannitol treatment in the emergency room.

METHODS

One hundred forty-one adult patients with traumatic, nonmissile, acute, intraparenchymal temporal lobe hemorrhages associated with early abnormal pupillary widening were prospectively and randomly assigned to receive emergency preoperative intravenous HDM treatment (approximately 1.4 g/kg; 72 patients) and were compared with a control group that was treated with a lower preoperative mannitol dose (approximately 0.7 g/kg; 69 patients).

RESULTS

Early preoperative improvement of abnormal bilateral pupillary widening was significantly more frequent in the study group than in the control group (P < 0.03). The same was true for abnormal unilateral pupillary widening (P < 0.01). Early HDM treatment in the emergency room was also associated with significantly better 6-month clinical outcomes (P < 0.005). The two groups of patients were well matched with respect to diameter of the temporal lobe hemorrhages (approximately 4 cm) as well as timing of clot removal (approximately 2.5 hours after injury). Postoperative physiological findings revealed statistically significant between-group differences, with higher intracranial pressure and lower cerebral extraction of oxygen (global relative cerebral hyperperfusion) in the control group than in the HDM group. Postoperative global brain ischemia (abnormally low arteriojugular lactate difference values) was rare and was found for less than 3% of the patients in both groups.

CONCLUSION

Early preoperative HDM administration in the emergency room was associated with improved clinical outcomes for adult comatose patients with acute, nonmissile, intraparenchymal temporal lobe hemorrhages and associated abnormal pupillary widening. Early improvement of bilateral or unilateral pupillary abnormalities and better postoperative control of intracranial hypertension and associated global relative cerebral hyperperfusion seemed to be relevant factors that were related to improved outcomes.

Delayed cranial vault reconstruction for sagittal synostosis in older children: an algorithm for tailoring the reconstructive approach to the craniofacial deformity

An algorithm for the management of sagittal synostosis in older children who underwent delayed cranial vault reconstruction is presented. This algorithm tailors the surgical approach to the specific craniofacial deformity present in each case. The scaphocephalic deformity characteristic of sagittal synostosis varies significantly when presentation is delayed beyond the first year of life, the time during which reconstruction is usually performed. Sixteen patients with sagittal synostosis who presented after 12 months of age, and were a mean of 3.2 years of age at the time of cranial vault reconstruction, were reviewed. Four patients demonstrated preoperative symptoms and objective findings indicative of increased intracranial pressure, including frequent headaches and emesis, papilledema, or digital markings on computed tomographic scan. Each of the 16 patients underwent either (1) single-stage total vault reconstruction with or without concomitant fronto-orbital expansion; (2) two-stage total vault reconstruction with anterior two-thirds vault expansion followed by transverse occipital expansion and recession a mean of 8.7 months later; or (3) anterior two-thirds vault reconstruction with or without fronto-orbital expansion. In each case, the extent of the scaphocephalic deformity determined the procedure used. The presence of severe frontal bossing associated with transverse restriction of the orbitotemporal region was an indication for fronto-orbital expansion in addition to vault reconstruction, whereas significant occipital protrusion was an indication for transverse posterior vault expansion and recession in addition to anterior two-thirds vault reconstruction. Excellent aesthetic results were obtained in all cases regardless of the type of reconstruction performed. However, it is essential that the extent of the deformity be carefully evaluated preoperatively to permit selection of the appropriate technique for reconstruction.

Decompressive craniectomy for the management of patients with refractory hypertension: should it be reconsidered?

INTRODUCTION

The management of refractory post-traumatic cerebral oedema remains a frustrating endeavor for the neurosurgeon and the intensivist. Mortality and morbidity rates remain high, despite refinements in medical and pharmacological means of controlling intracranial hypertension.

METHOD AND MATERIAL

In this retrospective study we have evaluated the efficacy of decompressive craniectomy as a last resort therapy, from the data of nine patients with severe brain injury and delayed cerebral oedema (diffuse injury type III), treated between January 1997 and September 1999. The following parameters were considered: age, Glascow Coma Scale, injury severity, intracranial pressure, CT findings, pupil reaction/posturing. Follow-up period was over at least 2 years and outcome measured on the GOS.

RESULTS

Patients have been operated on post-trauma median day 3, mean age 26+/-9, GCS 7+/-3.7, mean APACHE II 16+/-6.4, mean ISS 27.8+/-16.1, mean preoperative ICP 37.7+/-10.0, mean postoperative ICP 18.1+/-16.01. Seven patients have been operated by a frontotemporoparietal approach (six of them bilateral, one unilateral) and two patients have been operated on by a bilateral subtemporal approach. Mortality rates 22%, severe disability 11%, good recovery 66%.

DISCUSSION

Patients with STBI, developing delayed intracranial hypertension caused by diffuse cerebral oedema, definitely benefit from craniectomy when current medical treatment has failed. The encouraging results of outcome in this and more recent studies, indicate the need for a multi-institutional randomized prospective study evaluating early indicators of raised ICP, timing, efficacy of treatment, operative technique and complications of decompressive craniectomy.

Postoperative mental and morphological outcome for nonsyndromic brachycephaly

Bilateral coronal synostosis causes functional and morphological problems that require fronto-orbital advancement in infancy to correct the brachycephalic deformity and to prevent mental impairment caused by the intracranial hypertension. In this study, 99 children with isolated cases of brachycephaly were prospectively followed to study their preoperative and postoperative mental outcome, which was evaluated using developmental or intelligence quotients. Several factors were analyzed: age before treatment, age at the time of surgery, and the correlation between mental assessments before and after surgery. In a subgroup or patients tested for the FGFR3 P250R mutation (n = 48), mental and morphological assessments were analyzed. Before surgery, mental status was better in the patients tested before 1 year of age (p < 0.001). The preoperative mental assessment always correlated with the postoperative assessment (p < 0.0001). The postoperative mental outcome was better when surgery was performed before the patient reached 1 year of age (p < 0.02). Although both the morphological and functional outcomes were better in the subgroup of noncarriers of the mutation, the differences were not statistically significant. Prominent bulging of the temporal fossae was frequently responsible for poor morphological outcome in carriers of the mutation. This study confirms the need for early corrective surgery before 1 year of age in brachycephalic patients to prevent impairment of their mental development. Suboptimal morphological and mental outcomes can be expected in patients with nonsyndromic brachycephaly who carry the FGFR3 P250R mutation. Primary correction of the temporal bulging should be performed in conjunction with fronto-orbital advancement to improve the morphological outcome in patients with the mutation.

Surgical treatment of cerebral cysticercosis: long-term results and prognostic factors

OBJECT

Cysticercosis is the most frequent parasitosis of the central nervous system. Although anticysticercal drugs have proven efficient in some cases, many patients with NCC require palliative, occasionally curative, surgical procedures. The authors analyzed the data and prognostic factors obtained during the follow-up period (range 1-255 months, median 38 months) in 160 patients with cerebral cysticercosis who underwent surgical treatment.

METHODS

Different surgical approaches were indicated to control increased intracranial pressure (ICP) in most patients, and some patients had undergone decompressive surgery for local brain lesions. Most patients required more than one surgical procedure. Statistical analysis was performed using the Fisher exact, the log-rank, and the Kruskall-Wallis tests. Survival curves were calculated according the Kaplan-Meier method. The removal of a giant cyst from the parenchyma or cisterns for relief of increased ICP and for chiasm/optic nerve decompression improved most symptoms in patients. The removal of ventricular cysts was effective in the control of increased ICP in most patients. Patients with a ventricular cyst and ependymitis/arachnoiditis required placement of a ventriculoperitoneal (VP) shunt after the cyst was removed. This therapy effectively controlled increased ICP. Patients younger than 40 years of age at the time of treatment and male patients had worse outcomes. The outcome in patients who underwent VP shunt surgery or shunt surgery combined with reservoir implantation was worse than that in those who underwent cyst removal alone. Shunt-related infection was the most frequent complication, and the global mortality rate during the follow-up period was 21.2%. Although both complications were more frequent in the first 2 postoperative years, they occurred at any time.

CONCLUSIONS

Long-term prognosis in patients with cerebral cysticercosis who required surgery was not good. Cysts located in the basal cisterns and patient age younger than 40 years were poor prognostic factors.

A single-incision laparoscopic technique for retrieval and replacement of disconnected ventriculoperitoneal shunt tubing found in the peritoneum

A 7-year-old girl presented with signs and symptoms of increased intracranial pressure 2 years after insertion of a ventriculoperitoneal (VP) shunt. Evaluation revealed disconnection of the distal shunt catheter and migration into the peritoneal cavity. A single-incision laparoscopic procedure was performed to locate and remove the disconnected shunt tubing, and the new shunt catheter was inserted through the laparoscopic port site. Laparoscopy is being used more frequently for evaluation and repair of distal VP shunt malfunctions, but generally still requires multiple incisions for port placement and insertion of the new shunt catheter. The single-incision technique used here is technically feasible, allows excellent visualization of the peritoneal cavity and does not require any incisions beyond the previous one used for initial shunt insertion.

Slow pressure waves in the cranial enclosure

Slowly varying pressure oscillations in the cranial enclosure are well known, especially intracranial pressure waves as best described by the pioneering works of Janny and Lundberg. Nevertheless, in spite of over twenty five years research on intracranial pressure waves, their origin and regulation remain unclear but are often considered only as pathological. Our aim was to review data on these phenomena to clarify their biological status and the role that they could play in the management of patients suffering from such intracranial neurosurgical diseases as intracranial hypertension, severe head injury, and hydrocephalus. It appears that these pressure waves reveal important information on the function of the cerebral vasculature and as such have significance for influencing intracranial compliance. Pressure waves are also closely associated with autoregulation, in particular dynamic autoregulation. It seems evident that they are not only pathophysiological but also physiological, linked with other biological parameters such as the neurovegetative cardiovascular system, breathing, and sleeping. This study shows that it is not only important to continue to explore these slow waves, but also the methods of analysis in order to more fully clarify their clinical significance.

Vascular tunnel construction in the treatment of severe brain swelling caused by trauma and SAH. (evidence based on intra-operative blood flow measure)

Decompressive craniectomy with durotomy, is possible as a last resort therapy for severe traumatic brain swelling. Although the method successfully diminishes the ICP, partial or total vascular insufficiency occurs in the herniated part of the brain. The actual cause of the insufficiency is most likely due to the compression of the cortical veins and arteries supplying the herniated brain, caused by shearing and pressure forces between the dural edge and brain tissue. Furthermore venous congestion may induce edema in the protruding parts of the brain, thus further compromising neurone viability. The new surgical technique consists of a stellate type durotomy and the creation of a vascular tunnel around the main cortical veins and arteries, with the aim that the vessels do not become compressed by the dural or bone edge. The effect of the novel vascular tunnel technique was proven by measuring the blood flow of the protected and nonprotected veins with Doppler UH, intra-operatively. In the last two years 28 patients were operated on with this method. One case of edema was caused by SAH. All were in severe GCS 3 or GCS 4 status, with more than 30 mmHg ICP. In comparison with the traditional surgical and nonsurgical treatment, where the reported mortality rates are 80%-90% in these severe cases the mortality rate was reduced to 40%, and recovery (GOS 4, 5) rate also increased significantly. With this technique the ICP was significantly reduced and further edema and vascular insufficiency was prevented. This was due to protection of the arterial circulation and venous drainage of the herniated part of the brain, by the formation of a vascular tunnel at the durotomy edges.

[Decompressive craniectomy for severe intracranial hypertension due to cerebral infarction or meningoencephalitis]

We describe the clinical course and outcome following decompressive craniectomy in six patients. Five patients suffered from severe intracranial hypertension due to middle cerebral artery infarction. In one patient the cause was bacterial meningoencephalitis. Acute clinical and neuroradiological signs of intracranial hypertension were seen in all cases. Following ineffective conventional brain edema therapy, decompressive craniectomy was undertaken. In five cases intracranial pressure was sufficiently lowered. One patient developed transtentorial herniation with subsequent brain death. Four patients with middle artery infarction showed moderate neurological disorders and one patient with bacterial meningoencephalitis recovered completely after treatment. Craniectomy in malignant middle artery infarction should be taken into consideration if conventional brain edema therapy does not sufficiently reduce critically raised intracranial pressure. Craniectomy provides development of brain herniation. This treatment may reduce high lethality rate and high frequency of severe neurological disorders.