{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,30]],"date-time":"2026-04-30T01:49:21Z","timestamp":1777513761042,"version":"3.51.4"},"reference-count":14,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"11","license":[{"start":{"date-parts":[[2025,9,15]],"date-time":"2025-09-15T00:00:00Z","timestamp":1757894400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Neurosurg Case Lessons"],"published-print":{"date-parts":[[2025,9,15]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND<\/jats:title>\n                    <jats:p>Malignant middle cerebral artery (MCA) infarctions result in cerebral edema that can lead to brain herniation and death. Standard management includes decompressive hemicraniectomy (DHC) and comprehensive neurocritical care. Some patients may continue to decline despite these measures. Reopening of the scalp incision may allow for additional decompression and provide mortality benefit.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>OBSERVATIONS<\/jats:title>\n                    <jats:p>A 47-year-old man developed malignant right MCA territory infarction following intravenous thrombolysis and unsuccessful mechanical thrombectomy. Despite aggressive hyperosmolar therapy and a large DHC, the patient continued to exhibit clinical decline and radiological progression of cerebral edema. In response, the scalp incision was reopened to facilitate maximal external cerebral herniation, a strategy the authors believe was critical in managing the brain swelling. The patient was maintained on prophylactic antibiotics during this period, given the increased infection risk associated with exposed brain surface and potential CSF leakage. Following the resolution of cerebral swelling, a right partial hemispherectomy was performed to excise the infarcted hemisphere. Notably, the patient achieved significant functional recovery following the intervention and an extended period of rehabilitation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>LESSONS<\/jats:title>\n                    <jats:p>This case highlights the complexities encountered in the surgical management of malignant cerebral infarction, particularly when standard decompressive measures fail.<\/jats:p>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/thejns.org\/doi\/10.3171\/CASE2523\">https:\/\/thejns.org\/doi\/10.3171\/CASE2523<\/jats:ext-link>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/case2523","type":"journal-article","created":{"date-parts":[[2025,9,23]],"date-time":"2025-09-23T00:24:22Z","timestamp":1758587062000},"source":"Crossref","is-referenced-by-count":2,"title":["Managing malignant middle cerebral artery infarction with open scalp incision and partial hemispherectomy: illustrative case"],"prefix":"10.3171","volume":"10","author":[{"given":"Katherine L.","family":"Olivares","sequence":"first","affiliation":[{"name":"Department of Neurology, Wayne State University School of Medicine\/Detroit Medical Center, Detroit, Michigan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2316-4553","authenticated-orcid":true,"given":"Arun","family":"Sherma","sequence":"additional","affiliation":[{"name":"Department of Neurology, Wayne State University School of Medicine\/Detroit Medical Center, Detroit, Michigan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Chiu Yuen","family":"To","sequence":"additional","affiliation":[{"name":"Department of Surgery, St. John Providence Health System, Southfield, Michigan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-7489-9461","authenticated-orcid":true,"given":"Syeda Maria","family":"Muzammil","sequence":"additional","affiliation":[{"name":"Department of Neurology, Wayne State University School of Medicine\/Detroit Medical Center, Detroit, Michigan"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"9","key":"bib1","series-title":"Stroke","first-page":"2619","article-title":"Cerebral edema associated with large hemispheric infarction","volume":"50","author":"Liebeskind","year":"2019","unstructured":"Liebeskind DSJ\u00fcttler EShapovalov YYegin ALanden JJauch EC.Cerebral edema associated with large hemispheric infarction. Stroke. 2019;50(9):2619-2625."},{"issue":"4","key":"bib2","series-title":"Arch Neurol","first-page":"309","article-title":"\u201cMalignant\u201d middle cerebral artery territory infarction: clinical course and prognostic signs","volume":"53","author":"Hacke","year":"1996","unstructured":"Hacke WSchwab SHorn MSpranger MDe Georgia Mvon Kummer R.\u201cMalignant\u201d middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol. 1996;53(4):309-315."},{"issue":"9","key":"bib3","series-title":"Stroke","first-page":"2518","article-title":"Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial","volume":"38","author":"J\u00fcttler","year":"2007","unstructured":"J\u00fcttler ESchwab SSchmiedek PDecompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke. 2007;38(9):2518-2525."},{"issue":"9","key":"bib4","series-title":"Stroke","first-page":"1888","article-title":"Early hemicraniectomy in patients with complete middle cerebral artery infarction","volume":"29","author":"Schwab","year":"1998","unstructured":"Schwab SSteiner TAschoff AEarly hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke. 1998;29(9):1888-1893."},{"key":"bib5","series-title":"Front Neurosci","first-page":"988283","article-title":"Cerebral edema after ischemic stroke: pathophysiology and underlying mechanisms","volume":"16","author":"Gu","year":"2022","unstructured":"Gu YZhou CPiao ZCerebral edema after ischemic stroke: pathophysiology and underlying mechanisms. Front Neurosci. 2022;16:988283."},{"key":"bib6","article-title":"Treatment of elevated intracranial pressure.","author":"May","year":"2022","unstructured":"May CCSmetana KS.Treatment of elevated intracranial pressure.American College of Pharmacology; 2022. Accessed August 22, 2025. https:\/\/www.accp.com\/docs\/bookstore\/ccsap\/cc2022b1_sample.pdf"},{"key":"bib7","series-title":"Surg Neurol Int","first-page":"181","article-title":"Aggressive internal and external decompression as a life-saving surgery in a deeply comatose patient with fixed dilated pupils after severe traumatic brain injury: a case report","volume":"11","author":"Ebise","year":"2020","unstructured":"Ebise HKubota YOhbuchi HAggressive internal and external decompression as a life-saving surgery in a deeply comatose patient with fixed dilated pupils after severe traumatic brain injury: a case report. Surg Neurol Int. 2020;11:181."},{"issue":"9","key":"bib1","series-title":"Stroke","first-page":"2619","article-title":"Cerebral edema associated with large hemispheric infarction","volume":"50","author":"Liebeskind","year":"2019","unstructured":"Liebeskind DSJ\u00fcttler EShapovalov YYegin ALanden JJauch EC.Cerebral edema associated with large hemispheric infarction. Stroke. 2019;50(9):2619-2625."},{"issue":"4","key":"bib2","series-title":"Arch Neurol","first-page":"309","article-title":"\u201cMalignant\u201d middle cerebral artery territory infarction: clinical course and prognostic signs","volume":"53","author":"Hacke","year":"1996","unstructured":"Hacke WSchwab SHorn MSpranger MDe Georgia Mvon Kummer R.\u201cMalignant\u201d middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol. 1996;53(4):309-315."},{"issue":"9","key":"bib3","series-title":"Stroke","first-page":"2518","article-title":"Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial","volume":"38","author":"J\u00fcttler","year":"2007","unstructured":"J\u00fcttler ESchwab SSchmiedek PDecompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke. 2007;38(9):2518-2525."},{"issue":"9","key":"bib4","series-title":"Stroke","first-page":"1888","article-title":"Early hemicraniectomy in patients with complete middle cerebral artery infarction","volume":"29","author":"Schwab","year":"1998","unstructured":"Schwab SSteiner TAschoff AEarly hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke. 1998;29(9):1888-1893."},{"key":"bib5","series-title":"Front Neurosci","first-page":"988283","article-title":"Cerebral edema after ischemic stroke: pathophysiology and underlying mechanisms","volume":"16","author":"Gu","year":"2022","unstructured":"Gu YZhou CPiao ZCerebral edema after ischemic stroke: pathophysiology and underlying mechanisms. Front Neurosci. 2022;16:988283."},{"key":"bib6","article-title":"Treatment of elevated intracranial pressure.","author":"May","year":"2022","unstructured":"May CCSmetana KS.Treatment of elevated intracranial pressure.American College of Pharmacology; 2022. Accessed August 22, 2025. https:\/\/www.accp.com\/docs\/bookstore\/ccsap\/cc2022b1_sample.pdf"},{"key":"bib7","series-title":"Surg Neurol Int","first-page":"181","article-title":"Aggressive internal and external decompression as a life-saving surgery in a deeply comatose patient with fixed dilated pupils after severe traumatic brain injury: a case report","volume":"11","author":"Ebise","year":"2020","unstructured":"Ebise HKubota YOhbuchi HAggressive internal and external decompression as a life-saving surgery in a deeply comatose patient with fixed dilated pupils after severe traumatic brain injury: a case report. 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