Malignant Middle Cerebral Artery Infarction Research Articles

Decompressive craniotomy for the treatment of malignant infarction of the middle cerebral artery: mortality and outcome.

To assess, by Rankin scale, the functional disability of patients who had a malignant middle cerebral artery (MCA) ischemic stroke, who underwent decompressive craniotomy (DC) within the first 30 days. A cross-sectional study in a University hospital. Between June 2007 and December 2014, we retrospectively analyzed the records of all patients submitted to DC due to a malignant MCA infarction. The mortality rate was defined during the hospitalization period. The modified outcome Rankin score (mRS) was measured 30 days after the procedure, for stratification of the quality of life. The DC mortality rate was 30% (95% CI 14.5 to 51.9) for the 20 patients reported. The mRS 30 days postoperatively was ≥ 4 [3.3 to 6] for all patients thereafter. DC is to be considered a real alternative for the treatment of patients with a malignant ischemic MCA infarction.

Role and Assessment of Outcome of Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarction in Patients: A Hospital Based Retrospective Study

Role and Assessment of Outcome of Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarction in Patients: A Hospital Based Retrospective Study

A Retrospective Cohort Study to Assess Patient and Physician Reported Outcome Measures After Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke.

IntroductionDecompressive hemicraniectomy for malignant middle cerebral artery (MCA) infarction is known to reduce mortality. However, there are on-going concerns in terms of the quality of life in survivors. We aimed to examine the correlation between patient and physician reported outcome measures in decompressive hemicraniectomy.Patients and methodsWe analyzed outcomes in 21 patients who underwent decompressive hemicraniectomy for malignant MCA infarction between September 2003 and August 2013 within a regional health system. Patient and physician reported outcome measures were collected at follow-up. These were Stroke Impact Scale (SIS) Version 3, modified Rankin Scale (mRS), National Hospital Seizure Severity Scale, Headache Impact Test and Patient Health Questionnaire for depression.ResultsThere was a good correlation between physician and patient reported outcome measures. The Spearman's rank correlation coefficient between mRS and structured SIS Version 3 was -0.887 (p < 0.001); with unstructured SIS results, the correlation coefficient was -0.663 (p = 0.001). There was no statistically significant correlation between life worth and modified Rankin Scale: r = -0.3383 (p = 0.087).DiscussionOur findings of a statistically significant correlation between mRS and SIS have not previously been reported in patients with this condition. These findings provide further information to inform patient and next of kin discussions regarding outcomes from decompressive hemicraniectomy in malignant MCA infarction.

Early Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction: A single centre retrospective study (P4.290)

Early Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction: A single centre retrospective study (P4.290)

High Risk of Seizures and Epilepsy after Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke

Background: Decompressive hemicraniectomy (DHC) is a life-saving procedure for treatment of large malignant middle cerebral artery (MCA) strokes. Post-stroke epilepsy is an additional burden for these patients, but its incidence and the risk factors for its development have been poorly investigated. Objective: To report the prevalence and risk factors for post-stroke seizures and post-stroke epilepsy after DHC for treatment of large malignant MCA strokes in a cohort of 36 patients. Methods: In a retrospective cohort study of 36 patients we report the timing and incidence of post-stroke epilepsy. We analyzed if age, sex, vascular risk factors, side of ischemia, reperfusion therapy, stroke etiology, extension of stroke, hemorrhagic transformation, ECASS scores, National Institutes of Health Stroke Scale (NIHSS) scores, or modified Rankin scores were risk factors for seizure or epilepsy after DHC for treatment of large MCA strokes. Results: The mean patient follow-up time was 1,086 days (SD = 1,172). Out of 36 patients, 9 (25.0%) died before being discharged. After 1 year, a total of 11 patients (30.6%) had died, but 22 (61.1%) of them had a modified Rankin score ≤4. Thirteen patients (36.1%) developed seizures within the first week after stroke. Seizures occurred in 22 (61.1%) of 36 patients (95% CI = 45.17–77.03%). Out of 34 patients who survived the acute period, 19 (55.9%) developed epilepsy after MCA infarcts and DHC (95% CI = 39.21–72.59%). In this study, no significant differences were observed between the patients who developed seizures or epilepsy and those who remained free of seizures or epilepsy regarding age, sex, side of stroke, presence of the clinical risk factors studied, hemorrhagic transformation, time of craniectomy, and Rankin score after 1 year of stroke. Conclusion: The incidence of seizures and epilepsy after malignant MCA infarcts submitted to DHC might be very high. Seizure might occur precociously in patients who are not submitted to anticonvulsant prophylaxis. The large stroke volume and the large cortical ischemic area seem to be the main risk factors for seizure or epilepsy development in this subtype of stroke.

Malignant infarction of the middle cerebral artery in a porcine model. A pilot study.

Background and purposeInterspecies variability and poor clinical translation from rodent studies indicate that large gyrencephalic animal stroke models are urgently needed. We present a proof-of-principle study describing an alternative animal model of malignant infarction of the middle cerebral artery (MCA) in the common pig and illustrate some of its potential applications. We report on metabolic patterns, ionic profile, brain partial pressure of oxygen (PtiO2), expression of sulfonylurea receptor 1 (SUR1), and the transient receptor potential melastatin 4 (TRPM4).MethodsA 5-hour ischemic infarct of the MCA territory was performed in 5 2.5-to-3-month-old female hybrid pigs (Large White x Landrace) using a frontotemporal approach. The core and penumbra areas were intraoperatively monitored to determine the metabolic and ionic profiles. To determine the infarct volume, 2,3,5-triphenyltetrazolium chloride staining and immunohistochemistry analysis was performed to determine SUR1 and TRPM4 expression.ResultsPtiO2 monitoring showed an abrupt reduction in values close to 0 mmHg after MCA occlusion in the core area. Hourly cerebral microdialysis showed that the infarcted tissue was characterized by reduced concentrations of glucose (0.03 mM) and pyruvate (0.003 mM) and increases in lactate levels (8.87mM), lactate-pyruvate ratio (4202), glycerol levels (588 μM), and potassium concentration (27.9 mmol/L). Immunohistochemical analysis showed increased expression of SUR1-TRPM4 channels.ConclusionsThe aim of the present proof-of-principle study was to document the feasibility of a large animal model of malignant MCA infarction by performing transcranial occlusion of the MCA in the common pig, as an alternative to lisencephalic animals. This model may be useful for detailed studies of cerebral ischemia mechanisms and the development of neuroprotective strategies.

National Survey of Neurosurgeons and Stroke Physicians on Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction.

Several studies have evaluated the use of decompressive hemicraniectomy (DHC) in malignant middle cerebral artery infarction (MMCAI). In the United Kingdom, the National Institute for Health and Care Excellence (NICE) has set criteria for selection of patients for DHC in MMCAI. We set out to survey the attitudes and practice of neurosurgeons and stroke physicians within the United Kingdom towards DHC in MMCAI. An electronic survey of questions on management of MMCAI in various clinical scenarios was submitted to the academic committees of the Society of British Neurological Surgeons and the British Association of Stroke Physicians for approval before dissemination through the consultant members. Responses were collected over 2 months. A total of 78 responses, from 51 neurosurgeons and 27 stroke physicians, were included in final analysis. Atotal of 54% and 24% of all respondents would recommend DHC in patients aged 60-70 and 70-80 years, respectively; 60% would advocate surgery between 48 and 72 hours and 27% beyond 72 hours. A total of 36% indicated DHC with preoperative Glasgow Coma Scale 15/15. These findings do not conform to current NICE guidelines. Stroke physicians were statistically more likely to recommend DHC in patients older than 60 years (P= 0.032) and in those with dominant multiterritorial infarcts (P= 0.042) and accept a greater postoperative modified Rankin Scale (P= 0.034) compared with neurosurgeons. In view of evidence from recent trials and differences in NICE guidelines and current clinical practice within the United Kingdom, based on our survey results, it is important to reevaluate NICE guidelines.

Abstract TP316: Early Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction in Asian Patients

Background and purpose: Decompression craniectomy in acute malignant middle cerebral artery (MCA) ischemic stroke (IS) reduces mortality. However, its role in reducing disability in this group of patients is often questioned in the stroke community since previous studies have employed variable time intervals for surgical decompression as well as criteria for defining severe disability. We evaluated our Asian cohort of acute IS patients for determining the factors associated with favorable functional outcome. Methods: Data for all acute IS patients hospitalized to our tertiary center were entered into a prospectively maintained registry. In this retrospective analysis, data for all malignant MCA IS patients who underwent decompressive hemicraniectomy were extracted. Various demographic, clinical and neuroimaging factors were analyzed for identifying independent predictors of favorable functional outcome at 6 months, which was defined as modified Rankin Scale of 0-3. Results: From January 2005 to December 2014, a total of 75 patients with anterior circulation IS underwent decompressive hemicraniectomy. Median age was 55 years (IQR 44-64) with male preponderance (66%) and median NIH Stroke Scale (NIHSS) score 21 points (IQR 18-24). Considerable proportion of them (60%) received intravenous thrombolysis with tissue plasminogen activator (IV-tPA). Majority (70%) of patients suffered from acute right MCA IS and median time from symptom-onset to surgery was 31 hours (range18-51). Decompressive surgery was performed within 48 hours of symptom-onset in 50 (67%) of the patients. Favorable functional outcome was achieved by 25 (33.3%) patients at 6 months. Right sided stroke (OR 5.333; 95% CI 1.359- 20.927, p=0.016 ) and early decompression surgery (performed within 48 hours from symptom-onset (OR 3.636; 95% CI 1.032- 12.809, p=0.045 ) were independent predictors of favorable functional outcome at 6 months. Conclusion: Early decompression craniectomy, especially in right MCA ischemic stroke is associated with better favorable functional outcome at 6 months.

Functional Outcome After Decompressive Craniectomy in Patients with Dominant or Non-Dominant Malignant Middle Cerebral Infarcts.

Background: The use of decompressive craniectomy (DC) has been studied in the setting of different conditions, including traumatic brain injury, subarachnoid hemorrhage, and malignant middle cerebral artery (MCA) infarction. The rationale of this study is to determine the functional outcome after DC in patients with malignant MCA infarcts.Methods: A longitudinal cohort study was performed based on patients diagnosed with malignant MCA territory infarction admitted to the Neurosurgery Department of a tertiary care hospital in Islamabad, Pakistan between July 2015 and November 2016. All patients had a clinical diagnosis of stroke according to the World Health Organization (WHO) stroke criteria.Results: A total of 34 patients participated in this study, out of which 20/31 (64.5%) were males while 11/31 (35.5%) were females with a mean age of 51.61 ± 13.96 years. The mean time from diagnosis to surgery was 60.61 ± 49.83 hours. Out of 31 patients, 18 (58.1%) had a right middle cerebral artery infarct (RMCAI) and 13 (41.9%) had a left middle cerebral artery infarct (LCAI). Logistic regression was applied to assess the association between the type of MCA infarct with the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), modified Barthel Index (mBI) scores, and upper and lower limb motor power. However, the logistic regression model was not statistically significant χ2 (4) = 3.896, p = 0.866. There was a statistically significant mild improvement of neurological scores and upper and lower motor power over a course of six months, but the overall functional outcome was poor with mBI < 60 and mRS > 4 (p < 0.001) with total mortality of 8.7%.Conclusion: Decompressive craniectomy is a life-saving surgery that appears to benefit patients with malignant MCA infarcts of either the dominant or non-dominant cerebral hemisphere. Decompressive craniectomy results in mild improvements in neurological scores but still poor functional outcome after six months.

Chapter 16 - Decompressive craniectomy in acute brain injury

Decompressive surgery to reduce pressure under the skull varies from a burrhole, bone flap to removal of a large skull segment. Decompressive craniectomy is the removal of a large enough segment of skull to reduce refractory intracranial pressure and to maintain cerebral compliance for the purpose of preventing neurologic deterioration. Decompressive hemicraniectomy and bifrontal craniectomy are the most commonly performed procedures. Bifrontal craniectomy is most often utilized with generalized cerebral edema in the absence of a focal mass lesion and when there are bilateral frontal contusions. Decompressive hemicraniectomy is most commonly considered for malignant middle cerebral artery infarcts. The ethical predicament of deciding to go ahead with a major neurosurgical procedure with the purpose of avoiding brain death from displacement, but resulting in prolonged severe disability in many, are addressed. This chapter describes indications, surgical techniques, and complications. It reviews results of recent clinical trials and provides a reasonable assessment for practice.

Comparison of the decompressive surgery and medical therapy alone results in malignant middle cerebral artery infarction

Comparison of the decompressive surgery and medical therapy alone results in malignant middle cerebral artery infarction

Efficacy and Safety of Using N-Butyl Cyanoacrylate in Cranial Fixation Following Trauma and Other Pathologies.

Skull bone fixation following different cranial surgeries is essential and should be rigid, simple and cheap. We describe our technique of cranial fixation using the adhesive cyanoacrylates. At the end of cranial and intracranial surgeries the craniotomy flap and bone pieces are returned, realigned and fixed using HistoacrylŽ (N-Butyl Cyanoacrylate) glue. The glue is applied all around the flap in 360-degree fashion. The adhesive material was used in 24 cases after different surgeries involving the calvaria of the skull. Patient age ranged from 1 month to 55 years. Seven cases presented with depressed fractures, 5 traumatic hematomas, and 2 cases after decompressive craniotomies for malignant middle cerebral artery (MCA) infarctions, and 10 cases operated for brain tumors. No skin or bone flap infections were encountered during the follow up period and fusion of the edges of bone flap was observed on follow-up imaging in most of the cases. Skull bone realignment and fixation using glue is a simple, safe, and inexpensive method. The operative procedure was not prolonged. Good cosmetic appearance and realignment and fusion of the bone flap were achieved. Further neuroimaging methods are not prohibited. Glue is suitable for the growing skull of children. Glue is also suitable in compound depressed fractures of the skull with possibility of infection.

Attitudes of Patients and Relatives Toward Disability and Treatment in Malignant MCA Infarction.

Attitudes among patients and relatives toward the degree of acceptable disability and the importance of aphasia are critical in deciding on decompressive hemicraniectomy (DHC) in malignant middle cerebral artery infarction (MMI). However, most MMI patients are not able to communicate their will. Furthermore, attitudes of healthy individuals and relatives may not correspond to those of stroke patients. This is a multicenter survey among 355 patients and 199 relatives during treatment for acute minor or moderate severe ischemic stroke in Germany. Questions address the acceptance of disability, importance of aphasia, and the preferred treatment in the hypothetical case of future MMI. mRS scores of 2 or better were considered acceptable by the majority of all respondents (72.9-88.1%). A mRS of 3, 4, and 5 was considered acceptable by 56.0, 24.5, and 6.8%, respectively. Except for a mRS of 1, relatives indicated each grade of disability significantly more often acceptable than patients. Differences regarding acceptable disability and treatment decision were depending on family status, housing situation, need of care, and disability. The presence of aphasia was considered important for treatment decision by both patients (46.5%) and relatives (39.2%). Older respondents more often refrained from DHC (p<0.001). In Germany, there is substantial heterogeneity in patients and relatives regarding acceptable disability, aphasia, and treatment decision in the hypothetical case of MMI. Relatives significantly overestimate the degree of disability that is acceptable to stroke patients. Further studies are warranted to determine whether differences in attitudes impact on the decision to undergo DHC.

Impact of timing of cranioplasty on hydrocephalus after decompressive hemicraniectomy in malignant middle cerebral artery infarction

ObjectivePatients with malignant middle cerebral artery infarction frequently develop hydrocephalus after decompressive hemicraniectomy. Hydrocephalus itself and known shunt related complications after ventriculo-peritoneal shunt implantation may negatively impact patientś outcome. Here, we aimed to identify factors associated with the development of hydrocephalus after decompressive hemicraniectomy in malignant middle cerebral artery infarction. Patients and methodsA total of 99 consecutive patients with the diagnosis of large hemispheric infarctions and the indication for decompressive hemicraniectomy were included. We retrospectively evaluated patient characteristics (gender, age and selected preoperative risk factors), stroke characteristics (side, stroke volume and existing mass effect) and surgical characteristics (size of the bone flap, initial complication rate, time to cranioplasty, complication rate following cranioplasty, type of implant, number of revision surgeries and mortality). ResultsFrequency of hydrocephalus development was 10% in our cohort. Patients who developed a hydrocephalus had an earlier time point of bone flap reimplantation compared to the control group (no hydrocephalus=164±104days, hydrocephalus=108±52days, p<0.05). Additionally, numbers of revision surgeries after cranioplasty was associated with hydrocephalus with a trend towards significance (p=0.08). ConclusionCommunicating hydrocephalus is frequent in patients with malignant middle cerebral artery infarction after decompressive hemicraniectomy. A later time point of cranioplasty might lead to a lower incidence of required shunting procedures in general as we could show in our patient cohort.

The prediction of prognosis of malignant middle cerebral artery infarction by multimodular neurological function monitoring

The prediction of prognosis of malignant middle cerebral artery infarction by multimodular neurological function monitoring

Reduction of Midline Shift Following Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction.

Background and PurposeHemicraniectomy is a decompressive surgery used to remove a large bone flap to allow edematous brain tissue to bulge extracranially. However, early indicators of the decompressive effects of hemicraniectomy are unclear. We investigated whether reduction of midline shift following hemicraniectomy is associated with improved consciousness and survival in patients with malignant middle cerebral artery infarctions.MethodsWe studied 70 patients with malignant middle cerebral artery infarctions (MMI) who underwent hemicraniectomies. Midline shift was measured preoperatively and postoperatively using computed tomography (CT). Consciousness level was evaluated using the Glasgow Coma Scale on postoperative day 1. Patient survival was assessed six months after stroke onset.ResultsThe median time interval between preoperative and postoperative CT was 8.3 hours (interquartile range, 6.1–10.2 hours). Reduction in midline shift was associated with higher postoperative Glasgow Coma Scale scores (P<0.05). Forty-three patients (61.4%) were alive at six months after the stroke. Patients with reductions in midline shifts following hemicraniectomy were more likely to be alive at six months post-stroke than those without (P<0.001). Reduction of midline shift was associated with lower mortality at six months after stroke, after adjusting for age, sex, National Institutes of Health Stroke Scale score, and preoperative midline shift (adjusted hazard ratio, 0.71; 95% confidence interval, 0.62–0.81; P<0.001).ConclusionsReduction in midline shift following hemicraniectomy was associated with improved consciousness and six-month survival in patients with MMI. Hence, it may be an early indicator of effective decompression following hemicraniectomy.

10-Year Institutional Retrospective Case Series of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction (mMCAI)

A 10-year (2005-2015) retrospective case series of patients undergoing decompressive craniectomy for malignant middle cerebral artery infarction (mMCAI) was undertaken. Patient demographics, comorbidities, pre- and postoperative neurologic state, operative timescales, craniectomy dimensions, and Glasgow Outcome Scale scores were analyzed. Overall 40 patients underwent a decompressive craniectomy for mMCAI with a 30-day mortality of 17.5% (n= 7). Seventeen patients (42.5%) were male, with a mean age of 43 years (range: 16-64 years). Patients who survived had a lower mean age of 41 years (range: 16-59 years) than those who did not of 50 years (range: 42-63 years). The modal ictal and preoperative Glasgow Coma Scale scores were 14 (range: 5-15) and 7 (range: 3-12), which corresponded to motor scores of 6 and 5, respectively. The mean time from ictus to admission to the Institute of Neurological Sciences (INS) was 23.5 hours (range: 0.5-66 hours) and from INS admission to decompression 7.5 hours (range: 0.5-46 hours). Approximately 60% of patients had an "early" craniectomy (under 48 hours from ictus) and 60% of patients had a craniectomy performed less than 24 hours from INS admission. The mean maximum anteroposterior craniectomy diameter measured 13 cm (range: 10.93-15.12 cm) and the mean surface area was 92.68 cm2 (range: 76.14-124.42 cm2). Overall 80% of patients had a modal Glasgow Outcome Scale score of 3 (range: 2-5) at discharge, 3 months, 6 months, 9 months, and 12 months. The median length of stay was 3 days (range: 6hours to 11 days) for nonsurvivors and 13 days (range: 1-365 days) for survivors. Decompressive craniectomy for mMCAI is suitable in selected patients, and the local practice is consistent with current evidence.

Association Between Prolonged Seizures and Malignant Middle Cerebral Artery Infarction in Children With Acute Ischemic Stroke

BackgroundMalignant middle cerebral artery infarct syndrome is a potentially fatal complication of stroke that is poorly understood in children. We studied the frequency, associated characteristics, and outcomes of this condition in children. MethodsChildren, aged two months to 18 years with acute middle cerebral artery infarct diagnosed at our center between January 2005 and December 2012 were studied. Associations with malignant middle cerebral artery infarct syndrome were sought, including age, seizures, neurological deficit severity (Pediatric National Institute of Health Stroke Severity Score), stroke etiology, fever, blood pressure, blood glucose, infarct location, infarct volume (modified pediatric Alberta Stroke Program Early Computed Tomography Score), and arterial occlusion. Death and neurological outcomes were determined. ResultsAmong 66 children with middle cerebral artery stroke, 12 (18%) developed malignant middle cerebral artery infarct syndrome, fatal in three. Prolonged seizures during the first 24 hours (odds ratio, 25.51; 95% confidence interval, 3.10 to 334.81; P = 0.005) and a higher Pediatric National Institute of Health Stroke Severity Score (odds ratio, 1.22; 95% confidence interval, 1.08 to 1.45; P = 0.006) were independently associated with malignant middle cerebral artery infarct syndrome. All children aged greater than two years with a Pediatric National Institute of Health Stroke Severity Score ≥8 and initial seizures ≥5 minutes duration developed malignant middle cerebral artery infarct syndrome (100%). ConclusionsMalignant middle cerebral artery infarct syndrome affects nearly one in five children with acute middle cerebral artery stroke. Children with higher Pediatric National Institute of Health Stroke Severity Scores and prolonged initial seizures are at greatly increased risk for malignant middle cerebral artery infarct syndrome. Children with middle cerebral artery infarcts warrant intensive neuroprotective management and close monitoring to enable early referral for hemicraniectomy surgery.

Decompressive Hemicraniectomy in Malignant Middle Cerebral Artery Infarction: The ‘Real World' Beyond Studies

Background: Decompressive hemicraniectomy (DHC) is life-saving in patients with malignant middle cerebral artery infarction (MMI), but outcome, perspectives and complications after DHC in daily practice are largely unknown. Methods: From 2008 until 2014, we extracted patient's characteristics as well as complications from our database for patients with MMI who underwent DHC. Additionally, we analysed medical records from the different rehabilitation steps. Results: We identified 48 consecutive patients (mean 57 years, 21 male, 41.7% >60 years) with MMI who underwent DHC. The decision for DHC was made on an individual basis, including patients without impaired consciousness or stroke onset >48 h. In-hospital patients achieved only marginal clinical improvement. Seventy-five percent attended an early-rehabilitation, 44% achieved post-stroke rehabilitation and 6% carried on late-stage rehabilitation. In all, 45.5% returned home after rehabilitation. In-hospital mortality was 14.6%, overall mortality was 16.7%. Surviving patients (78.9%) had a modified Rankin Scale of 4-5. Frequent neurologic complications were symptomatic epilepsy and delirium. Following DHC/bone-flap-reimplantation, wound-healing disorders, epidural hematoma and wound infections were major surgery-related complications. Pulmonary infections were frequent in the acute-phase and urinary tract infections were predominant in the late-phase. Conclusions: DHC is a life-saving technique in patients with MMI, but complications are frequent, were underestimated in randomized clinical trials and may worsen the functional outcome.

Malignant Middle Cerebral Artery Infarction Secondary to Traumatic Bilateral Internal Carotid Artery Dissection. A Case Report

Traumatic bilateral dissection of the carotid arteries is a rare condition with potentially life-threatening complications. The case of a 57-year-old male patient with acute onset left sided hemiparesis, twelve hours after a blunt head injury, caused by a horse kick, is reported. A cerebral CT scan revealed right middle cerebral artery (MCA) territory infarction. Based on Duplex ultrasound and Angio CT scan findings, a diagnosis of bilateral ICA dissection was established. Despite antithrombotic treatment, the patient presented with a progressive worsening of his neurological status. The control CT scan evidenced malignant right MCA territory infarction that required decompressive craniotomy. The patient was discharged with significant neurological deficits. Together with this case, the aetiologies, clinical manifestations, diagnostic and therapeutical options and outcome of carotid artery dissection are discussed.