Primary Ischemic Core Resection (Corectomy) with Immediate Bone Flap Replacement in Malignant Middle Cerebral Artery Infarction: A Case Series and Systematic Comparison with Decompressive Craniectomy Outcomes

Abstract

Background

Malignant middle cerebral artery (MCA) infarction is associated with high mortality due to massive cerebral edema and herniation. While decompressive craniectomy (DC) reduces mortality, it often results in severe disability and necessitates secondary cranioplasty. Alternatives such as ischemic core resection with immediate bone flap replacement (“corectomy”) may provide internal decompression while avoiding secondary surgery.

Objective

The aim of the study is to describe a single-center experience with ischemic core resection and immediate bone flap replacement in patients with malignant MCA infarction, and to compare outcomes with historical DC cohorts.

Materials and Methods

We retrospectively reviewed seven consecutive patients (mean age 55.1 years) treated with core resection and immediate bone flap replacement for malignant MCA infarction between 2021 and 2025. Inclusion criteria included infarction ≥2/3 of MCA territory, midline shift ≥5 mm, and MRI demonstrating a core >50% of the ischemic stroke. The surgical technique involved a large craniotomy, resection of infarcted tissue guided by intraoperative assessment, and immediate cranial closure. Outcomes analyzed included in-hospital mortality, modified Rankin Scale (mRS) at discharge and at 3 months, complications, ICU stay, and reinterventions. A comparative analysis was conducted against the existing literature.

Results

All patients survived hospitalization (0% mortality). Median ICU stay was 3 days (range 0–10), and median total hospital stay was 30 days. No patient required reintervention or delayed cranioplasty. At discharge, one patient had mRS 1, one had mRS 3, four had mRS 4, and one had mRS 5. At 3 months, two patients achieved mRS ≤3 (28.5%). Compared with the literature, ICU stay was shorter (mean 3.7 vs. 7.5 days; p = 0.057), and functional outcome was comparable to that reported for DC (28.5% vs. 25–45% mRS ≤3). The rate of surgical reintervention was significantly lower (0/7 vs. 5/7; p = 0.0257).

Conclusion

Core resection with immediate bone flap replacement may offer a safe and technically feasible alternative to DC in selected patients with malignant MCA infarction. This single-stage procedure was associated with no mortality, reduced ICU stay, and eliminated the need for cranioplasty, potentially lowering complication rates and overall surgical burden and costs. Although functional recovery was limited, outcomes were similar to those of conventional DC. These findings support further investigation of corectomy in prospective, controlled studies to better define its role in neurocritical care.

Keywords

decompressive craniectomy - ischemic core resection - malignant middle cerebral artery - strokectomy - modified Rankin scale

Introduction

Malignant middle cerebral artery (MCA) infarction is one of the most catastrophic forms of ischemic stroke, characterized by an extensive hemispheric infarction involving at least two-thirds of the MCA vascular territory, with rapid progression to severe cerebral edema, mass effect, herniation, and death in a high percentage of cases, even under conventional intensive care.[1] Mortality rates without surgical intervention range between 70 and 80% in the first few weeks.[2]

In this context, decompressive craniectomy (DC) has been proposed as a lifesaving intervention supported by robust clinical evidence.[1] [2] [3] This technique consists of the surgical removal of a wide frontotemporoparietal bone flap, together with dural opening, allowing extracranial expansion of the edematous brain parenchyma and reduction of intracranial pressure (ICP), to prevent brain herniation and preserve perfusion of vital structures.[2] An early surgical approach within 48 hours of stroke onset has been evaluated in three pivotal randomized clinical trials: DECIMAL (France), DESTINY (Germany), and HAMLET (Netherlands). These studies showed that in patients younger than 60 years with clinical and radiological signs of malignant infarction, DC significantly reduces mortality.[3] [4]

A combined meta-analysis of these three trials concluded that early DC reduced absolute mortality by 49% and significantly increased the proportion of patients with a modified Rankin Scale (mRS) score ≤3 at 1 year.[5] These findings consolidated DC as the therapeutic standard for this condition, particularly in young patients with progressive neurological deterioration and a midline shift ≥5 mm.

Despite these benefits, DC is not without significant limitations. All patients require a second surgical intervention for delayed cranioplasty, which carries inherent risks, including infection, subgaleal hematomas, hydrocephalus, cosmetic alterations, and neurocognitive complications secondary to the persistent bone defect.[6] [7] Furthermore, in the cohort of patients older than 60 years, as evidenced in DESTINY II, although survival is improved, the proportion of patients with severe disability (mRS 4–5) remains high, raising ethical and clinical debate on the usefulness of this surgery in this age group.[8]

Core resection or “strokectomy” as currently described in the literature, has been redefined as “corectomy” since the infarct includes an area of core, penumbra, and risk area, all of which are part of the infarct, but our approach is oriented on the infarct core. This strategy consists of performing a wide craniotomy, resecting the necrotic brain parenchyma or high-volume infarcted areas (core), confirmed with magnetic resonance imaging (MRI), and immediately repositioning the bone flap, after significant reduction of the infarct volume, thereby avoiding the creation of a permanent cranial defect,[9] and the need for subsequent cranioplasty. The pathophysiological hypothesis behind this technique proposes that, by directly eliminating the infarcted and non-viable brain volume, ICP is effectively reduced, without the need for prolonged external decompression, potentially decreasing the complications associated with craniectomy.

Early studies have shown encouraging results. In a series published by Pilloni et al, 15 patients with malignant infarction treated with strokectomy and cisternal drainage had a mortality rate of 6.7%, and more than 50% achieved functional independence (mRS ≤3) at 1 year.[9] In a recent meta-analysis that included this technique, Moughal et al observed that strokectomy was associated with lower rates of surgical complications and functional outcomes comparable to DC, although they cautioned about the limited available evidence and the heterogeneity of the techniques described.[10]

In this emerging scenario, we consider it essential to explore the feasibility and safety of this technique in our setting. The objective of this study is to describe our institutional experience with corectomy in a series of seven patients with malignant MCA infarction who underwent ischemic core resection with immediate bone flap replacement, and to indirectly compare their clinical outcomes with those historically reported for conventional DC.

Materials and Methods

Study Design and Selection Criteria

A retrospective observational study was conducted in a single tertiary center, including all consecutive patients who underwent craniotomy with resection of the ischemic core and immediate bone flap replacement for malignant MCA infarction between January 2021 and April 2025. During the study period, seven consecutive patients met all inclusion criteria and underwent ischemic core resection with immediate bone flap replacement. No additional patients were excluded, ensuring a complete consecutive series.

This technique, initially described as “strokectomy,”[9] is proposed as an alternative to conventional DC.

Inclusion criteria were: (1) computed tomography (CT) or MRI diagnosis of extensive supratentorial infarction in the MCA territory (≥2/3 of the hemisphere) and MRI with core greater than 50% of the total infarct area, (2) progressive clinical neurological deterioration, (3) radiological evidence of intracranial hypertension (midline shift ≥5 mm, cisternal collapse, signs of subfalcine or uncal herniation), and (4) absence of surgical contraindications. Patients with bilateral infarction, massive hemorrhagic transformation, a history of moderate to severe functional disability (mRS ≥3), or major medical contraindication were excluded.

The protocol was approved by the institutional ethics committee, and each case was discussed in a neurosurgical clinical meeting.

Surgical Technique

In all cases, a wide frontotemporoparietal craniotomy was performed, followed by resection of the infarcted brain tissue and immediate cranial closure. This technique was based on the strokectomy descriptions of Pilloni et al[9] and the technical criteria recently systematized by Moughal et al.[10]

Under general anesthesia, an incision was made in a traditional “question mark scalpel incision” followed by subperiosteal detachment and craniotomy with a minimum diameter of 10 cm. The bone flap was completely removed and preserved under sterile conditions. The dura was then opened to expose the cerebral convexity.

Neuronavigation was available for all patients; however, its intraoperative use was surgeon-dependent, with variable intensity according to individual preference and familiarity with the system. No intraoperative MRI or CT perfusion was used; instead, resections were guided by preoperative MRI and CT. Preoperative MRI sequences included diffusion-weighted imaging (DWI), apparent diffusion coefficient (ADC) maps, fluid-attenuated inversion recovery, and perfusion-weighted imaging. The infarct core was identified as the region of restricted diffusion showing marked hyperintensity on DWI and corresponding hypointensity on ADC maps, consistent with irreversible cytotoxic edema. The surrounding penumbra was inferred from areas showing preserved or only mildly decreased ADC values combined with hypoperfusion on perfusion maps, indicating potentially viable tissue.Intraoperatively, this correlation guided resection boundaries: infarcted core tissue appeared grayish, soft, non-bleeding, and friable, whereas peripheral penumbral tissue remained pink, firmer, and exhibited mild bleeding. Resection was intentionally limited to the MRI-defined infarct core to preserve the potentially viable penumbral region.

Cortical resection was performed using neuronavigation intraoperatively to determine the size of the infarct and the limits of the core, to proceed with core resection with corticotomy up to approximately 1 cm from the boundary of the core toward the penumbra in its entire area ([Fig. 1]).

Fig. 1 Sequence of ischemic corectomy with immediate bone flap replacement in malignant middle cerebral artery infarction. (A) Patient positioned with anatomical skin marking. (B) Skin and myocutaneous flap reflected; bone flap removed, exposing a tense dura under significant intracranial hypertension. (C) Dural opening reveals a swollen and hyperemic cortical surface under pressure. (D) Resection of infarcted cortical and subcortical tissue (ischemic core), achieving immediate decompression and visible cortical relaxation. (E) Preoperative axial non-contrast CT showing a large territory MCA infarct with significant midline shift and ventricular compression. (F) Second patient with tense brain parenchyma herniating through the craniectomy defect prior to dural opening. (G) Dural opening exposes edematous cortical structures. (H) Final view following resection of infarcted tissue showing decompressed brain with preserved cortical vasculature and hemostasis achieved. MCA, middle cerebral artery.

Dural closure was then performed. Finally, the bone flap was repositioned and secured with standard miniplates. No subdural or parenchymal drains were used. Hemostasis was carefully monitored. A follow-up CT scan was performed within the first 6 postoperative hours.

Variables and Monitoring

Following variables were collected:

• Clinical data: age, sex, comorbidities, baseline modified Rankin Scale (mRS), Glasgow Coma Scale (GCS) on admission, and estimated NIHSS.

• Neuroimaging presurgical: affected hemisphere, midline shift, presence of cisternal collapse, and herniation.

• Surgical data: laterality, stroke-surgery time (hours), technique, resected volume, bone flap (relocated or not), and use of drains.

• Postoperative evolution: complications (infectious, neurological, systemic), need for reoperation, days in ICU, total days of hospitalization, mRS at discharge and 90 days, in-hospital mortality.

Functional assessment was performed at discharge and 3 months postoperatively in an outpatient setting, using the mRS, in which 0 represents complete independence and 6 corresponds to death.

Indirect Comparison with the Literature

Since there was no internal control group, a pseudo-historical control comparison was performed using previous studies on DC for malignant MCA infarction. The randomized controlled trials DECIMAL,[2] DESTINY,[4] HAMLET,[3] and DESTINY II[8] were used as references, as well as recent systematic reviews[5] [10]—

PubMed, Scopus, and Cochrane Library databases were searched until June 2025. MeSH and free text terms incorporated: “malignant MCA infarction,” “DC,” “strokectomy,” “core resection,” and “craniectomy” outcomes. Publications in English or Spanish, with a clinical trial design, case series, or systematic review were filtered, excluding gray literature, non-peer-reviewed abstracts, or duplicate reports.

All selected articles were reviewed in full text. The surgical techniques compared were classified as: (1) conventional DC (bone flap removed), and (2) strokectomy or resection with immediate cranial closure. This approach allowed for a contextualized evaluation of the technique used versus the traditional therapeutic standard.

Statistical Analysis

Descriptive analysis was used. Continuous variables were expressed as medians with ranges (minimum–maximum), and categorical variables as absolute frequencies and proportions. Hypothesis testing and inferential analysis were not performed due to the limited sample size (n = 7). Data management was performed using structured spreadsheets and manual cross-checking to ensure accuracy.

Results

Seven patients, with a clinical-radiological diagnosis of malignant MCA infarction, were included; six of the seven patients (85.7%) were female, reflecting a predominance of women in this small cohort. The mean age was 55.1 years (range, 37–71), and all patients had a baseline mRS score of 0, indicating full independence prior to the ischemic event. The most prevalent comorbidity was arterial hypertension, present in four patients (57.1%), followed by type 2 diabetes mellitus in two patients (28.5%). Chronic tobacco and alcohol use were documented in two patients (28.5%), though less prominent in this cohort ([Table 1]).

Table 1 Detailed demographic, clinical, and radiological characteristics of each patient included in the series

Patient	Age	Sex	Comorbidities	mRS pre	GCS on admission	CGS preoperative	Estimated NIHSS	Hemisphere	Midline shift	Collapsed cisterns	Herniation present
P1	58	M	Hypertension, hypothyroidism, smoking (+), alcohol (+)	0	12	11	12–14 pts	Left	>10 mm	No	No
P2	37	F	No known comorbidities	0	13	13	6	Right	5–10 mm	No	Transcalvarial / Subfalcine
P3	62	F	Hypertension, type 2 diabetes, dyslipidemia, cholecystectomy, hysterectomy	0	14	13	16	Right	>10 mm	No	Subfalcine
P4	71	M	TIA 2022, atrial fibrillation on anticoagulation, hypertension, dyslipidemia, bilateral hearing loss	0	10	12	21	Right	>10 mm	No	Subfalcine
P5	59	F	Hypertension, type 2 diabetes, dyslipidemia, glaucoma	0	14	11	14	Right	5–10 mm	No	Subfalcine
P6	53	F	No known comorbidities	0	11	8	15	Left	<5 mm	No	No
P7	46	F	Smoking (+), alcohol (+), social vulnerability	0	14	10	23	Right	5–10 mm	Yes	Transcalvarial

Abbreviations: GCS, Glasgow Coma Scale; NIHSS, National Institutes of Health Stroke Scale.

At admission, the median GCS score was 11 (range, 8–14), reflecting moderate impairment of consciousness. The National Institutes of Health Stroke Scale (NIHSS) scores ranged from 6 to 23, with a mean of 15.7, highlighting a broad spectrum of moderate to severe neurological deficits. Radiologically, a midline shift ≥10 mm was observed in four patients (57.1%), while the remaining three presented a shift between 5 and 10 mm. Subfalcine or transtentorial herniation signs were identified in six patients (85.7%), underscoring the severity of the space-occupying effect. The infarcted hemisphere was right-sided in five patients (71.4%) and left-sided in two (28.5%). Regarding surgical timing, five patients (71.4%) underwent surgery beyond 48 hours after stroke onset, whereas two patients (28.5%) received intervention within the first 24 hours.

In [Table 1], detailed demographic, clinical, and radiological characteristics of each patient included in the series were presented. Variables include patient age, sex, baseline mRS score prior to stroke, comorbidities, GCS score on admission, estimated NIHSS score, affected hemisphere, degree of midline shift, presence of collapsed cisterns, and type of herniation documented on imaging studies.

All patients underwent a large frontotemporoparietal craniotomy (≥10 cm), followed by targeted resection of the infarcted ischemic core, as described in the technical protocol. [11] [12] Immediate bone flap replacement was performed in all cases, and no intradural or subgaleal drains were placed, facilitating early closure and potentially reducing CSF leakage risks. The surgical technique was completed successfully in all patients without intraoperative complications such as major hemorrhage, intraoperative brain swelling, or dural closure failures. No technical difficulties were reported, and all bone flaps were replaced and fixed without requiring secondary adjustments.

Regarding postoperative complications, non-surgical infections were the most common. One patient (14.3%) developed bacterial meningitis, which resolved with targeted intravenous antibiotic therapy. One patient (14.3%) experienced aspiration pneumonia requiring transient respiratory support and antibiotic treatment. A urinary tract infection was documented in one patient (14.3%), and transient bacteremia occurred in another case (14.3%). All infectious complications were managed conservatively without surgical intervention, and no deep surgical site infections or wound dehiscence were observed. Additionally, two patients (28.5%) required prolonged mechanical ventilation (>48 hours) due to transient neurological or respiratory deterioration, but did not necessitate tracheostomy or further surgical measures.

Importantly, no patient required reintervention or delayed cranioplasty throughout the hospital stay or during the 3-month follow-up, suggesting a potential advantage of single-stage surgery in reducing overall surgical burden ([Table 2]).

Table 2 Surgical parameters and postoperative complications

Stroke onset–surgery time	Surgical technique	Bone flap	Drain used	Reintervention required?	Complications
>48 h	Craniotomy + resection	Replaced	None	No	Bradytachy arrhythmia syndrome – urinary tract infection
>48 h	Craniotomy + resection	Replaced	None	No	Febrile syndrome without source
>48 h	Craniotomy + resection	Replaced	None	No	Febrile syndrome: bacteremia due to Streptococcus suis
>48 h	Craniotomy + resection	Replaced	None	No	Drop in GCS to 8–> Orotracheal intubation
>48 h	Craniotomy + resection	Replaced	None	No	Aspiration pneumonia
<24 h	Craniotomy + resection	Replaced	None	No	Orotracheal intubation due to consciousness fluctuation
<24 h	Craniotomy + resection	Replaced	None	No	Meningitis

The median intensive care unit (ICU) stay was 3 days (range 0–10), indicating a limited need for prolonged critical care despite the severity of the initial presentation. The median total hospital stay was 30 days (range 18–59), aligning with lengths of stay reported in major DC series, though potentially shortened by avoiding staged cranioplasty procedures ([Table 3]).

Table 3 Functional outcomes and length of hospital stay

	mRS at discharge	mRS at 3 mo	In-hospital mortality	Days in ICU	Days in general NICU	Total hospital stay (d)
P1	5	4	No	0	48	59
P2	3	1	No	3	9	18
P3	5	4	No	4	26	30
P4	4	5	No	9	3	32
P5	4	5	No	0	20	30
P6	4	5	No	0	16	56
P7	4	3	No	10	7	49

Abbreviation: NICU, neonatal intensive care unit.

Summary of surgical timing, technique, bone flap management, need for reintervention, and early postoperative complications among the seven patients treated with ischemic core resection and immediate bone flap replacement. No patient required reoperation. The most common complications were febrile syndromes and respiratory or neurological deterioration requiring intubation.

Regarding functional outcomes, at discharge, four patients (57.1%) had mRS scores of 4, representing severe disability but with some preserved self-care capacity. One patient each had mRS scores of 1 (minor symptoms but functionally independent), 3 (moderate disability but able to walk unassisted), and 5 (severe disability requiring continuous care). At the 3-month follow-up, two patients showed partial functional improvement: one maintained mRS 1, and the other improved to mRS 3. The remaining five patients (71.4%) persisted with severe disability (mRS 4–5), and no patient achieved complete functional recovery (mRS 0). Notably, no mortality was recorded either during hospitalization or at 3 months, resulting in a 0% short-term mortality rate ([Fig. 2]).

Fig. 2 Distribution of modified Rankin Scale (mRS) scores at discharge and 3 months after surgery. Bar plot showing the frequency of mRS scores among patients at hospital discharge (blue) and at 3-month follow-up (orange). A slight shift toward improved functional outcome is observed over time, though most patients remained in the moderate to severe disability range (mRS 3–5). No patient achieved full independence (mRS ≤2).

mRS scores at discharge and at 3-month follow-up for each patient treated with ischemic core resection. No in-hospital mortality was recorded. The table also summarizes intensive care unit (ICU) days, days in the general neurology intermediate care unit, and total duration of hospitalization.

Overall, this series underscores the feasibility and initial safety of ischemic core resection with immediate bone flap replacement as an alternative surgical strategy in malignant MCA infarction. The absence of reinterventions, the low rate of severe complications, and the 0% mortality are particularly remarkable, although the persistently high disability rates at follow-up emphasize the complexity and severe nature of this patient population.

Discussion

Core resection with immediate bone flap replacement in the setting of malignant MCA infarction. This technique, known as corectomy, allowed effective control of cerebral edema and prevented in-hospital mortality, without requiring permanent DC or subsequent cranioplasty.

A predominance of female patients was observed in our cohort. Although this pattern may appear unbalanced, it most likely reflects the limited sample size and recruitment period rather than a genuine sex-related effect. Nevertheless, it is acknowledged as a potential source of bias and should be interpreted with caution.

Despite the small sample of patients, the most notable finding was the zero mortality rate in all patients who underwent surgery, including those with a midline shift ≥10 mm and radiological signs of herniation. This rate contrasts favorably with the historical results of DC in classic series. For example, in the DECIMAL study, mortality with DC was 33%,[2] and in HAMLET it reached 22%.[3] In patients older than 60 years, the rate was even higher: in DESTINY II, mortality with DC was reduced from 70 to 33%, but more than 70% of survivors still became severely disabled.[8] In this context, our series shows that corectomy can be a promising surgical alternative to reduce mortality without resorting to a permanent decompressive approach.

Indirect comparison with historical studies shows notable differences. In the DECIMAL study, 1-year mortality was 33% with DC, with 25% of patients achieving mRS ≤3.[2] In HAMLET, survival with mRS ≤3 was only 25% with surgery.[3] In our series, mortality was 0%, and two of seven patients (28.5%) achieved mRS ≤3 at 3 months, a result comparable to that of the trials, although with obvious limitations due to the sample size. These comparisons are presented solely for contextual orientation. Given the clear differences in study design, inclusion criteria, and cohort size, our results should not be interpreted as directly comparable to the randomized trials (DECIMAL, DESTINY, and HAMLET), but rather as hypothesis-generating data that place our findings within the context of existing literature.

In DESTINY II, which included patients older than 60 years, mortality was reduced from 70 to 33% with DC, but more than 70% of survivors remained with mRS 4–5.[8] In our cohort, five of seven patients (71.4%) had similar results, indicating that the technique, although effective in preventing death, is still associated with high rates of functional dependence when applied to patients of advanced age or with surgical delay ([Fig. 3]).

Fig. 3 Comparison of mean intensive care unit (ICU) stay and total hospitalization duration between the institutional cohort treated with ischemic core resection and historical literature averages for decompressive craniectomy. The figure illustrates a trend toward reduced ICU stay in the institutional cohort, with comparable overall hospitalization duration.

Finally, when comparing our cohort with published series of strokectomy, such as that of Pilloni et al,[9] which reported a mortality of 6.7 and 53% of patients with mRS ≤3 at 1 year, our results are similar in terms of survival, although with a slightly lower rate of early functional recovery. Moughal et al,[10] in their meta-analysis, reported mRS ≤3 in 45% of cases, although with high heterogeneity between the series.

When comparing our cohort data with the average values reported in the literature on DC, a numerical reduction in ICU length of stay was observed (mean 3.7 vs. 7.5 days). The difference trended toward statistical significance (t = −2.35, p = 0.057), which could reflect a lower requirement for critical care support in patients treated with corectomy. Regarding the total length of stay, no significant difference was observed compared with historical values (mean 39.1 vs. 45 days; t = −1.00, p = 0.356). These observations, although preliminary, reinforce the possibility that this technique may reduce the immediate care burden, especially in critical care units.

Additionally, none of the seven patients required subsequent reintervention. This figure contrasts markedly with reports in the literature on DC, where all survivors required a second scheduled surgery for cranioplasty placement. In our analysis, this difference was statistically significant (0/7 vs. 5/7; Chi[2], p = 0.0257), reinforcing the potential of corectomy as a single-stage surgical strategy.

The pathophysiological hypothesis supporting corectomy is that targeted resection of infarcted tissue acts as an “internal decompression” mechanism by directly removing necrotic mass that contributes to intracranial hypertension and the displacement of critical structures.[9] Unlike classical DC, which facilitates external parenchymal expansion, corectomy aims to restore volumetric equilibrium without creating a permanent extracranial defect. This approach potentially reduces the incidence of post-craniectomy syndrome and minimizes dynamic cerebrospinal fluid (CSF) alterations and vascular changes induced by atmospheric pressure.[6] [7]

Furthermore, DC followed by cranioplasty is associated with substantial complication rates. A comprehensive review of 164 patients revealed that 55.5% experienced at least one complication following DC or cranioplasty, including cortical herniation through the defect (25.6%), subdural effusion (49.4%), seizures (22%), hydrocephalus (14%), and syndrome of the trephined (1.2%). Cranioplasty-specific complications included infection (11.6%) and bone flap resorption (7.2%).[7]

In our cohort, all patients underwent immediate bone replacement without evidence of secondary compressive complications. This contrasts with studies in which early replacement was associated with a risk of reactive intracranial hypertension.[11] By combining core resection with immediate bone closure, the net intracranial load is likely maintained within physiological ranges, thereby relieving pressure without requiring a second cranioplasty. Overall, corectomy may reduce the complication burden, maintain intracranial homeostasis, and eliminate the need for staged reconstruction and reoperations, strengthening the clinical advantage of a single-stage surgical strategy with the potential to improve both short- and long-term outcomes.

Another notable aspect was the absence of surgical reinterventions. Unlike DC, which necessitates a scheduled secondary cranioplasty with its inherent risks,[12] none of the patients in our series required repeat surgery for bone closure or structural complications. This implies a potential reduction in costs, anesthetic risks, and surgical burden, which is particularly relevant in resource-limited healthcare systems or in frail patients who may not tolerate repeated procedures.

Regarding functional outcome, results were mixed. Only two patients (28.5%) achieved favorable functional recovery (mRS ≤3) at 3 months, while the remaining five maintained severe disability. These data are consistent with those reported in major randomized trials: in the combination of DECIMAL, DESTINY, and HAMLET, the proportion of patients with mRS ≤3 after DC was 43%.[5] In the series by Pilloni et al, 53% achieved mRS ≤3 with strokectomy.[9] The meta-analyzed series by Moughal et al showed an overall rate of good functional outcome of 45%.[10] Although our rate is somewhat lower, the small sample size and the fact that five of the seven patients were operated on more than 48 hours after the stroke must be considered, which has been shown to reduce surgical efficacy even in conventional DC.[4] [13]

One of the most relevant elements to consider in this technique is surgical timing. In our cohort, five of the seven patients underwent surgery more than 48 hours after the event, which may have influenced the functional results, given that the literature has shown that decompression beyond this time threshold is associated with less clinical benefit.[13] However, even in this late subgroup, 100% survival was achieved without the need for reintervention, suggesting that corectomy may retain its pathophysiological effect even in extended time windows, possibly due to the direct removal of already formed necrotic tissue.

Furthermore, the volume of resected tissue varied among patients, raising the hypothesis that there is an optimal resection threshold to achieve effective decompression without generating additional functional deficit. This question remains unanswered in the current literature. In the review by Moughal et al, high heterogeneity was identified in the extent of resection and in the definition of the “ischemic core,” making it difficult to establish unified technical protocols.[10] In animal models, segmental resection of the temporal lobe has been shown to reduce ICP levels proportionally to the volume removed,[14] but direct extrapolation to the human clinical context is still limited.

One possible explanation for the control of edema with this technique is the reduction in the production of inflammatory mediators and reactive species that accompany tissue necrosis. The persistence of necrotic tissue within the closed cranial compartment could amplify the adjacent vasogenic and cytotoxic edema, while its removal would partially eliminate this source of secondary dysfunction. This hypothesis has been outlined in studies of hemorrhagic infarction, where early surgical evacuation improves the perilesional neurochemical environment.[15]

From an economic and logistical perspective, corectomy has several advantages. It avoids the need for secondary cranioplasty, a procedure that in many centers entails high costs, surgical waiting lists, and associated morbidity. Cost-benefit studies on DC have indicated that up to 30% of the total cost is associated with the second reconstructive procedure.[16] Eliminating this surgical phase could substantially reduce the hospital burden, especially in resource-constrained systems. Furthermore, our patients required a median of only 3 days in the ICU, lower than the average reported in series with conventional DC, which ranges from 5 to 10 days.[3] [17] This difference could reflect a shorter time on mechanical ventilation and faster postoperative intracranial stabilization, as also observed in the Taiwanese series with combined strokectomy.[18]

Despite these positive findings, limitations must be acknowledged. First, the small number of patients (n = 7) prevents statistically robust conclusions and limits the generalizability of the results. Second, the lack of a contemporary control group prevents direct comparison of the technique with traditional DC. Although an indirect comparison with historical studies was made, the biases inherent in this methodology are well known. Third, functional follow-up was limited to 3 months, which prevents assessment of long-term cognitive recovery and autonomy.

Regarding the technique itself, unresolved questions remain. The selection of tissue for resection is not standardized, and the optimal extent of resection that balances effective decompression with functional preservation remains undefined. There are also no validated biomarkers or radiological parameters that guide the ideal indication for this technique versus DC. The integration of advanced neuroimaging, such as perfusion MRI or diffusion CT, could help accurately identify nonviable areas and optimize intraoperative resection.

Finally, it is important to emphasize that this technique does not replace DC in all cases. In patients with extensive hemispheric infarcts accompanied by bilateral involvement, midbrain entrapment syndrome, or fulminant intracranial hypertension, external decompression remains the most immediate and safest option. However, in selected patients with clearly defined necrotic tissue, good prior functional reserve, and initial clinical stability, coretomy could represent a viable alternative.

The design of multicenter, prospective, and ideally randomized studies is essential to validate this strategy. Direct comparisons between corectomy and conventional DC, with functional follow-up at 6 to 12 months, quality-of-life analysis, postoperative neuroimaging, and cost-effectiveness analyses, will allow this technique to be positioned within the therapeutic algorithm for malignant MCA infarction.

Conclusion

Resection of the ischemic core with immediate bone flap replacement (corectomy) represents a feasible and technically reproducible approach for selected patients with malignant MCA infarction. In this small retrospective series, the procedure was associated with hospital survival in all patients, absence of reinterventions, and reduced ICU stay, while eliminating the need for secondary cranioplasty. These preliminary findings should be interpreted with caution due to the limited sample size and retrospective design. Further prospective and controlled studies are warranted to validate the safety, reproducibility, and long-term efficacy of this technique before generalization. From an anatomical and pathophysiological perspective, corectomy offers an effective form of decompression, allowing relief of mass effect without altering the structural integrity of the skull. Its potential to reduce surgical morbidity, treatment costs, and hospital burden merits special attention in resource-limited settings. Despite the limitations inherent to the retrospective design and small sample size, our findings justify prospective, comparative studies to validate its usefulness in the therapeutic algorithm for extensive stroke. Corectomy can be considered a promising surgical alternative, with the potential to redefine the surgical approach to malignant hemispheric infarcts, and whose systematic implementation could optimize outcomes in critically ill patients. Further prospective and controlled studies are warranted to validate its safety, reproducibility, and long-term efficacy.

Conflict of Interest

None declared.

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Publication History

Article published online:
23 January 2026