Brain Herniation Research Articles

Secondary hyperperfusion injury following surgical evacuation for acute isolated epidural hematoma with concurrent cerebral herniation.

Hemispherical cerebral swelling or even encephalocele after head trauma is a common complication and has been well elucidated previously. However, few studies have focused on the secondary brain hemorrhage or edema occurring regionally but not hemispherically in the cerebral parenchyma just underneath the surgically evacuated hematoma during or at a very early stage post-surgery. In order to explore the characteristics, hemodynamic mechanisms, and optimized treatment of a novel peri-operative complication in patients with isolated acute epidural hematoma (EDH), clinical data of 157 patients with acute-isolated EDH who underwent surgical intervention were reviewed retrospectively. Risk factors including demographic characteristics, admission Glasgow Coma Score, preoperative hemorrhagic shock, anatomical location, and morphological parameters of epidural hematoma, as well as the extent and duration of cerebral herniation on physical examination and radiographic evaluation were considered. It suggested that secondary intracerebral hemorrhage or edema was determined in 12 of 157 patients within 6 h after surgical hematoma evacuation. It was featured by remarkable, regional hyperperfusion on the computed tomography (CT) perfusion images and associated with a relatively poor neurological prognosis. In addition to concurrent cerebral herniation, which was found to be a prerequisite for the development of this novel complication, multivariate logistic regression further showed four independent risk factors contributing to this type of secondary hyperperfusion injury: cerebral herniation that lasted longer than 2 h, hematomas that were located in the non-temporal region, hematomas that were thicker than 40 mm, and hematomas occurring in pediatric and elderly patients. Secondary brain hemorrhage or edema occurring within an early perioperative period of hematoma-evacuation craniotomy for acute-isolated EDH is a rarely described hyperperfusion injury. Because it plays an important prognostic influence on patients' neurological recovery, optimized treatment should be given to block or reduce the consequent secondary brain injuries.

Clinical Improvement and Tumor Regression in Parturient With a Brain Tumor and Intracranial Bleeding After C-Section with General Anesthesia

Brain tumors and intracranial bleeding are rare cases in pregnancy. Anesthesia management for a C-section with comorbidity remains challenging. We presented a 33-year-old woman (34–36 weeks pregnant) with the complaint of weakness in her right extremities, blurred vision, and ptosis of her left eye from a month before hospitalization. The brain computed tomography (CT) revealed a mass at the left parasellar region with a bleeding component and cerebral edema accompanied by subfalcine herniation. We conducted general anesthesia for cesarean delivery in a patient with a brain-protective technique. Brain CT revealed a decrease in the mass size and neither intracranial bleeding nor cerebral edema. In conclusion, general anesthesia management provided a good outcome in a parturient with a brain tumor and intracranial bleeding that underwent C-section. The mechanism of clinical improvement and tumor regression is unclear and requires further research, but it is believed that it is related to pregnancy hormones.

Craniovertebral Junction Instability in the Setting of Chiari Malformation.

Described in the seminal paper by Hans Chiari in 1891, the Chiari I malformation (CMI) is a radiographic diagnosis commonly encountered by neurosurgeons and is often treated surgically with generally positive clinic outcomes. Studies have documented that 1% to 4% of patients undergoing MRI of the brain or cervical spine will be diagnosed with CMI, characterized by greater than 5mm tonsillar herniation below the foramen magnum. More recently CMI has been described as a spectrum of disease, which includes Chiari 0, Chiari 1.5, and the complex Chiari. Primarily through multicenter clinical outcomes research, our understanding of the pathology continues to evolve.

Infarto cerebral e meningoencefalite trombótica em um bezerro devido a candidíase

ABSTRACT: We described a case of cerebral infarction and thrombotic meningoencephalitis due to candidiasis in a seven-month-old calf. The death occurred three days after the onset of apathy, fever, and the head’s lateral deviation to the left. Macroscopic changes in the brain consisted of asymmetry of telencephalic hemispheres; the right hemisphere was enlarged, causing cerebellar herniation. A focally extensive red area was observed on the surface of the right occipital lobe. At cross-sections of the fixed brain, the lesions revealed to be extensive, red-brown, soft or cavitated areas affecting the white and grey matter from the level of the thalamus to the cerebellum and compressing subjacent structures. Histologically, there was acute, coalescent, multifocal necrosupurative meningoencephalitis, associated with vasculitis, congestion, thrombosis, edema, infarction, and intralesional fungal hyphae. The diagnosis of cerebral infarction and thrombotic meningoencephalitis due to candidiasis was made by the pathological changes, the staining and morphological characteristics of the agent, and immunohistochemistry. The cerebral infarction and thrombotic meningoencephalitis in cattle can result from vascular lesions due to infection by Candida sp.; although uncommon, this case demonstrated that candidiasis should be part of a list of differential diagnoses of severe brain injuries in cattle.

A benchtop brain injury model using resected donor tissue from patients with Chiari malformation.

The use of live animal models for testing new therapies for brain and spinal cord repair is a controversial area. Live animal models have associated ethical issues and scientific concerns regarding the predictability of human responses. Alternative models that replicate the 3D architecture of the central nervous system have prompted the development of organotypic neural injury models. However, the lack of reliable means to access normal human neural tissue has driven reliance on pathological or post-mortem tissue which limits their biological utility. We have established a protocol to use donor cerebellar tonsillar tissue surgically resected from patients with Chiari malformation (cerebellar herniation towards the foramen magnum, with ectopic rather than diseased tissue) to develop an in vitro organotypic model of traumatic brain injury. Viable tissue was maintained for approximately 2 weeks with all the major neural cell types detected. Traumatic injuries could be introduced into the slices with some cardinal features of post-injury pathology evident. Biomaterial placement was also feasible within the in vitro lesions. Accordingly, this 'proof-of-concept' study demonstrates that the model offers potential as an alternative to the use of animal tissue for preclinical testing in neural tissue engineering. To our knowledge, this is the first demonstration that donor tissue from patients with Chiari malformation can be used to develop a benchtop model of traumatic brain injury. However, significant challenges in relation to the clinical availability of tissue were encountered, and we discuss logistical issues that must be considered for model scale-up.

Predictor of the Postoperative Swelling After Craniotomy for Spontaneous Intracerebral Hemorrhage: Sphericity Index as a Novel Parameter.

Spontaneous intracerebral hemorrhage is a serious type of stroke with high mortality and disability rates. Surgical treatment options vary; however, predicting edema aggravation is crucial when choosing the optimal approach. We propose using the sphericity index, a measure of roundness, to predict the aggravation of edema and guide surgical decisions. We analyzed 56 cases of craniotomy and hematoma evacuation to investigate the correlation between the sphericity index and patient outcomes, including the need for salvage decompressive craniectomy (DC). The patients included 35 (62.5%) men and 21 (37.5%) women, with a median age of 62.5 years. The basal ganglia was the most common location of hemorrhage (50.0%). The mean hematoma volume was 86.3 cc, with 10 (17.9%) instances of hematoma expansion. Cerebral herniation was observed in 44 (78.6%) patients, intraventricular hemorrhage in 34 (60.7%), and spot signs in 9 (16.1%). Salvage DC was performed in 13 (23.6%) patients to relieve intracranial pressure. The median follow-up duration was 6 months, with a mortality rate of 12.5%. The sphericity index was significantly correlated with delayed swelling and hematoma expansion but not salvage DC. The sphericity index is a promising predictor of delayed swelling and hematoma expansion that may aid in the development of surgical guidelines and medication strategies. Further large-scale studies are required to explore these aspects and establish comprehensive guidelines.

Idiopathic Intracranial Hypertension Presenting as Seizures

Idiopathic Intracranial Hypertension is a condition characterised by raised cerebrospinal fluid pressure of unknown etiology seen predominantly in obese, middle aged patients. The typical clinical features include headache, pulsatile tinnitus, diplopia and transient visual obscurations. Seizures are a rare symptom seen in IIH patients. We present a case of a young, obese female patient who presented with headache and seizures. Imaging showed evidence of Idiopathic Intracranial Hypertension with temporal lobe encephalocoeles and brain herniation into arachnoid granulations. The diagnosis was subsequently confirmed by clinical workup and she was started on treatment for the same.

Studded Brainstem Tuberculoma Presenting with Bilateral Inter-Nuclear Ophthalmoplegia.

Sir, A 17-year-old male with a history of low-grade fever for 2 months, headache for 15 days, and diplopia and drooping of the right upper eyelid for 10 days, was admitted to our hospital. There was no history of altered sensorium, convulsion, weakness, paresthesia, weight loss, or cough. There was no history of trauma, joint pain, rash, and high-risk behavior. His general examination was normal. Nervous system examination revealed a Glasgow Coma Scale of 15, normal visual acuity with bilateral Grade 2 papilledema, bilateral restriction of adduction movement of the eyeball with ptosis of the right eye, and dilated fixed right pupil [Figure 1a]. The rest of cranial nerve examination was unremarkable. He had bilateral upper motor neuron quadriparesis with power of 4+/5 with bilateral extensor plantars. Sensory and cerebellar functions were intact. Meningeal signs were present. Rest of the systemic examination was unremarkable.Figure 1: (a) On presentation, clinical image showing right-sided ptosis with restriction of bilateral adduction. MRI brain (i-iv) showing multiple T2 hypointense/FLAIR hyperintense signal changes in midbrain with ring enhancement in gadolinium contrast along with hydrocephalus. (b) At 1 month of follow-up, clinical image showing improvement in right-sided ptosis with reduced restriction of bilateral adduction. MRI brain (i-iv) showing reduction of midbrain lesions and resolving hydrocephalus. MRI: Magnetic resonance imaging, FLAIR: Fluid-attenuated inversion recoveryHis laboratory blood parameters showed normal hemogram with normal renal, liver, and thyroid functions with normal glucose and electrolytes. Serological examination was negative for HIV, hepatitis B and C, Leptospira, and Listeria. His cerebrospinal fluid examination revealed lymphocytic pleocytosis with elevated protein level, CBNAAT negative state, negative for Gram stain, fungal stain, and culture sensitivity. Magnetic resonance imaging (MRI) brain revealed multiple coalesced ring enhancing lesions of the midbrain with extension to upper pons with hydrocephalus [Figure 1a]. He was started on standard antitubercular treatment and corticosteroid. He showed improvement clinically within 10 days in the form of partial recovery in ptosis and adduction movements of the eyeball [Figure 1b]. Headache and fever resolved within 2 weeks. MRI brain was repeated at 1 month, which showed resolving hydrocephalus and reduction in size of the brainstem tuberculomas [Figure 1b]. The entity of the brainstem tuberculoma is a rare phenomenon in tuberculosis of central nervous system with incidence of 2.5%–8%.[1] The clinical presentation of the brainstem tuberculoma is pleomorphic. The site, size, and morphology of the lesions determine this versatility of manifestation.[2] Nuclear gaze palsy, ocular motor palsy, facial palsy, bulbar palsy, ataxia, and long tract signs are some important features of brainstem involvement.[3] A multitude of etiology can have similar presentation of brainstem encephalitis including infections, autoimmune disorders, neoplastic (gliomas), and vascular. Brainstem lesions are notorious for complications in the form of hydrocephalus, respiratory insufficiency, fatal arrhythmias, and brain herniation.[4] A thorough workup and aggressive management is prudent for correct diagnosis and better outcome. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

СЛУЧАЙ УСПЕШНОГО ОТКРЫТОГО ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ ГИГАНТСКОЙ АНЕВРИЗМЫ СУПРАКЛИНОИДНОГО ОТДЕЛА ВНУТРЕННЕЙ СОННОЙ АРТЕРИИ

Methods: Despite the progress in developing high-tech methods for neurosurgical patient treatment, managing giant internal carotid artery (ICA) aneurysms remains challenging. We report a case of the successful surgical treatment of a patient with a highly complex clinical problem – a giant aneurysm (GA) at the right supraclinoid ICA. First, the extent of an open surgical intervention was as follows: the ICA was exposed using a linear neck incision and mobilized. Then, osteoplastic skull trepanation in the pterional region and the aneurysmal portion of supraclinoid ICA was performed. The chosen surgical tactics prevented recurrent subarachnoid and intracerebral hemorrhage, ischemia, edema, and brain compression, which are closely related to death and disability. Based on the above, the treatment method has been considered a practical option for treating this cohort of patients. Keywords: Internal carotid artery, aneurysm, clipping, intracranial hemorrhage, intraventricular hemorrhage.

Management of chronic non-cancer pain in primary care.

Management of chronic non-cancer pain in primary care.

Case report of CT-guided lung biopsy complicated by air embolism

Rationale: Cerebral arterial air embolism is a rare but potentially fatal complication of Computed Tomography (CT)-guided lung biopsy. Hyperbaric oxygen (HBO2) is the first line of treatment for arterial gas embolism and needs to be administered immediately after the event. Early HBO2 can reduce the mortality rate of cerebrovascular air embolism. Patient concerns: A 65-year-old woman was diagnosed with a pulmonary nodule with a diameter of approximately 0.8 cm in the right lower lung. The patient developed consciousness, convulsions, and arrhythmia after CT-guided lung biopsy. Diagnosis: Cranial CT revealed arborizing/linearly distributed gas in the right temporal, parietal, and occipital lobes and left frontal and parietal lobes. Chest CT showed a small amount of pneumothorax. Interventions: The patient was administered HBO2 twice and also received other medical treatments and bone flap decompressive craniectomy. Outcomes: The patient developed multiple acute cerebral infarctions and even brain herniation complicated with acute myocardial infarction. Three months after the event, the patient’s consciousness was still “open eyes coma” and GCS score was 8t points (E4VtM4). Head CT showed multiple cerebral infarctions and softening lesions. ECG showed sinus rhythm, normal range of the electrocardiogram axis, T wave change, and low voltage on the limb leads. Lessons: Cerebral arterial air embolism is a serious complication of CT-guided lung biopsy. The recommended standard HBO2 should be used as early as possible. However, too severe injury caused by severe arterial air embolism may not be significantly improved by one to two sessions of HBO2.

Case report of CT-guided lung biopsy complicated by air embolism

Rationale: Cerebral arterial air embolism is a rare but potentially fatal complication of Computed Tomography (CT)-guided lung biopsy. Hyperbaric oxygen (HBO2) is the first line of treatment for arterial gas embolism and needs to be administered immediately after the event. Early HBO2 can reduce the mortality rate of cerebrovascular air embolism. Patient concerns: A 65-year-old woman was diagnosed with a pulmonary nodule with a diameter of approximately 0.8 cm in the right lower lung. The patient developed consciousness, convulsions, and arrhythmia after CT-guided lung biopsy. Diagnosis: Cranial CT revealed arborizing/linearly distributed gas in the right temporal, parietal, and occipital lobes and left frontal and parietal lobes. Chest CT showed a small amount of pneumothorax. Interventions: The patient was administered HBO2 twice and also received other medical treatments and bone flap decompressive craniectomy. Outcomes: The patient developed multiple acute cerebral infarctions and even brain herniation complicated with acute myocardial infarction. Three months after the event, the patient’s consciousness was still “open eyes coma” and GCS score was 8t points (E4VtM4). Head CT showed multiple cerebral infarctions and softening lesions. ECG showed sinus rhythm, normal range of the electrocardiogram axis, T wave change, and low voltage on the limb leads Lessons: Cerebral arterial air embolism is a serious complication of CT-guided lung biopsy. The recommended standard HBO2 should be used as early as possible. However, too severe injury caused by severe arterial air embolism may not be significantly improved by one to two sessions of HBO2.

Tension Pneumocephalus Caused by Ethmoidal Roof Fracture: Emergent Surgical Decompression.

Tension pneumocephalus is a neurosurgical emergency that occurs when air is trapped in the intracranial cavity, leading to brain compression and causing severe neurological symptoms such as decreases in motor function, sensory function, and consciousness. Most cases of pneumocephalus require conservative treatment; however, because of the possible fatal complications, rapid diagnosis and appropriate treatment are important. Here, we present the case of an 81-year-old male patient who had undergone head trauma three hours prior to being admitted to our emergency room (ER) because of mental cloudiness. The radiologic findings showed tension pneumocephalus caused by an ethmoidal roof fracture. Emergency reconstruction of the ethmoidal roof with craniotomy was performed to remove the intracranial air using normal saline irrigation. By sharing our experience with this case, we hope to provide an option for the treatment of such cases.

Evaluation of the outcome in ischemic stroke acute period

Introduction. As a major cause of both temporary and permanent disability, ischemic stroke is the most common type of cerebrovascular accident (CVA).
 Objective. To assess fatal outcome probability in the acute period of ischemic stroke.
 Materials and methods. We performed post-hoc analysis of the fatal outcome probability in the patients with acute ischemic stroke at the Neurology Department of the Ufa Emergency Hospital, the Republic of Bashkortostan, Russian Federation. The analysis included data from the randomly selected medical records of 31 patients with fatal outcomes and 55 patients discharged with favorable outcomes.
 Results. The patients with fatal outcomes were significantly (p 0.001) older, with more severe strokes and a higher prevalence of disorders of consciousness, medical co-morbidities, and recurrent strokes as compared to the group of patients with favorable outcomes. Regression coefficients showed that brain herniation, kidney and liver disease, post-infarction cardiosclerosis, diabetes mellitus, and atrial fibrillation were associated with a higher probability of the fatal outcome. Increased severity of disorders of consciousness, NIHSS and mRS scores, specific blood tests values, age, and heart rate were associated with a more probable fatal outcome, while elevated hemoglobin, total protein, red blood cells, and lymphocytes, a higher GCS score, and a history of hypotensive drug therapy were associated with a less probable fatal outcome.
 Multivariate analysis showed that the stroke fatal outcome was related with the age, a NIHSS score, and elevated creatinine and total bilirubin levels.
 Conclusion. The detected predictors of the stroke fatal outcome can be used as reference points to choose management strategy for patients in the acute period of ischemic stroke.

Ischemic Stroke Following Thrombolytic Therapy for Acute Inferior Myocardial Infarction: The Third Reported Case

Background: Ischemic stroke following thrombolysis for ST-segment elevation myocardial infarction(STEMI) is a rare and perplexing complication. We present an intriguing case of ischemic stroke following fibrinolytic therapy with tenecteplase for a STEMI.
 This is an extremely rare condition, and our case appears to be the third one reported in our departement. The three cases had one thing in common: ST-segment elevation in the inferior leads.
 Case Presentation: We describe the case of a 50-year-old north-african woman who suffered an acute inferior STEMI 6 hours after chest pain onset. Thrombolysis with tenecteplase was performed and few hours later an extensive right sylvian artery stroke occurred with subfalcine herniation.
 Decision-Making: The refractory intracranial hypertension despite medical therapy compelled a decompressive craniectomy. On the follow up, neurological deficits had increased, congestive heart failure developed, and finally the patient died on the tenth day in the intensive care unit.
 Conclusion: Hemorrhagic complications are not the only one, ischemic stroke can also occur after thrombolysis even if it is extremely odd. The pathophysiology is still poorly established.
 The prevalent implication of the inferior territory in the three cases described in the literature may open to future research prospects.

Case Report: Cerebral Edema and Tonsillar Herniation Leading to Brain Death After Cocaine Use in a Patient with End-Stage Renal Disease

The effect of cocaine use on the cerebral vasculature is well understood, with potential for ischemic or hemorrhagic stroke. The risk of adverse effects can be prolonged and amplified in patients with renal dysfunction and uremia. Uremia-induced osmotic gradients and upregulation of aquaporin channels along with cocaine-induced blood-brain barrier degradation may act synergistically. We present the first known case of a non-compliant dialysis patient who suffers cerebral edema, tonsillar herniation, and brain death following cocaine use. A 32-year-old female with end-stage renal disease presented with shortness of breath and flu-like symptoms for one week and was alert and oriented with no neurologic deficits. The patient had missed her last 5 dialysis treatments and labs revealed hyperkalemia and uremia. Urine drug screen was positive for cocaine, opiates, and tetrahydrocannabinol (THC). Following dialysis and metabolic correction, she developed an irregular respiratory pattern and stridor and received neck computed tomography (CT). The patient became unresponsive with dilated and nonreactive pupils. CT revealed absent intraluminal carotid and vertebral artery flow at the skull base, cerebellar tonsil herniation, and anoxic brain injury. Vital signs were maintained, and cerebral edema was managed with 45-degree head-of-bed elevation and mannitol. Following cerebral edema treatment, the patient had preserved respiratory drive, fixed and dilated pupils, no corneal reflex, no cough or gag reflex, and negative oculocephalic reflex. Repeat cranial CT angiography revealed bilateral hemispheric edema, basal subarachnoid hemorrhage, and confirmed absent intracranial blood flow. Brain death was diagnosed with a radioisotope cerebral blood flow study. The use of cocaine in patients with renal dysfunction may increase the risk of cerebral edema and tonsillar herniation due to synergistic physiologic effects. Physicians should be aware of this interaction to allow for preventative measures.

Acute dural venous sinus thrombosis in a child with idiopathic steroid-dependent nephrotic syndrome: a case report

Nephrotic syndrome (NS) is a hypercoagulable state in which children are at risk of venous thromboembolism. A higher risk has been reported in children with steroid-resistant NS than in those with steroid-sensitive NS. The mortality rate of cerebral venous sinus thrombosis (CVST) is approximately 10% and generally results from cerebral herniation in the acute phase and an underlying disorder in the chronic phase. Our patient initially manifested as a child with massive proteinuria and generalized edema. He was treated with albumin replacement and diuretics, angiotensin-converting enzyme inhibitor, and deflazacort. Non-contrast computed tomography showed areas of hyperattenuation in the superior sagittal sinus when he complained of severe headache and vomiting. Subsequent magnetic resonance imaging revealed empty delta signs in the superior sagittal, lateral transverse, and sigmoid sinuses, suggesting acute CVST. Immediate anticoagulation therapy was started with unfractionated heparin, antithrombin III replacement, and continuous antiproteinuric treatment. The current report describes a life-threatening CVST in a child with steroid-dependent NS, initially diagnosed by contrast non-enhanced computed tomography and subsequently confirmed by contrast-enhanced magnetic resonance imaging, followed by magnetic resonance venography for recanalization, addressing successful treatment.

Clinical Findings And Visual Pathway Disorders Due To Tumor, What MRI can be Found?

The 10th most common cause of mortality for both men and women is brain and other nervous system cancer. These tumors can cause serious ocular signs and symptoms as well as neurologic complications due to increased intracranial pressure, cranial nerve disturbances, or brain compression. CT and MRI are the modalities most commonly used to evaluate visual disturbances around the visual pathway. MRI is the preferred imaging modality for evaluating tumors because it does not use X-rays but uses a magnetic field, producing clearer images

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

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.

Decompressive craniectomy: Comparative analysis between surgical time and better prognosis.

Malignant ischemic stroke is characterized by the involvement of 2/3 of the area of the middle cerebral artery, associated with cerebral edema, intracranial hypertension (ICH) and cerebral herniation, generating high morbidity and mortality. Over the years, several therapies have been studied in an attempt to reverse or reduce the damage caused by this vascular disorder, including decompressive craniectomy (DC), a surgical technique reserved for cases that evolve with refractory ICH. This study seeks to perform a comparative analysis on the effectiveness of decompressive craniectomy using four randomized clinical trials and the results found in the retrospective study conducted in a neurosurgical reference center between 2010 and 2018. The total sample consisted of 263 patients, among which 118 were randomized and 145 were part of the retrospective study. The outcome was analyzed based on the modified Rankin Scale (mRS) for 6 and 12 months. The mean time to perform the DC was 28.4 h in the randomized trials, with the late approach (> 24 h) associated with unfavorable outcomes (mRS between 4 and 6). Compared to the aforementioned studies, the study by Bem Junior et al. shows that a surgical approach in < 12 h had a better outcome, with 70% of the patients treated early classified as mRS 2 and 3 at the end of 12 months (1). Decompressive craniectomy is currently the most effective measure to control refractory ICH in cases of malignant ischemic stroke, and the most appropriate approach before surgery is essential for a better prognosis for patients.