Middle cerebral artery infarction

Schwab S, Schwarz S, Spranger M, Keller E, Bertram M, Hacke W. Moderate hypothermia in the treatment of patients with severe middle cerebral artery infarction. Stroke 1998 29 2461-2466. 

Schwab S, Steiner T, Aschoff A, Schwarz S, Steiner HH, Jansen O, Hacke W. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 1998 29 1888-1893. 

FIGURE 8.1 Massive middle cerebral artery 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... 

Qureshi AI, Suarez JI, Yahia AM, Mohammad Y, Uzun G, Suri MF, Zaidat OO, Ayata C, Ali Z, Wityk RJ. Timing of neurological deterioration in massive middle cerebral artery infarction a multicenter review. Crit Care Med 2003 31(l) 272-277. 

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. 

Ralafut MA, Schriger DL, Saver XL, Starkman S. Detection of early CT signs of >1/3 middle cerebral artery infarctions interrater reliability and sensitivity of CT interpretation by physicians involved in acute stroke care. Stroke 2000 31 1667-1671. 

Berger C, Annecke A, Aschoff A, Spranger M, Schwab S. 1999. Neurochemical monitoring of fatal middle cerebral artery infarction. Stroke 30(2) 460-463. 

Saunders D. E., Howe F. A., van den Boogaart A., McLean M. A., Griffiths J. R., and Brown M. M. (1995). Continuing ischemic damage after acute middle cerebral artery infarction in humans demonstrated by short-echo proton spectroscopy. Stroke 26 1007-1013. 

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...

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... 

Schwab S., Schwarz S., Aschoff A., Keller E., and Hacke W. (1998) Moderate hypothermia and brain temperature in patients with severe middle cerebral artery infarction. Acta Neurochir. Suppl. 71, 131-134. 

The early ischemic changes on CT are subtle and the CT may appear normal if performed in the first few hours. The sensitivity of CT within five hours of ischemic stroke was reported as 58% in one early study (Horowitz et al. 1991) although a higher rate of 68% has been reported within two hours (von Kummer et al. 1994) and even higher of 75% within three hours with middle cerebral artery infarction (Barber et al. 2000). The interobserver reliability and reproducibility of CT in the estimation of the degree of ischemic... 

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. 

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...

Saunders DE, Clifton AG, Brown MM (1995). Measurement of infarct size using MRI predicts prognosis in middle cerebral artery infarction. Stroke 26 2272-2276 Saur D, Lange R, Baumgaertner A et al. (2006). Dynamics of language reorganization after stroke. Brain 129 1371-1384... 

Intracerebral extension of the hemorrhage occurs in at least a third of patients. Patients with a large hematoma and depressed consciousness might require immediate evacuation of the hematoma, preferably preceded by occlusion of the aneurysm (Niemann et al. 2003). Alternatively, extensive craniectomy can be employed to allow expansion of the brain, as for maUgnant middle cerebral artery infarction (Smith et al. 2002). Subdural hematomas are rare but life threatening and should be removed. 

A 27-year-old woman (21) with acute promyelocytic leukemia was given arsenic trioxide 0.15 mg/kg/day intravenously. Her white cell count was 8.2 x 10 /1 after two doses it rose to 15 x 10 /1 and after three doses to 21 X 10 /1. The white blood cell count continued to rise to 101 x 10 /1 on day 7 and 213 x 10 /1 on day 8 the platelet count was 61 x 10 /1. Arsenic trioxide was withdrawn. Later that day she became confused with slurred speech and right-sided weakness. A CT scan showed a left middle cerebral artery infarct. 

A 58-year-old man had a right middle cerebral artery infarction leading to, among many other neurological deficits, left-sided neglect (7). When he took bromocriptine 20 mg/day this abnormality worsened and then improved again on withdrawal. 

Truwit CL, Barkowich AJ, Gean-Marton A et al (1990) Loss of the insular ribbon another early CT sign of acute middle cerebral artery infarction. Radiology 176 801-806. 

Von Kummer R, Holle R, Grzyska U, Hofmann E et al (1996) Interobserver agreement in assessing early CT signs of middle cerebral artery infarction. Am J Neuroradiol 17 1743-1748. 

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