Malignant Middle Cerebral Artery Territory Research Articles

Modifying skin flaps for achieving very large decompressive craniectomies in malignant middle cerebral artery territory infarcts: A technical note.

Decompressive craniectomy is a well described treatment to salvage life in large middle cerebral artery (MCA) territory infarcts. The size of the craniectomy is limited by the size of the skin incision and very large craniectomies need large skin flaps that are prone to necrosis at the wound margins. We describe two modifications in the skin flap that we have used in 7 patients to achieve very large bony decompressions in malignant MCA infarctions without compromising on flap vascularity. One consists of a linear extension posteriorly from the question mark or reverse question mark incision while the other is an "n" shaped incision. With these modifications we achieved craniectomies of size 15.6-17.8 cm in the anteroposterior and 10.7-12 cm in vertical axis of the bone flap removed in our patients. There were no additional procedural or wound related complications in a 6-month follow up. Removal of a standard size bone flap may achieve suboptimal decompression in cases of large MCA territory infarctions. Imaginative tailoring of skin flaps helps to remove larger volumes of skull with no added procedural morbidity.

Decompressive craniectomy index: Does the size of decompressive craniectomy matter in malignant middle cerebral artery infarction?

Malignant middle cerebral artery (MCA) infarction is associated with high mortality, mainly due to intracranial hypertension. This malignant course develops when two-thirds or more of MCA territory is infarcted. Randomized clinical trials demonstrated that in patients with malignant MCA infarction, decompressive craniectomy (DC) is associated with better prognosis. In these patients, some prognostic predictors are already known, including age and time between stroke and DC. The size of bone flap was not associated with long-term prognosis in the previous studies. Therefore, this paper aims to further expand the analysis of the bone removal toward a more precise quantification and verify the prognosis implication of the bone flap area/whole supratentorial hemicranium relation in patients treated with DC for malignant middle cerebral infarcts. This study included 45 patients operated between 2015 and 2020. All patients had been diagnosed with a malignant MCA infarction and were submitted to DC to treat the ischemic event. The primary endpoint was dichotomized modified Rankin scale (mRS) 1 year after surgery (mRS≤4 or mRS>4). Patients with bad prognosis (mRS 5-6) were on average: older and with a smaller decompressive craniectomy index (DCI). In multivariate analysis, with adjustments for "age" and "time" from symptoms onset to DC, the association between DCI and prognosis remained. In our series, the relation between bone flap size and theoretical maximum supratentorial hemicranium area (DCI) in patients with malignant MCA infarction was associated with prognosis. Further studies are necessary to confirm these findings.

Redefining the upper age limit of decompressive craniectomy surgery for malignant middle cerebral artery infarct

Background: Decompressive craniectomy is an effective treatment for malignant middle cerebral artery (MCA) territory infarct. But the age limit for surgery is not well defined. The time window of the surgery is considered less than 96 hours.Methods: This retrospective study of 60 patients of MCA territory infarct who underwent decompressive craniectomy surgery is selected in this study and using modified Rankin score.Results: In this study 36 patients were less than 60 years and were above 60 years. 38 patients were right sided and 22 were left sided MCA infarct. Out of 60 patients, 22 patients were operated within 48 hours of onset of symptoms and 38 were operated between 48 to 96 hours. 49% patients operated within 48 hours had modified Rankin score (mRS) 0–3 at 3 months follow up while only 37% patients operated after 48 hours had mRS 0–3 at 3 months follow up.Conclusions: Decompressive craniectomy in malignant MCA infarction can reduce the case fatality rate but the favorable outcome is questionable. Hence the surgical decision should depend on social and patient factors.

REtrospective Multicenter INdian Study of Derivo Embolization Device (REMIND): Periprocedural Safety.

PurposeThe treatment of aneurysms with characteristics such as complex morphology, fusiform, blister-like, wide neck, or large size has been revolutionized with the introduction of flow diverters. Though flow diverters have several advantages over coiling, they also have certain important disadvantages such as the lack of immediate protection against rupture, the risk of ischemic stroke, the need for antiplatelet therapy, and long latency for complete effect. The Derivo Embolization Device (DED) is a second-generation self-expanding device that is claimed to be less thrombogenic than conventional devices. We retrospectively evaluated the periprocedural safety and risks associated with the DED across 5 centers in India.Materials and MethodsThis is a multicentric, retrospective, observational study of DED, conducted at 5 high volume endovascular therapy centers in India from May 2018 to June 2020. Periprocedural demographic, clinical, and angiographic data were collected from a retrospective review of patient charts.ResultsA total of 96 patients, including 56 (58.3%) females, aged between 16–80 years (60±12.7 years) harboring 106 aneurysms were studied. Seven (7.3%) were noted to harbor multiple aneurysms: 6 had 3 aneurysms each, while 1 patient had 5 aneurysms. The following aneurysm characteristics were noted: average size, 9.8±8.2 mm; average neck size, 6.9±8.5 mm; wide-necked (>4 mm), 63 (59.4%); giant (>25 mm), 8 (7.5%); and anterior circulation location, 98 (92.5%). Eighteen (17%) of these were ruptured. Additional balloon angioplasty was performed in 5 (5.2%) patients. Intraprocedural problems were encountered in 3 (3.1%), of which only 1 had clinical implications, the device fish-mouthing with stent thrombosis resulting in a malignant middle cerebral artery territory infarction. The modified Rankin scale at 3 months was worse in 1 patient.ConclusionDED is a newer generation flow diverter stent with a low periprocedural complication rate.

Decompressive craniectomy for malignant middle cerebral artery territory infarct: an institutional experience

Background: Decompressive craniectomy is the surgical procedure to reduce intracranial pressure, refractory to medical measures. We have described our experience associated with the clinical profile, radiological profile, postoperative status and long term outcome in patients with malignant middle cerebral artery (MCA) territory infarct.Methods: Data were collected from patients who underwent hemispheric decompressive craniectomy for malignant MCA territory infarct in our hospital from May 2014 to June 2019. Clinical, radiological, surgical profile and long term outcome were studied.Results: There were a total of 51 patients aged between 28 years to 76 years. Hypertension (70%) was the most common comorbidity associated. All the patients had at least one focal neurological deficit at the time of presentation. Mean time from the first symptoms to surgery was 2.4 days (about 58 hours). 7 patients died within one month of the surgery. Two third improved objectively within 1 month of surgery. Out of 44 patients, who survived beyond one month, none of the patients were functionally independent after one year of surgery (modified Rankin scale (mRS) of 0 or 1). The patients had a mean mRS of 3.8 at one year.Conclusions: Over several decades decompressive craniectomy has been found to be the most effective measure to reduce mortality and morbidity associated with malignant MCA territory infarct. Early surgery (<48 hours) in patients with good Glasgow Coma scale score reduces the mortality. Larger multicentric trials are required to look at the long term effect on morbidity and mortality.

Decompressive Craniotomy for Malignant Middle Cerebral Artery Infarction: Optimal Timing and Literature Review

To compare the results of early or delayed decompressive craniotomy for patients with malignant middle cerebral artery infarction. A prospective randomized study was carried out of a series of 46 consecutive patients with malignant middle cerebral artery territory infarction. Patients were divided randomly into 2 groups: group I, 27 patients who were followed until obvious deterioration of level of consciousness; group II, 19 patients who were operated on prophylactically in 6 hours of presentation even with no clear deterioration of level of consciousness or radiologic findings. Patients were assessed clinically using the Glasgow Coma Scale, motor power by the United Kingdom Medical Research Council, and functionally by the National Institutes of Health Stroke Scale and modified Rankin Scale. Radiologically, patients had primary magnetic resonance imaging on admission, followed by computed tomography scan. Infarction behavior including volume of infarct area, midline shift, and secondary hemorrhage were calculated. At final follow-up, both groups showed good improvement in level of consciousness, motor power, and functional outcome; however, statistically significant neurologic improvement was shown in group II. Functional outcome also showed statistically significant improvement (P < 0.05) in this ultraearly decompression group (group II). There was a significant difference in mortality in both groups; more than half (52%) of group I died as a result of delay in surgery or its other consequences. Another significant difference was in the progression of infarction volume, which was observed more in group I (statistically insignificant). Despite the possible complications from surgery, early decompressive craniotomy (within 6 hours of ictus without waiting for neurologic deterioration) has a significant impact on prognosis. Delay in transferring the patient, diagnosing the condition, or taking the decision of surgery significantly affects mortality and overall outcome.

Safety and Efficacy of Hypothermia (34°C) after Hemicraniectomy for Malignant MCA Infarction.

ObjectiveThe beneficial effect of hypothermia after hemicraniectomy in malignant middle cerebral artery (MCA) infarction has been controversial. We aim to investigate the safety and clinical efficacy of hypothermia after hemicraniectomy in malignant MCA infarction.MethodsFrom October 2012 to February 2016, 20 patients underwent hypothermia (Blanketrol III, Cincinnati Sub-Zero, Cincinnati, OH, USA) at 34°C after hemicraniectomy in malignant MCA infarction (hypothermia group). The indication of hypothermia included acute cerebral infarction >2/3 of MCA territory and a Glasgow coma scale (GCS) score <11 with a midline shift >10 mm or transtentorial herniation sign (a fixed and dilated pupil). We retrospectively collected 27 patients, as the control group, who had undergone hemicraniectomy alone and simultaneously met the inclusion criteria of hypothermia between January 2010 and September 2012, before hypothermia was implemented as a treatment strategy in Dong-A University Hospital. We compared the mortality rate between the two groups and investigated hypothermia-related complications, such as postoperative bleeding, pneumonia, sepsis and arrhythmia.ResultsThe age, preoperative infarct volume, GCS score, National institutes of Health Stroke Scale score, and degree of midline shift were not significantly different between the two groups. Of the 20 patients in the hypothermia group, 11 patients were induced with hypothermia immediately after hemicraniectomy and hypothermia was initiated in 9 patients after the decision of hypothermia during postoperative care. The duration of hypothermia was 4±2 days (range, 1 to 7 days). The side effects of hypothermia included two patients with arrhythmia, one with sepsis, one with pneumonia, and one with hypotension. Three cases of hypothermia were discontinued due to these side effects (one sepsis, one hypotension, and one bradycardia). The mortality rate of the hypothermia group was 15.0% and that of the control group was 40.7% (p=0.056). On the basis of the logistic regression analysis, hypothermia was considered to contribute to the decrease in mortality rate (odds ratio, 6.21; 95% confidence interval, 1.04 to 37.05; p=0.045).ConclusionThis study suggests that hypothermia after hemicraniectomy is a viable option when the progression of patients with malignant MCA infarction indicate poor prognosis.

A standardized method to measure brain shifts with decompressive hemicraniectomy

BackgroundA standardized, reliable, and practical method for measuring decompressive hemicraniectomy (DHC) defects and brain shifts in malignant middle cerebral artery (MCA) territory infarction is needed for reliable comparisons between computed tomography (CT) scans. Such a method could facilitate further studies on the effects of DHC. New methodWe describe and apply a method for measuring DHC defects and brain shifts on CT scans in 25 patients with malignant MCA territory infarction. Craniectomy area is adjusted for variations in head size, CT slice orientation is standardized, and the site of each measurement is defined. This method uses standard radiology platforms and volume-acquired helical CT scans. ResultsThe measurements include a DHC size index (adjusted for variations in head size), midline brain shift (subfalcine), outward brain herniation (transcalvarial), and the diameter of the contralateral atrium of the lateral ventricle. Inter-rater agreement for these measurements in a sample of 15 subjects is excellent (correlation coefficients 0.90–0.98). Comparison with existing methodsIn contrast to previously reported methods, this method is tested in acute stroke patients, compensates for variability in head size, and includes a midline brain shift (subfalcine) and brain ventricular system measurements. ConclusionsA practical method for measuring DHC size and brain shifts designed to be consistent between scans is proposed. This method should facilitate comparisons of measurements between serial scans, between patients, and perhaps between studies. This method could be useful in medical and surgical studies of brain herniations in malignant MCA territory infarction, and possibly other conditions.

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.

Extended Use of Hypothermia in Elderly Patients with Malignant Cerebral Edema as an Alternative to Hemicraniectomy.

Background and PurposeThe use of decompressive hemicraniectomy (DHC) for the treatment of malignant cerebral edema can decrease mortality rates. However, this benefit is not sufficient to justify its use in elderly patients. We investigated the effects of therapeutic hypothermia (TH) on safety, feasibility, and functional outcomes in elderly patients with malignant middle cerebral artery (MCA) infarcts.MethodsElderly patients 60 years of age and older with infarcts affecting more than two-thirds of the MCA territory were included. Patients who could not receive DHC were treated with TH. Hypothermia was started within 72 hours of symptom onset and was maintained for a minimum of 72 hours with a target temperature of 33°C. Modified Rankin Scale (mRS) scores at 3 months following treatment and complications of TH were used as functional outcomes.ResultsEleven patients with a median age of 76 years and a median National Institutes of Health Stroke Scale score of 18 were treated with TH. The median time from symptom onset to initiation of TH was 30.3±23.0 hours and TH was maintained for a median of 76.7±57.1 hours. Shivering (100%) and electrolyte imbalance (82%) were frequent complications. Two patients died (18%). The mean mRS score 3 months following treatment was 4.9±0.8.ConclusionsOur results suggest that extended use of hypothermia is safe and feasible for elderly patients with large hemispheric infarctions. Hypothermia may be considered as a therapeutic alternative to DHC in elderly individuals. Further studies are required to validate our findings.

Predicting Mortality in Patients With "Malignant" Middle Cerebral Artery Infarction Using Susceptibility-Weighted Magnetic Resonance Imaging: Preliminary Findings.

To evaluate malignant middle cerebral artery (MCA) infarction (defined as space-occupying edema in more than 50% to 75% of the MCA territory) on magnetic resonance imaging (MRI) with susceptibility-weighted imaging (SWI) sequence and assess the usefulness of SWI findings, diffusion-weighted imaging (DWI) findings, and apparent diffusion coefficient (ADC) as predictors of clinical outcome.Data from 16 patients with large MCA infarction previously admitted to our institution between December 2009 and October 2012 were retrospectively collected and analyzed. Within 7 days after stroke onset, 1 neurologist and 1 neuroradiologist estimated the area of infarction on DWI/ADC and extent of prominent vessel sign (PVS) on SWI images using the Stroke Program Early MR Score (SPEMRS). The PVS on SWI was defined as a local prominence of hypointense vessels with either increased vessel number or diameter in the target area, when compared with the number or diameter of the contralateral MCA territory vessels.Six patients died and 10 survived. Although the DWI/ADC-SPEMRS and clinical profiles were similar between the nonsurvivor and survivor groups, SWI-SPEMRS was significantly lower in the nonsurvivor group (P < 0.001).The area of deoxygenation on SWI in patients with malignant MCA infarction can predict mortality. Lower SWI-SPEMRS is a potentially better predictor of poor outcome than lower DWI-SPEMRS. A larger prospective study is needed to clarify the role of SWI as a therapeutic guide in malignant MCA.

Updated Korean Clinical Practice Guidelines on Decompressive Surgery for Malignant Middle Cerebral Artery Territory Infarction.

Clinical practice guidelines (CPGs), which provide systemic reviews of accumulated scientific evidence, are used by clinicians to choose optimal treatment modalities. In Korea, the Clinical Research Center for Stroke (CRCS) published the first version of its CPGs for stroke in October 2009; it was based on articles that had been reported before June 2007 [1]. Since then, major trials of decompressive surgery for malignant middle cerebral artery (MCA) have been published, and the CRCS and Korean Society of Cerebrovascular Surgeons (KSCVS) therefore decided to revise the CPGs to reflect this new evidence. To select source papers for the revision, we searched Pubmed for English-language articles published between July 2007 and May 2014 that contained the word “stroke,” plus any one of the following terms or phrases: “malignant MCA infarction,” “hemicraniectomy,” and “decompressive surgery.” We retrieved 122 articles with the key words “stroke” and “malignant MCA infarction,” 136 articles with “stroke” and “hemicraniectomy,” and 225 articles with “stroke” and “decompressive surgery.” We then narrowed this pool of articles down by limiting the search to prospective, randomized clinical trials, pooled analyses, and meta-analyses and found five such articles that were published during this period. We reviewed a total of five randomized, clinical trials [2-6], one pooled analysis [7], and one meta-analysis [4], including three studies [2,3,7] that were mentioned in the first edition. The revised versions of the CPGs for decompressive surgery from the European Stroke Organization (ESO) (May 2008) [8], the Scottish Intercollegiate Guidelines Network (December 2008) [9], the National Clinical Guidelines for Stroke of the Royal College of Physicians (July 2008) [10], and the American Heart Association (AHA)/American Stroke Association (ASA) guidelines (published, respectively, in 2013 and 2014) [11,12] were also considered. After we reviewed these articles and described new evidence in guidelines, each piece of evidence and recommendation was given a strength based on a definition of evidence level and recommendation grade used in the KSCVS and the CRCS guidelines (Table 1). Table 1. Evidence levels and recommendation grades used by the Korean Society of Cerebrovascular Surgeons and the Clinical Research Center for Stroke

Low Alberta Stroke Program Early CT Score (ASPECTS) Associated with Malignant Middle Cerebral Artery Infarction

Background: Early decompressive hemicraniectomy following malignant middle cerebral artery (MCA) infarction reduces mortality and improves clinical outcome. Imaging predictors of malignant infarction may serve as ‘red flags', prompting intensive neurological monitoring and timely intervention. Our objective is to investigate whether lower ASPECTS (Alberta Stroke Program Early CT Score) is associated with malignant MCA infarction. Methods: A retrospective cohort study of all patients with MCA territory ischemic strokes who were admitted to the Royal Melbourne Hospital (RMH) between 1 January 2009 and 31 December 2009 (226 patients included). The main outcome measures were ASPECTS on admission for each patient and the development of malignant MCA infarction. Results: One-hundred-and-eight patients out of 226 (48%) developed malignant MCA infarction. Good (>0.8) inter-rater agreement between observers scoring ASPECTS was observed using weighted kappa, intra-class correlation coefficient and Lin's concordance coefficients. Using receiver operating characteristic (ROC) curve analysis, we validated that ASPECTS 7 was the optimal cut-off score to determine progression to malignant infarction, providing 50% sensitivity and 86% specificity. One hundred and fifty six patients had ASPECTS >7 (69%) and 70 patients had ASPECTS ≤7 (31%). Patients with ASPECTS ≤7 were significantly younger than those with ASPECTS >7, with the median age of each group being 72.5 and 78 respectively (p = 0.02); otherwise the groups were well-matched. With ASPECTS ≤7, 54 out of 70 patients (77%) developed malignant MCA infarction, compared with 54 out of 156 patients (35%) with ASPECTS >7 (age-adjusted OR = 0.12, 95% CI: 0.06, 0.25; p < 0.0001). If ASPECTS ≤7 is a positive result, then the positive predictive value is 77% and the negative predictive value is 65%. The median ASPECTS for developing malignant MCA infarction was 7.5 (IQR: 5 to 10), while the median ASPECTS for not developing MCA infarction was 10 (IQR: 8 to 10), resulting in a significant age-adjusted median difference of 2 (95% CI: 0.8, 3.2; p < 0.0001). We also found that coma on admission is associated with the development of malignant MCA infarction (OR = 22.63, 95% CI: 1.3, 393.7; p = 0.0323) and that a history of hypertension is not associated with the development of malignant MCA infarction (OR = 0.9707, 95% CI: 0.54, 1.75; p = 0.9213). Conclusions: ASPECTS ≤7 on initial brain CT in a patient with MCA infarction is associated with the development of malignant MCA infarction. We recommend close monitoring of, and early consideration of decompressive hemicraniectomy for, acute stroke patients with ASPECTS ≤7.

Decompressive hemicraniectomy for malignant middle cerebral artery territory infarction: is life worth living?

Although decompressive hemicraniectomy has been shown to reduce death and improve functional outcome following malignant middle cerebral artery territory infarction, there is ongoing debate as to whether surgery should be routinely performed, considering the very high rates of disability and functional dependence in survivors. Through a systematic review of the literature, the authors sought to determine the outcome from a patient's perspective. In September 2010, a MEDLINE search of the English-language literature was performed using various combinations of 12 key words. A total of 16 papers were reviewed and individual study data were extracted. There was significant variability in study design, patient eligibility criteria, timing of surgery, and methods of outcome assessment. There were 382 patients (59% male, 41% female) with a mean age of 50 years, 25% with dominant-hemisphere infarction. The mortality rate was 24% and the mean follow-up in survivors was 19 months (range 3-114 months). Of 156 survivors with available modified Rankin Scale (mRS) scores, 41% had favorable functional outcome (mRS Score ≤ 3), whereas 47% had moderately severe disability (mRS Score 4). Among 157 survivors with quality of life assessment, the mean overall reduction was 45%: 67% for physical aspect and 37% for psychosocial aspect. Of 114 screened survivors, depression affected 56% and was moderate or severe in 25%. Most patients and/or caregivers (77% of the 209 interviewed) were satisfied and would give consent again for the procedure. Despite high rates of physical disability and depression, the vast majority of patients are satisfied with life and do not regret having undergone surgery.

Malignant MCA territory infarction in the pediatric population: subgroup analysis of the Greater Cincinnati/Northern Kentucky Stroke Study

Malignant middle cerebral artery (MCA) infarctions are thought to be rare in children. In a recent hospital-based study, only 1.3% of pediatric ischemic strokes were malignant MCA infarctions. However, population-based rates have not been published. We performed subgroup analysis of a population-based study to determine the rate of malignant MCA infarctions in children. In 2005 and 2010, all ischemic stroke-related emergency visits and hospital admissions among the 1.3 million residents of the five-county Greater Cincinnati/Northern Kentucky area were ascertained. Cases that occurred in patients 18years and younger were reviewed in detail, and corresponding clinical and neuroimaging findings were recorded. Infarctions were considered malignant if they involved 50% or more of the MCA territory and resulted in cerebral edema and mass effect. In 2005, eight pediatric ischemic strokes occurred in the study population, none of which were malignant infarctions. In 2010, there were also eight ischemic strokes. Of these, two malignant MCA infarctions were identified: (1) a 7-year-old boy who underwent hemicraniectomy and survived with moderate disability at 30days and (2) a 17-year-old girl with significant prestroke disability who was not offered hemicraniectomy and died following withdrawal of care. Thus, among 16 children over 2years, there were two malignant MCA infarctions (12.5%, 95% CI 0-29). Malignant MCA infarctions in children may not be as rare as previously thought. Given the significant survival and functional outcome benefit conferred by hemicraniectomy in adults, future studies focusing on its potential role in pediatric patients are warranted.

Abstract 2356: Predicting Factors Of Developing The Malignant Middle Cerebral Artery (MCA) Infarction For An Acute Mca Infarction With Main Mca Occlusion

Background : Malignant middle cerebral artery (MCA) infarction is leading cause of death for acute MCA infarction patients. Early detection of patients who can develop the malignant MCA infarction (MMI) is important for timely decision for life-saving treatment such as an decompressive surgery. So we studied to figure out a reliable predicting parameters for developing MMI using acute stroke magnetic resonance imaging (MRI) such as diffusion and perfusion images. Methods : We included 209 MCA infarction patients with main MCA occlusion within 6 hours of symptom onset between January 2007 and December 2010 in Dong-A University Stroke center. All patients were performed brain MRI including diffusion and perfusion images. Vessel occlusion was diagnosed by MR angiography. We used regional cerebral blood volume (rCBV) ratio as a representing parameters of perfusion image. The rCBV ratio was calculated by comparing the blood volume of the ischemic lesion with that of the corresponding unaffected contralateral region.Definition of the malignanat MCA infarction was as following : 1) deterioration of neurological and consciousness with clinical signs of uncal herniation and mass effect, 2) large space-occupying MCA infarction or at least two-third of the MCA territory with compression of ventricles of midline shifting. We observed any changes of neurological deterioration within 7 days of symptom onset. Severity of neurological symptom and clinical outcome were assessed by using National Institute Stroke Severity Scale (NIHSS) and the modified Rankin Scale (mRS). Results : Among 209 pts, 84 (40.2%) developed MMI, and 125 (59.8%) did not (non-MMI). In a univariate analysis, MMI group was more older (69.08 vs 63.54), more additional lesion in ACA or PCA territory (13.1% vs 1.6%), higher NIHSS score. In MMI group, MCA with ipsilateral ICA occlusion was more frequent (76.2% vs 40.0%), and larger diffusion volume (99.13 vs 21.57), lower rCBV ratio (0.53 vs 0.87). Also, the presence of diffusion-perfusion mismatch (DPM) was more common in non-MMI group (80.8% vs 46.4%). In MMI group, large portion of patients were included in mRS 5-6 group (61.4%) compared with non-MMI group (15.8%). In a multivariate analysis, these parameters were identified as a predicting factors of MMI : larger diffusion volume (OR :1.02, 1.01-1.04, p&lt;0.001), lower rCBV ratio (OR :0.97, 0.95-0.99, p&lt;0.001), higher NIHSS on admission (OR: 1.31, 1.16-1.47, p&lt;0.001). The cutoff value of diffusion volume, NIHSS on admission and rCBV ratio were 69ml, 15 point and 0.66 respectively. Conclusion : Brain MRI including diffusion and perfusion image, especially diffusion volume and rCBV ratio can predict malignant course in MCA infarction with main MCA occlusion patients within 6 hours of symptom onset.

Quality of Life Following Hemicraniectomy for Malignant MCA Territory Infarction

Decompressive hemicraniectomy (DH) has been shown to reduce mortality in patients with malignant middle cerebral artery (MCA) territory infarction. However, many patients survive with moderate-to-severe disability and controversy exists as to whether this should be considered good outcome. To answer this question, we assessed the quality of life (QoL) of patients after DH for malignant MCA territory infarction in our milieu. The outcome of all patients undergoing DH for malignant MCAterritory infarction between 2001 and 2009 was assessed using retrospective chart analysis and telephone follow-up in survivors. Functional outcome was determined using Glasgow outcome scale, modifed Rankin scale (mRS), and Barthel index (BI). The stroke impact scale was used to assess QoL. There were 14 patients, 6 men and 8 women, with a mean age of 44 years (range 27-57). All patients had reduced level of consciousness preoperatively. Five had dominant-hemisphere stroke. Median time to surgery was 45 hours (range 1- 96). Two patients died and one was lost to follow-up. Of 11 survivors, 7 (63.6%) had a favorable functional outcome (mRS<4). No patient was in persistent vegetative state. Despite impaired QoL, particularly in physical domains, the majority of interviewed patients and caregivers (7 of 8), including those with dominant-hemisphere stroke, were satisfied after a median follow-up of 18 months (range 6-43). Most patients report satisfactory QoL despite significant disability even in the face of moderate-to-severe disability and dominant-hemsiphere stroke. Dominant-hemisphere malignant MCA territory infarction should not be considered a contraindication to DH.

Acute Decompressive Hemicraniectomy to Control High Intracranial Pressure in Patients with Malignant MCA Ischemic Strokes

Malignant middle cerebral artery (MCA) infarction occurs in about 10% of all patients with supratentorial ischemic strokes. The infarction involves the entire MCA territory. Due to the consequences of severe brain edema, brain herniation, elevated intracranial pressure (ICP), and midline shift, these events carry a mortality rate of up to 80%. No clinical trials have been conducted to study the efficacy of the osmotic agents such as mannitol or hypertonic saline. Furthermore, aggressive use of such treatments may be detrimental. Surgical decompression has previously been proposed as a way to relieve the vicious cycle of malignant cerebral edema and reduced cerebral perfusion. Its use in relieving ICP is also controversial. Recently, a pooled analysis of three independent European trials has shown that decompressive hemicraniectomy is clearly beneficial in reducing mortality from large hemispheric infarctions. Although controversies still exist on its indications, surgical decompression can effectively reduce ICP, reduce mortality, and improve neurologic outcomes in selected patients with a malignant MCA stroke syndrome.

Decompressive Craniectomy Is Not an Independent Risk Factor for Communicating Hydrocephalus in Patients With Increased Intracranial Pressure

It was recently suggested that communicating hydrocephalus is an almost universal finding after hemicraniectomy and that early cranioplasty may prevent the need for permanent cerebrospinal fluid diversion in these patients. To conduct a study in an attempt to verify these findings. The medical records of all patients who underwent decompressive craniectomy for medically refractory elevated intracranial pressure between 2001 and 2009 were retrospectively reviewed. Patients with subarachnoid hemorrhage, intraventricular hemorrhage, or head trauma were excluded. Hydrocephalus was classified as internal or external and as clinically significant or asymptomatic. The patient population consisted of 17 patients, 8 men and 9 women, with a median age of 44 years (range, 27-53 years). Etiologies included malignant middle cerebral artery territory infarction in 12 patients, hemorrhagic transformation of ischemic cerebrovascular accident in 2 patients, dural sinus thrombosis in 2 patients, and hemorrhagic cerebrovascular accident in 1 patient. The extent of craniectomy ranged from a large bone flap in 4 patients to a standard hemicraniectomy in 13 patients. Two patients died and 1 was lost to follow-up during the acute stage. The remaining 14 patients underwent cranioplasty after a median interval of 21 days (range, 3-42 days). In none of these patients did clinically significant hydrocephalus develop requiring cerebrospinal fluid diversion. Asymptomatic extra-axial cerebrospinal fluid collections developed in 2 patients that resolved spontaneously after cranioplasty. Our results suggest that, contrary to some beliefs, hydrocephalus does not frequently occur after decompressive craniectomy.

Is decompressive craniectomy for malignant middle cerebral artery territory infarction of any benefit for elderly patients?

Background Malignant middle cerebral artery (MCA) infarction is characterized by mortality rate of up to 80%. The aim of this study was to determine the value of decompressive craniectomy in patients who present with malignant MCA territory infarction and to compare functional outcome in elderly patients with younger patients. Methods Patients with malignant MCA territory infarction treated in our hospital between January 1997 and March 2003 were included in this retrospective analysis. The National Institutes of Health Stroke Scale (NIHSS) assessed neurologic status at admission, operation, and at 1 week after surgery. All patients were followed up for assessment of functional outcome by the Barthel Index (BI) and the modified Rankin Scale (RS) at 3 to 9 months after infarction. Results Twenty-five patients underwent decompressive craniectomy. The mortality was 7.7% in younger patients (ages <60 years) compared with 33.3% in elderly patients (ages ≥60 years) ( P > .05). All patients had significant decrease of NIHSS after surgery ( P < .001). At follow-up, younger patients who received surgery had significantly better outcome with mean BI of 75.42 and Rankin score of 3.00; however, none of the elderly survivors had a BI score above 60 or a Rankin score below 4. Conclusion Decompressive craniectomy in younger patients with malignant MCA territory infarction improves both survival rates and functional outcomes. Although survival rates were improved after surgery in elderly patients, functional outcome and level of independence were poor.