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 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. 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. 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. 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). 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.