661: ROLE OF DECOMPRESSIVE HEMICRANIECTOMY IN PEDIATRIC MALIGNANT MIDDLE CEREBRAL ARTERY INFARCTION

Abstract

Introduction: Malignant conversion of cerebral infarct leading to cerebral herniation is well described in adults. There is a lack of sufficient literature on malignant infarction in children. We report a rare case of middle cerebral artery infarct (MCAI) in a teenage girl with initial improvement (honeymoon period), followed by progression to malignant MCAI (MMCAI), requiring an urgent decompressive hemicraniectomy (DHC). Additionally, we report improvement at discharge and at 4-month follow-up. Description: A 14-year-old previously healthy female presented with loss of consciousness for 45 minutes followed by right side weakness. Her MRI of the brain showed acute infarct without hemorrhage involving the territory of the left MCA requiring PICU management. The initial diagnostic workup was suggestive of idiopathic MCAI. She had right-sided hemiplegia, and National Institute of Health Stroke Scale (NIHSS) score of 19. On hospital day 3, she showed improvement with NIHSS changing from 19 to 15. On the evening of hospital day 5, she developed progressively worsening headaches, emesis, and loss of consciousness. CT head demonstrated malignant cerebral edema, midline shift and uncal and sub-falcine herniation. She was intubated and taken emergently to the operating room for a left-sided DHC. She was then managed in the PICU with neuroprotective strategies, aggressive management of her elevated intracranial pressure, and goal-directed management of her cerebral perfusion pressure. She subsequently improved with successful extubation on hospital day 21 and discharge on hospital day 66. At a 4-month follow-up in the neurosurgery clinic, she was alert, interactive, verbal with slow speech, able to identify simple objects, lift right shoulder, and extend the right lower extremity. Discussion: Our case described above is a unique report of DHC in a pediatric patient who had rare MMCAI with a positive outcome. The additional feature of our case worth reporting was the initial honeymoon period before malignant conversion. This rare presentation highlights the importance of monitoring the neurological status in a patient with an MCAI for progression to life-threatening malignant MCAI. This case report also highlights the importance of consideration of DHC for a favorable outcome of MMCAI.