Stroke is a worldwide leading cause of mortality and disability, and there are substantial economic costs for post-stroke [1] . A large hemispheric ischemic stroke is a severe form of stroke that may occur in up to 10% of stroke cases [2] [3] . Patients present with symptoms and signs of large hemispheric stroke syndrome, including hemiplegia and deteriorating consciousness in the first 48 hours resulting from raised intracranial pressure [4] [5] . With conservative medical treatment, there is an 80% mortality rate within the first week after stroke [6] . In these cases, decompressive craniectomy (DC) is an effective strategy to reduce early case fatality in the setting of uncontrolled intracranial hypertension due to brain swelling [7] - [13] . It can allow brain tissue to expand, consequently facilitating control of increased ICP and reducing the risk of herniation, which may improve the outcome of patients. This technique appears to offer a clear survival advantage, reducing the risk of death or severe disability [14] - [18] . In this study, the authors present their experience in the management of large hemispheric stroke in patients who underwent decompressive craniotomy.

This study is a retrospective analysis of 9 patients who underwent decompressive craniotomy for large hemispheric stroke from February 2021 to January 2024. Demographic, clinical, and radiologic variables were collected from the hospital archives. All patients underwent head CT scan or MRI showing the involvement of the majority or complete middle cerebral artery distribution area. Hemicraniectomy with duraplasty was the main surgical procedure. The anteroposterior length of the craniectomy was more than 10 cm and the inferior part of the temporal bone to the floor of the middle cranial fossa was removed. Duraplasty was performed using epicrane or fascia lata aponeurosis. The mortality and the outcome using Modified Rankin Scale (mRS) were reported.

A total of 9 patients with large hemispheric stroke who underwent DC were reviewed retrospectively. The mean age was 53 years with extremes of 39- and 67-year-old. There were 6 males and 3 females. The main risk factors of stroke were hypertension and diabetes in 5 and 3 cases, respectively. Six of our patients were admitted with initial GGS at 15, whereas the preoperative GCS was less than 15 in all cases ( Table 1 ). Diagnosis of stroke was made by head CT scan ( Figure 1 ) in 7 patients and MRI ( Figure 2 ) in 2 patients. Dominant hemisphere was involved in 3 cases. The mean time from stroke onset to craniotomy was 53 hours. The large craniectomy was made and the dura was opened in the stellate fashion. Duraplasty was performed using epicrane ( Figure 2 ) in 7 patients and fascia lata aponeurosis in 2 patients. In the postoperative course, 4 (44%) patients died in 1 month, and the mortality rate was 66.6% in 6 months ( Table 2 ).

Initially described by Kocher in 1901 for the treatment of posttraumatic brain edema [10] , decompressive craniotomy has recently been applied to patients with massive hemispheric cerebral infarction [4] - [15] . Brain edema can develop after large ischemic stroke, leading to increased intracranial pressure and ensuing brain herniation. DC is a procedure whereby part of the skull is removed, and the underlying dura is opened, providing additional space for the swollen brain and mitigating the risk of ICP elevation and herniation.

Many studies in the literature [19] - [21] have proven the effectiveness of DC in terms of life-saving and quality of life. Decompressive craniotomy can reduce the mortality rate from 80% to 30%, and if the surgery is performed within 24 to 48 hours of stroke onset, the mortality rate can decrease to 10% [22] . In our study, the high mortality rate could be explained by many factors, such as patient selection criteria and timing of surgery.

The significant predictor factor of poor outcome and death after DC is elderly patients. In a systematic review, Gupta et al. [16] report a favorable outcome in patients less than 50 years old in whom DC was performed and mortality rate was 32% in patients more than 50 years old compared to 14% in patients less than 50 years old. In our study, 5 of 9 patients were more than 50 years of age.

Another significant predictor factor of outcome is timing of surgery. Many studies suggest that DC must be done within the first 48 hours [23] . In a trial, in which patients were randomized up to 4 days after stroke, there was no benefit from DC when delayed from 48 to 96 hours after stroke onset [21] . In our study, the mean timing of DC was 53 hours after stroke onset and all of our patients experienced clinical worsening with GCS less than 15 before DC. This delay could be explained by the concern of patients and families about surgery.

Many other factors and comorbidities have been shown to be predictive of poor outcomes after DC, such as hypertension, coronary artery disease, cardiac arrhythmias, diabetes mellitus and arterial occlusive diseases [24] .

Decompressive craniectomy is a life-saving procedure used to manage cerebral edema after stroke onset. In our study, the high mortality rate could be explained by many factors, such as patient selection criteria and timing of surgery. Early surgery within the first 48 hours in patients less than 60 years old with large hemispheric stroke is recommended.