Intensive medical therapy with therapeutic hypothermia for malignant middle cerebral artery infarction

Abstract

Intensive medical therapy with therapeutic hypothermia for malignant middle cerebral artery infarction Kyu sun Lee, Jin soo Lee, Ji man Hong Ajou University Medical Center, Republic of Korea Background/Purpose: Malignant middle cerebral artery (MCA) infarction is a large hemispheric infarct caused by proximal MCA or internal carotid artery occlusion with deteriorating progress. Decompressive hemicraniectomy has been regarded effective for increased intracranial pressure. However, it might not be available in elderly or medically unstable patients. Therefore, we compared clinical findings and prognosis between intensive medical therapy with hypothermia (best medical therapy group) and decompressive hemicraniectomy (surgery group) for malignant MCA infarction. Methods: We collected acute MCA infarction patients who underwent brain MRI within 6 hours since onset in a stroke center over 4 years. Malignant MCA infarction was defined as greater than 82 mL on DWI within 6 hours or greater than 145 mL on follow-up DWI or CT. Results: Among total 46 cases, best medical therapy group were 18, and surgery group were 16. Initial National Institutes of Health Stroke Scale (NIHSS) did not differ between the groups. Initial infarct volume on DWI within 6 hours significantly differs between the groups: mean 254.0 ± 107.0 mL in surgery vs 127.2 ± 44.0 mL in best medical therapy (P b .001). NIHSS at discharge, prevalence of good outcome (mRS 0-2), and mortality at 3 months did not differ between the groups. The prevalence of poor outcome (mRS 5-6) at 3 months significantly differ between the groups: 14 (87.5%) in surgery and 16 (53.3%) in best medical therapy (P = .020). Conclusions: This study suggests that intensive medical therapy with hypothermia has lower prevalence of poor outcome than decompressive hemicraniectomy despite relatively similar clinical severity on baseline. Therefore, systematized medical therapy with therapeutic hypothermia might be a feasible strategy to avoid invasive hemicraniectomy in malignant MCA infarction.