Middle infarct

Launes J, Ketonen L. Dense middle cerebral artery sign an indicator of poor outcome in middle cerebral artery area infarction. J Neurol Neurosurg Psychiatry 1987 50 1550-1552. 

Zorzon M, Mase G, Pozzi-MuceUi F, Biasutti E, Antonutti L, Iona L, Cazzato G. Increased density in the middle cerebral artery by nonenhanced computed tomography. Prognostic value in acute cerebral infarction. Eur Neurol 1993 33 256-259. 

Lev MH, Segal AZ, Farkas J, Hossain ST, Putman C, Hunter GJ, Budzik R, Harris GJ, Buonanno FS, Ezzeddine MA, Chang Y, Koroshetz WJ, Gonzalez RG, Schwamm LH. Utility of perfusion-weighted CT imaging in acute middle cerebral artery stroke treated with intra-arterial thrombolysis prediction of final infarct volume and clinical outcome. Stroke 2001 32 2021-2028. 

Izumi Y Roussel S, Pinard E, Seylaz J. Reduction of infarct volume by magnesium after middle cerebral artery occlusion in rats. J Cereb Blood Flow Metab 1991 11 1025-1030. 

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. 

Curry Jr, WT, Sethi MK, Ogilvy CS, Carter BS. Factors associated with outcome after hemicraniectomy for large middle cerebral artery territory infarction. Neurosurgery 2005 56 681-692 [discussion 681-692]. 

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. 

Wijdicks EE, Diringer MN. Middle cerebral artery territory infarction and early brain swelling progression and effect of age on outcome. Mayo Clin Proc 1998 73 829-836. 

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. 

Kiening KL. Schneider GH, Unterherg AE, Lanksch WR. Effect of tromethamine (THAM) on infarct volume following permanent middle cerebral artery occlusion in rats. Acta Neurochir 1997 70 188-190. 

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. 

Gupta R, Connolly ES, Mayer S, Elkind MS. Hemicraniectomy for massive middle cerebral artery territory infarction a systematic review. Stroke 2004 35(2) 539-543. 

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. 

Table 5.1 Effects of compound 231617 on infarct volume in the middle cerebral occlusion model of focal stroke...

Martz, D., Rayos, G., Schielke, G.P. and Betz, A.L. (1989). Allopurinol and dimethylthiourea reduce brain infarction following middle cerebral artery occlusion in rats. Stroke 20, 488-494. 

N-Nitro-L-arginine methyl ester (L-NAME) is an inhibitor of NOS L-NAME reportedly reduces the volume of cortical and striatal infarct after middle cerebral artery occlusion in the rat. This protection can be reversed by co-injection of L-arginine. L-NAME also reduced the excitotoxic damage induced by NMDA injection. Finally, the authors showed that L-NAME reduced glutamate efflux produced by ischaemic injury in rats. The authors concluded that NOS induced by NMDA receptor overstimulation is a key event in the neuronal injury cascade (Buisson eta/., 1993). 

In contrast to the deleterious effects of arginine described by Buisson, L-arginine was shown to decrease infarct size caused by middle cerebral artery occlusion in spontaneously hypertensive rats. L-Arginine is a precursor for NO synthesis by NOS. The authors attributed the protection to dilation of cerebral blood vessels by NO (Morikawa et 1992). These examples illustrate the difficulty that the NO villain/protector paradox presents to us. 

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