Middle cerebral artery malignant infarction

To date, only nonrandomized smdies of hemicraniectomy in massive hemispheric stroke have been performed. Rieke et al. found that mortality was reduced from 79% in control patients to 34% in those who underwent DC, with a concomitant reduction in poor functional outcome from 95% to 50%. The mean time interval from stroke to surgery was 39 hours in this study, relatively early in the time course, which may have prevented the patients from having secondary injury due to herniation. Schwab et al. reduced mortality with DC to 16%. Both of these studies, however, found that functional outcome was consistently less improved in the elderly population. The Swedish Malignant Middle Cerebral Artery Infarction Study looked at the long-term (median 3.4 years) outcome... 

Jaramillo A, Gongora-Rivera F, Labreuche J, Hauw JJ, Amarenco R Predictors for malignant middle cerebral artery infarctions a post-mortem analysis. Neurology 2006 66(6) 815-820. 

Foerch C, Lang JM, Krause J, Raabe A, Sitzer M, Seifert V, Steinmetz H, Kessler KR. Functional impairment, disability, and quality of life outcome after decompressive hemicraniectomy in malignant middle cerebral artery infarction. J Neurosurg 2004 101(2) 248-254. 

Thomalla GJ, Kucinski T, Schoder V, Fiehler J, Knab R, Zeumer H, Weiller C, Rother J (2003) Prediction of malignant middle cerebral artery infarction by early perfusion- and diffusion-weighted magnetic resonance imaging. Stroke 34 1892-1899... 

Surgical decompression for malignant middle cerebral artery infarction... 

Fig. 21.2. A CT brain scan showing the development of malignant middle cerebral artery infarction in a young woman who subsequently underwent hemicraniectomy.

Fig. 21.3. A pooled analysis of data from three small randomized trials of hemicraniectomy versus medical treatment for malignant middle cerebral artery infarction (Vahedi eta . 2007). Surgery within 48 hours of stroke onset reduced case-fatality from 71% to 22% and left 43% of survivors with only mild or moderate disability (modified...

Fig. 1.1. Upper row, computed tomography of a patient with malignant right middle cerebral artery infarction on day one after onset of symptoms. Lower row, on day two massive edema with midline shift in spite of hemicraniectomy...

Hacke W., Schwab S., HomM., Spranger M., De Georgia M., and von Kummer R. (1996) Malignant middle cerebral artery territory infarction clinical course and prognostic signs. Arch. Neurol. 53, 309-315. 

Malignant middle cerebral artery territory infarction is defined as a large middle cerebral artery infarct with marked edema and swelling, leading to raised intracranial pressure and a high risk of coning (Fig. 

Steiner T, Eriede T, Aschoff A, Schelhnger PD, Schwab S, Hacke W. Effect and feasibihty of controlled rewarming after moderate hypothermia in stroke patients with malignant infarction of the middle cerebral artery. Stroke 2001 32(12) 2833-5. 

Wagner S, Schnippering H, Aschoff A, Koziol JA, Schwab S, Steiner T. Suboptimum hemicraniectomy as a cause of additional cerebral lesions in patients with malignant infarctions of the middle cerebral artery. J Neurosurg 2001 94(5) 693-696. 

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