Malignant Middle Cerebral Artery Syndrome Research Articles

Abstract TMP9: Covid-19 Increases The Risk Of Malignant Middle Cerebral Artery Infarction In Acute Stroke

Introduction: Stroke as a presenting feature of COVID-19 infection is being increasingly recognized. The prevalence of malignant middle cerebral artery syndrome (MMC) in acute stroke associated with COVID-19 is yet unknown. Methods: This is a retrospective cohort study of ischemic stroke patients admitted in a health center in Brazil. We investigated the prevalence of malignant middle cerebral artery syndrome in COVID-19 and associated stroke patients. Results: We included 881 ischemic stroke patients (53% male). COVID-19 patients represented 5.3% (N = 47). Mean age was 65.6 years (SD 13.2). COVID-19 patients were significantly younger (mean: 61.4 years; SD: 13.5; p = 0.025) and disclosed a higher odds of previous ischemic heart disease (OR: 4.1 - CI: 1.98-8.16). The frequency of main stroke risk factors was similar for both groups. COVID-19 patients had significantly higher NIHSS (11 points vs 8.2 in non-Covid-19 group - p = 0.006). MMC occurred more frequently in COVID-19 patients (19.5% vs 4.1% of non-covid-19 group - p < 0.001) (Risk ratio: 5.1; CI: 2.63-10.01 - p < 0.001). COVID-19 stroke patients had a longer hospital stay (p < 0.001) and disclosed a higher risk for in-hospital infection (Risk ratio: 4.3 - CI: 2.47-7.53). Rankin scale at 90 days was significantly higher for COVID-19 patients (p <0.001). Case-fatality was higher among COVID-19 stroke patients (49.4% vs 2.5% in non-covid-19 group; p < 0.0001). Among those patients with MMC, the lethality was significantly higher among COVID-19 patients (66.6% vs 41.3% in non-covid-19 group; p< 0.0001). Multivariate logistic regression with MMC as outcome and adjusted for age, sex, NIHSS and comorbidity index, disclosed COVID-19 infection as the main independent preditor for MMC (OR: 6.3 - CI: 2.26-17.52 - p < 0.0001 - adjusted R2 = 0.2623). Conclusion: In this cohort study, COVID-19 infection was an independent predictor for malignant middle cerebral artery syndrome in ischemic stroke.

Malignant middle cerebral artery syndrome with thrombotic thrombocytopenia following vaccination against SARS-CoV-2.

Cases of thromboses at unusual sites with thrombocytopenia have been reported following vaccination against Sars-CoV-2. This new syndrome, christened vaccine-induced thrombotic thrombocytopenia (VITT), mainly results in venous thromboses. We report the case of a young woman with a right middle cerebral artery stroke following vaccination with ChAdOx1 nCoV-19. A diagnosis of VITT was made and platelet counts began to recover shortly after commencing treatment with argatroban, intravenous immunoglobulins and corticosteroids. On day 6 following admission, the patient deteriorated neurologically and decision made to proceed with decompressive hemicraniectomy. There were no perioperative complications and anticoagulation with argatroban was reinitiated on the first postoperative day. VITT is a rare condition resembling auto-immune heparin-induced thrombocytopenia. All critical care staff should be aware of the rare link between vaccination against SARS-CoV-2 and VITT and the need to rapidly commence both anticoagulation, using heparin alternatives, and immunomodulation.

Hemicraniectomy for Malignant Middle Cerebral Artery Syndrome: A Review of Functional Outcomes in Two High-Volume Stroke Centers

Despite recent landmark randomized controlled trials showing significant benefits for hemicraniectomy (HCT) compared with medical therapy (MT) in patients with malignant middle cerebral artery infarction (MMCAI), HCT rates have not substantially increased in the United States. We sought to evaluate early outcomes in patients with MMCAI who were treated with HCT (cases) in comparison to patients treated with MT due to the perception of procedural futility by families (controls). We retrospectively evaluated consecutive patients with acute MMCAI treated in 2 tertiary care centers during a 7-year period. Pretreatment National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 3 months were documented. Functional independence (FI) and survival without severe disability (SWSD) were defined as mRS of 0-2 and 0-4, respectively. A total of 66 patients (37 cases and 29 controls) fulfilled the study inclusion criteria (mean age 59 ± 15 years, 52% men, median admission NIHSS score: 19 points [interquartile range {IQR}: 16-22]). Cases were younger (51 ± 11 versus 68 ± 13 years; P < .001) and tended to have lower median admission NIHSS than controls (18 [IQR:16-20] versus 20 [IQR:18-23]; P = .072). The rates of FI and SWSD at 3 months were higher in cases than controls (16% versus 0% [P = .031] and 62% versus 0% [P < .001]), while 3-month mortality was lower (24% versus 77%; P < .001). Multivariable Cox regression analyses adjusting for potential confounders identified HCT as the most important predictor of lower risk of 3-month mortality (hazard ratio: .02, 95% confidence interval: .01-0.10; P < .001). HCT is a critical and effective therapy for patients with MMCAI but cannot provide a guarantee of functional recovery.

Efficacy of decompressive craniectomy in the management of intracranial pressure in severe traumatic brain injury.

Traumatic brain injury (TBI) is a common cause of permanent disability for which clinical management remains suboptimal. Elevated intracranial pressure (ICP) is a common sequela following TBI leading to death and permanent disability if not properly managed. While clinicians often employ stepwise acute care algorithms to reduce ICP, a number of patients will fail medical management and may be considered for surgical decompression. Decompressive craniectomy (DC) involves removing a component of the bony skull to allow cerebral tissue expansion in order to reduce ICP. However, the impact of DC, which is performed in the setting of neurological instability, ongoing secondary injury, and patient resuscitation, has been challenging to study and outcomes are not well understood. This review summarizes historical and recent studies to elucidate indications for DC and the nuances, risks and complications in its application. The pathophysiology driving ICP elevation, and the corresponding medical interventions for their temporization and treatment, are thoroughly described. The current state of DC - including appropriate injury classification, surgical techniques, concurrent medical therapies, mortality and functional outcomes - is presented. We also report on the recent updates from large randomized controlled trials in severe TBI (Decompressive Craniectomy [DECRA] and Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of ICP [RESCUEicp]), and recommendations for early DC to treat refractory ICP elevations in malignant middle cerebral artery syndrome. Limitations for DC, such as the equipoise between immediate reduction in ICP and clinically meaningful functional outcomes, are discussed in support of future investigations.

053Decompressive Craniectomy for Malignant Middle Cerebral Artery Syndrome: The Irish Experience

053Decompressive Craniectomy for Malignant Middle Cerebral Artery Syndrome: The Irish Experience

Clinical and Radiological Predictors of Malignant Middle Cerebral Artery Infarction Development and Outcomes

Optic nerve sheath diameter (ONSD) can predict intracranial hypertension and outcomes in severe traumatic brain injury. Its utility in middle cerebral artery (MCA) stroke is unknown. We reviewed serial radiological measurements, including ONSD, in patients with MCA stroke undergoing decompressive craniectomy (DC) for malignant MCA syndrome and compared demographic, clinical, and radiological data with an age- and gender-matched group of nonmalignant MCA stroke patients. Patients admitted to a large tertiary hospital in London, UK, between April 2012 and October 2016 with MCA infarction were identified through 2 data sources. We quantified ONSD, eyeball transverse diameter (ETD), ONSD/ETD ratio, midline shift (MLS), and infarct volume on computed tomography (CT). We identified 19 patients (mean age = 49.8 years [standard deviation = 12.5]) with malignant MCA stroke and 19 patients (47.8 years [16.0]) with nonmalignant MCA stroke. Mean ONSD, ONSD/ETD ratio, MLS, and infarct volume on initial CT all significantly increased after developing malignant MCA syndrome and decreased (except infarct volume, which increased) following DC (all Ps <.05). ONSD and ONSD/ETD ratios in the malignant group did not correlate with functional outcomes but were significantly higher on initial CT compared with the nonmalignant group (mean ONSD: 5.66 mm [.6] versus 4.97 mm [.5], P = .001; mean ONSD/ETD ratio: .25 [.03] versus .22 [.02], P = .002). ONSD, ONSD/ETD ratio, MLS, and infarct volume change dynamically in patients with malignant MCA infarction who undergo DC. An ONSD of more than 5.25 mm and an ONSD/ETD ratio of more than .232 on initial CT may identify MCA stroke patients at high risk of developing malignant MCA syndrome.

Abstract TP433: Early Decompressive Hemicraniectomy Optimizes Highest Rehabilitation Potential in Patients With Acute Malignant Middle Cerebral Artery Syndromes

Objectives: Early decompressive hemicraniectomy in malignant middle cerebral artery (MCA ) syndrome is shown to improve long term clinical outcomes in patients. Longer hospitalization and ventilator days expose patients to increased risk of complications. We explore pertinent short term clinical predictors for the highest potential of functional recovery with acute rehabilitation in patients who present with malignant MCA syndromes requiring decompressive hemicraniectomy. Methods: This is a retrospective review of 53 patients from 2008-2013 on patients with acute ischemic malignant MCA strokes who underwent decompressive hemicraniectomy. We quantified midline shifts on brain imaging obtained prior to surgery. The primary objective was identifying patient factors leading to acute rehabilitation compared to other discharge outcomes including long term acute care facilities (LTAC), subacute nursing facilities (SNF), or expiration. Results: See Table. Conclusions: Younger patients presenting with malignant MCA syndromes receiving decompressive hemicraniectomies at smaller midline shifts are observed to achieve less ventilator days, reduced hospital length of stay and discharge with optimal rehabilitation potential.

Management of the Malignant Middle Cerebral Artery Syndrome

The malignant middle cerebral artery syndrome, characterized by cerebral edema following large anterior circulation ischemic stroke, is a disease entity with high morbidity and mortality that is easy to recognize, but challenging to manage. In this review, we begin by discussing important aspects of the clinical presentation of the syndrome, including risk factors for deterioration. We then discuss medical measures that can be undertaken before symptomatic cerebral edema occurs and then outline both medical and surgical options for subsequent neurologic worsening. Shared decision making with patients' surrogates regarding decompressive craniectomy in the setting of available clinical trial data is addressed. The authors conclude with a brief discussion of promising novel therapies for preventing cerebral edema.

Decompressive surgery for malignant middle cerebral artery syndrome

Decompressive craniectomy has been considered the most attractive option for surgical treatment of malignant middle cerebral artery (MCA) infarction. We retrospectively reviewed the clinical and radiological records of 78 patients with malignant MCA infarction who underwent decompressive craniectomy with dura augmentation over a 6-year period. Twenty-six patients had undergone additional anterior temporal resection during decompressive craniectomy. The overall mortality at 30days after surgery was 25.6% while the mortality rate at 6months after surgery was 30.8%. At 6months after surgery, 30.8% of the patients were considered to have good outcomes, while 69.2% had a poor outcome (16.7% suffered from severe disability, 21.8% remained in a vegetative state, and 30.8% died). Ipsilateral surgery was performed on 48 patients with infarction on the dominant side and on 30 patients with lesions on the non-dominant side. No significant difference was noted between these two groups at the 30-day mortality rate. Although no patient with an infarction on the dominant side recovered effective verbal ability during the 6months of follow-up, there was no significant difference between the two groups in clinical outcome at 6months after surgery. The 30-day survival rate in the 26 patients who underwent additional anterior temporal lobectomy was significantly higher (84.6%) than that in patients who underwent decompressive craniectomy and duroplasty only (69.2%) (p<0.05). However, in patients who survived, this additional procedure does not appear to improve the functional outcome.

High diastolic blood pressure is a risk factor for in-hospital mortality in complete MCA stroke patients

Complete middle cerebral artery (MCA) stroke is a life-threatening condition, which can lead to death in the form of "malignant MCA syndrome"; characterized by massive brain edema and cerebral herniation. Moreover, patients with complete MCA infarct have high mortality due to complications. The aim of this study was to evaluate the clinical predictors of in-hospital mortality in patients with complete MCA stroke. Consecutive patients with complete MCA stroke were enrolled in a prospective single center in-hospital outcome study having mortality as its end point. Among 780 ischemic stroke patients, 125 had complete MCA strokes (16%) and 44 (35.2%) of these died in hospital. A high NIHSS-score (OR 1.17 95%CI 1.03-1.34, P=0.013) and high diastolic blood pressure on admission (OR 1.05 95%CI 1.01-1.09) resulted being independent predictors of in-hospital mortality in patients with complete MCA stroke. The median value of diastolic blood pressure at admission was 90 mmHg in patients who died and 80 mmHg in survivors (P=0.01). The risk of death increased by 5% for each mmHg increase in diastolic blood pressure on admission after adjusting for other risk factors. The rate of mortality was 22% in patients with diastolic blood pressure lower than 90 mmHg, 56% for those with diastolic blood pressure between 90 and 109 mmHg and 67% for those with diastolic blood pressure higher than 110 mmHg. This study suggests that high diastolic blood pressure on admission in acute MCA stroke patients is linearly correlated with in-hospital mortality.

Clinical Course and Surgical Management of Massive Cerebral Infarction

Acute occlusion of the proximal middle cerebral artery (MCA) can lead to rapid development of fatal brain swelling and ischemic strokes. Decompressive surgery, if performed early in this subpopulation of patients, can reduce mortality and result in a favorable outcome. In this article, we describe our surgical approach for treating malignant MCA syndrome and compare it with other management strategies. This is a retrospective review of patients who developed acute occlusion of the proximal MCA and underwent aggressive surgical decompression (large craniectomy, anterior temporal lobectomy, resection of infarcted tissue, and duraplasty). The outcome of this management strategy is compared with the previously published outcomes of hemicraniectomy and dural augmentation. Twelve patients were included in the study. The group consisted of six men and six women (mean age, 46.8 yr). Nine patients had right MCA stroke, and three had left MCA infarction. The causes of the strokes were cardioembolic, iatrogenic, small-vessel occlusive disease, and others. The interval between infarction and clinical evidence of herniation varied from 24 hours to 10 days. Two patients died, five were independent or had moderate disabilities, and five had severe disability. Surgical decompression consisting of a large craniectomy, anterior temporal lobectomy, resection of infarcted tissue, and duraplasty is beneficial to a significant number of patients with massive MCA stroke and clinical signs of herniation.