Massive Middle Cerebral Artery Infarction Research Articles

Rare case of massive middle cerebral artery infarct after bronchial artery embolisation

Bronchial artery embolization (BAE) is a procedure that aims to control bleeding from bronchial arteries in massive and chronic haemoptysis. It is considered to be a life-saving measure in severe life-threating haemoptysis. Although it is minimally invasive and has a high success rate, it still carries a list of complications. These include post-embolisation syndrome, chest pain, back pain, dysphagia, vascular injury at the site of the embolisation leading to dissection, perforation, pseudoaneurysm and, very rarely, embolic infarction to non-target vessels. Stroke is one of the rare complications post BAE, and it can be severe and fatal. Few cases of stroke post BAE have been reported in the literature, and they were mainly due to posterior cerebral circulation infarction. Here, we report a case of a stroke post BAE due to massive middle cerebral artery (MCA) infarction and to our knowledge it seems to be the first reported case of MCA infarction post BAE. The discussion will cover the possible mechanisms of embolic passage, the outcome of the case including rehabilitation perspectives and the learning points. These will also highlight the importance of early recognition, which can save patients from a disabling stroke in the future.

20-hydroxyeiscosatetraenoic acid may be as a predictor of malignant middle cerebral artery infarction in patients with massive middle cerebral artery infarction

BackgroundEarly identification of massive middle cerebral artery infarction (MCAI) at risk for malignant MCAI (m-MCAI) may be useful in selecting patients for aggressive therapies. The aim of this study was to determine whether CYP metabolites may help to predict impending m-MCAI.MethodsThis is a prospective, two-center observational study in 256 patients with acute massive MCAI. Plasma levels of 20-hydroxyeicosatetraenoic acid (20-HETE), epoxyeicosatrienoic acids, and dihydroxyeicosatrienoic acids were measured at admission. Brain computed tomography (CT) was performed at admission and repeated between day 3 and 7, or earlier if there was neurological deterioration. The primary outcome was m-MCAI. The m-MCAI was diagnosed when follow-up brain CT detected a more than two-thirds space-occupying MCAI with midline shift, compression of the basal cisterns, and neurological worsening.ResultsIn total of 256 enrolled patients, 77 (30.1%) patients developed m-MCAI. Among the 77 patients with m-MCAI, 60 (77.9%) patients died during 3 months of stroke onset. 20-HETE level on admission was significantly higher in patients with m-MCAI than those without m-MCAI. There was an increase in the risk of m-MCAI with increase of 20-HETE levels. The third and fourth quartiles of 20-HETE levels were independent predictors of m-MCAI (OR: 2.86; 95% CI: 1.16 – 6.68; P = 0.025, and OR: 4.23; 95% CI: 1.35 – 8.26; P = 0.002, respectively).ConclusionsIncidence of m-MCAI was high in patients with massive MCAI and the prognosis of m-MCAI is very poor. Elevated plasma 20-HETE may be as a predictor for m-MCAI in acute massive MCAI, and it might useful in clinical practice in therapeutic decision making.

Decompressive Craniectomy in Patients with Malignant Middle Cerebral Artery Infarction: Prognostic Factors and Timing Dilemma

Abstract Background: About 10 percent of ischemic strokes are defined as a malignant one due to associated massive brain edema which is severe enough to produce elevated intracranial pressure and brain herniation. Decompressive Craniectomy (DC) with duraplasty is a surgical technique that involves the creation of extra roomy space and incision of the tight dural covering the brain allowing swollen brain tissue to herniate outwards to reduce the Intracranial Pressure (ICP). Aim of Study: This study aims to share the experience of performing decompressive craniectomy in the treatment of malignant Middle Cerebral Artery Infarction (MMCAI) >48 hours after stroke with an analysis of the results and prognostic factors. Patients and Methods: From January 2016 to June 2018, we performed a decompressive craniectomy in eleven patients with massive middle cerebral artery infarction. Retrospectively we reviewed the clinical and radiological data, Glasgow coma scale at admission, pre and post-operatively. Serial Computed Tomography (CT) with measurement of midline shift pre and post-operatively. Patients were evaluated according to the following factors: Age, sex, the time between admission and surgery, the time between deterioration and surgery, the pre and post-operative Glasgow coma scale, pre and post-operative midline shift on CT scan, dominancy, and Glasgow outcome scale. Results: Eleven patients (11) have been operated on by decompressive hemicraniectomy and duroplasty, there were no significant changes in outcome in relation to the admission GCS, GCS (p=0.2599) or in GCS (p=0.3713), but there was a significant correlation between the pre-operative GCS and outcome and decompressive craniectomy leads to highly significant relieve of the midline shift (p < 0.000). No significant correlation was detected between the time interval elapsed between admission and the time surgery and patient outcome (p=0.3032), but there was also a significant correlation between the time interval between patient deterioration and time of decompressive craniectomy and patient outcome (p=0.92161). Conclusion: Very strict close observation of patients with Malignant Middle Cerebral Artery (MMCA) infarction in the Neuro ICU is highly recommended and surgery should be done as early as possible before the clinical deterioration of the brain herniation for better benefit. Decompressive craniec-tomy could be a life-saving procedure for large hemispheric infarction but postoperative morbidity and quality of life are the main challenges. Although early surgery is recommended by many studies but still DC even after 48 hours may be a life-saving procedure for some patients especially those operated on within a small time window once the clinical deterioration has happened but the post-operative morbidity and quality of life are the main challenges.

Pulmonary vein thrombosis and cerebral infarction after video-assisted thoracic surgery of the left upper lobe: a case series

BackgroundPulmonary vein thrombosis (PVT) and cerebral infarction are rare but critical complications after video-assisted thoracic surgery (VATS).Case presentationWe experienced two cases of massive middle cerebral artery infarction after VATS for the left upper lobe. Although the precise source of their embolus was never identified, both cases were clinically suspected PVT. Unfortunately, case 2 died because of progressive cerebral herniation. We decided to perform contrast-enhanced computed tomography routinely after VATS for the left upper lobectomy (VATS-LUL) after these cases. Case 3, a 79-year-old female patient, underwent VATS-LUL for lung cancer. She developed PVT in the stump of the left upper pulmonary vein on postoperative day 4. Anti-coagulation therapy was begun immediately and continued for 3 months. She was free of complications 7 months after the operation.ConclusionPVT and cerebral infarction may occur after VATS-LUL. Appropriate postoperative management is required to recognize PVT and to prevent life-threatening stroke.

Clinical Profile and Risk Factors of Massive Middle Cerebral Artery Infarction in a Tertiary Care Centre in Central Tamilnadu

Clinical Profile and Risk Factors of Massive Middle Cerebral Artery Infarction in a Tertiary Care Centre in Central Tamilnadu

Abstract TMP40: Secondary Motor Nerve Deficit Correlates With Poorer Outcome in Acute Stroke Patients

Introduction: Anterograde degeneration after stroke leads to secondary injury of peripheral motor nerves. It remains unclear whether this secondary dysfunction affects functional improvement and whether early electrophysiological parameters could possibly predict rehabilitative outcome. Methods: A total of 43 adult patients of middle cerebral artery infarction (MCAI) within 2 weeks after onset was prospectively recruited from January 2016 to December 2017. Ten healthy subjects were recruited as control. All the subjects were investigated by electromyography to record and analyze electrophysiological parameters on admission. All the patients were evaluated by NIHSS, BI, mRS, Fugl-Meyer assessment (FMA) and Alberta Stroke Program Early CT score on admission, then by BI, mRS and FMA in the 6-month follow-up. Multiple regression analysis was used to screen the possible predictive factor for neurological outcome. Results: Twenty-six patients were with massive MCAI and 17 patients with subcortical MCAI. The compound muscle action potential (CMAP) amplitude of median, ulnar, tibial and common peroneal nerves, and motor unit number estimation in abductor of pollicis brevis were significant decreased in the hemiplegic limbs than those in the unaffected limbs and in the healthy controls, and further diminished in massive MCAI compared to those in subcortical MCAI. Fibrillation potentials / positive sharp waves in abductor digiti minimi and tibialis anterior were found in majority of patients, and were more frequently detected in massive MCAI, confirming the motor axonal deficit. CMAP amplitude of the affected ulnar nerves was significantly decreased in patients with unfavorable outcome (mRS&gt;3) 3 and 6 months after attack, shown as an independent predictor for poorer outcome. In addition, the affected ulnar CMAP ≥10.45mV was associated with more than 50% decrement of mRS 6 months post stroke, with sensitivity and specificity of nearly 80%. Conclusions: The data indicated that secondary peripheral motor deficit occurred within 2 weeks after stroke, correlated with severity of the disease. Relatively low CMAP amplitude of hemiplegic ulnar nerve could serve as an independent factor to predict poorer outcome and worse recovery in the 6-month follow-up.

Hemicraniectomy for Massive Middle Cerebral Artery Infarction: A Review

Hemicraniectomy and opening underlying dura mater permits the expansion of infarcted, swollen brain outwards, reversing dangerous intracranial pressure elevations and the risk of fatal transtentorial temporal lobe or diencephalic herniation. Recently published randomized controlled trials have proven this procedure a powerful life-saving measure in the setting of malignant middle cerebral artery infarction and allayed concerns that a reduction in mortality is accompanied by an unacceptable increase in patients suffering severe neurological impairments. Appropriate patients are relatively young, in the first five decades of life, suffering infarction of a majority of the middle cerebral artery (MCA) territory in either hemisphere, and decompression should be performed prior to progression to coma or two dilated, fixed pupils. Lethargy combined with midline shift and uncal herniation on neuroimaging is an appropriate trigger to consider and discuss surgical intervention. Families and, when possible, patients themselves, should be informed of the certainty of at least moderate to mild permanent deficits, and the possibility of worse. To be successful decompression must be extensive, targeting a bone flap measuring 14 cm from front to back, and extending 1 to 2 cm lateral to the midline sagittal suture to the floor of the middle cranial fossa at the level of the coronal suture. An augmentation duraplasty is mandatory.

Factors predictive of fatality in massive middle cerebral artery territory infarction and clinical experience of decompressive hemicraniectomy

To determine the factors predictive of fatality in massive middle cerebral artery (MCA) territory infarction and outcome of decompressive hemicraniectomy, 62 patients who were retrospectively verified with first event massive MCA infarctions were enrolled in this study. Amongst them, 21 received decompressive hemicraniectomy during hospitalization. Clinical data between early and late hemicraniectomy groups were also compared. Significant deterioration occurred in 40 cases, 21 of whom received decompressive hemicraniectomy. The other 19 received conservative treatment. The mortality rate of these 40 cases between decompressive hemicraniectomy and conservative treatment was 29% (six of 21) and 42% (eight of 19), respectively. Factors that predicted fatalities in our massive MCA infarction patients with or without decompressive hemicraniectomy were total scores of baseline GCS at the time of admission, associated with coronary artery diseases, and significant deterioration during hospitalization. This study confirms the lifesaving procedure of hemicraniectomy that prevents death in patients deteriorating because of cerebral edema after infarction, although it may produce severe disability with an unacceptably poor quality of life in survival. Despite high mortality and morbidity, decompressive hemicraniectomy to prevent cerebral herniation when significant deterioration is demonstrated are essential for maximizing the potential for survival.

Computed Tomographic Parameters Predicting Fatal Outcome in Large Middle Cerebral Artery Infarction

Background: Large middle cerebral artery (MCA) ischaemic stroke when associated with extensive mass effect can result in brain herniation and neurological death. As yet there are few guidelines to aid the selection of patients for aggressive interventional therapies, such as decompression hemicraniectomy and/or hypothermia. Methods: We studied a cohort of patients from seven centres with large MCA infarction requiring neurocritical care. The purpose of this analysis was to assess the use of early radiological signs on follow-up computed tomographic (CT) signs performed within 48 h of stroke onset for predicting mortality at 30 days. The CT parameters assessed included horizontal displacement of the septum pellucidum, pineal shift, complete or partial infarction of the temporal lobe, involvement of additional vascular territories, and the presence of hydrocephalus. The primary outcome measure was in-hospital death within 30 days. Results: One hundred and thirty-five patients who had follow-up CT scans within 48 h were identified from a total of 201 patients with large MCA infarction that received conventional medical therapy alone. The median age was 68 (range 29–99), 56% were female, and the median NIHSS category was 26–30 at 48 h. Among CT variables in univariable analysis, anteroseptal shift ≧5 mm, pineal shift ≧2 mm, complete temporal lobe infarction, involvement beyond the MCA territory, and moderate or severe hydrocephalus were equally predictive of death. Multivariable analysis adjusting for time to CT scan revealed the following predictors of fatal outcome: anteroseptal shift ≧5 mm (OR 10.9; 95% CI 3.2–37.6), NIHSS within 48 h >20 (OR 6.6; 95% CI 2.3–19.3), and infarction beyond the MCA territory (OR 4.9; 95% CI 1.6–15.0). Conclusions: We identified the role of early CT signs in predicting death following massive MCA infarction. The CT parameters anteroseptal shift (>5 versus ≤5 mm), pineal shift ≧2 mm, hydrocephalus, temporal lobe infarction, and other vascular territory infarction if present were predictive of fatal outcome. These CT parameters require prospective validation before they should be considered reliable markers for decision-making.

Timing of neurologic deterioration in massive middle cerebral artery infarction: a multicenter review.

To determine the time interval between symptom onset and neurologic deterioration related to cerebral edema in patients with massive middle cerebral artery infarction. The time period between onset and neurologic deterioration represents the window for surgical intervention. Multicenter retrospective chart review. Five university-affiliated medical centers. Fifty-three patients with massive middle cerebral artery infarction who experienced neurologic deterioration defined by a decrease in the Glasgow Coma Scale score of two or more points attributable to mass effect. A total of 53 patients (mean age, 62 +/- 18 yrs; 25 [47%] were men) with neurologic deterioration were identified by using International Classification of Diseases (9th revision) codes and local registries. Medical records and neuroimaging studies were reviewed by a stroke neurologist or neurointensivist to identify the time of neurologic deterioration. Thrombolytics were used at presentation in 19 (35%) patients. A total of 19 (36%) patients had neurologic deterioration within 24 hrs of symptom onset. By 48 hrs, 36 (68%) patients had manifested clinical deterioration. A few patients had later neurologic deterioration on day 3 (n = 10), day 4 (n = 2), day 5 (n = 2), and day 6 or after (n = 3). A total of 25 (47%) of the 53 patients died during hospitalization. The highest frequency of deaths occurred on day 3. Neurologic deteriorations related to cerebral edema after massive middle cerebral artery infarction occur in most patients within 48 hrs of symptom onset.

818 Functional Outcome after Decompressive Hemicraniectomy for Massive Middle Cerebral Artery Infarction: Results of an Open Prospective Study

818 Functional Outcome after Decompressive Hemicraniectomy for Massive Middle Cerebral Artery Infarction: Results of an Open Prospective Study

818 Functional Outcome after Decompressive Hemicraniectomy for Massive Middle Cerebral Artery Infarction: Results of an Open Prospective Study

818 Functional Outcome after Decompressive Hemicraniectomy for Massive Middle Cerebral Artery Infarction: Results of an Open Prospective Study

DECOMPRESSIVE CRANIECTOMY FOR MASSIVE CEREBRAL INFARCTION—A JOINT‐CENTRE EXPERIENCE *

Massive cerebral infarction often carries a high mortality rate despite the best medical treatment.1 Over the recent years there has been renewed interest in the use of decompressive surgery for the treatment of malignant cerebral oedema secondary to cerebral infarction.2–5 The procedure involves the fashioning of a large craniectomy and dural augmentation which creates extra space to accommodate the brain swelling so as to relieve or prevent life‐threatening transtentorial herniation. In this review, we report our experience with this treatment modality at two local neurosurgical centres.We performed a retrospective analysis of nine consecutive patients who underwent decompressive craniectomy for massive middle cerebral artery (MCA) infarction from January 1999 to June 2000. Five patients were treated at Queen Mary Hospital and four at Pamela Youde Eastern Hospital. Only patients who suffered from supratentorial ischaemic infarction involving the MCA territory, secondary to either thrombo‐embolism or arterial dissection were included. Those who suffered from cerebellar infarction and post‐traumatic brain swelling were excluded.Decompressive craniectomy is effective in combating malignant cerebral oedema following massive MCA infarction. The procedure can improve patient survival although residual functional deficit may be significant. Timing of surgical intervention and more well‐defined patient selection criteria would be the key to more efficacious and rational application of this treatment option.

Cardiovascular complications in patients with massive middle cerebral artery infarction

P242 Background: Patients with cerebral infarction have a high frequency of underlying cardiac diseases. Acute cardiac events may be observed in patients with massive middle cerebral artery (MCA) infarction due to the severity of neurological insult. We performed this study to determine the frequency of acute cardiac events in this patient population and their impact on outcome and management. Methods: Patients with massive MCA infarction were identified at five university affiliated medical centers using ICD-9 codes or local stroke registries. The medical and neuroimaging records were reviewed at each center by a neurointensivist or stroke neurologist. Only patients who underwent neurological deterioration, defined as a decline in Glasgow Coma Scale (GCS) score of ≥2, attributable to cerebral edema were included. All cardiac events and treatment required during hospitalization were recorded. Outcome was determined at 1 month using Glasgow outcome scores and modified Rankin scale. Results: A total of 54 patients (mean age 62.5±18.0 years; 26 were men) were studied. Underlying cardiac diseases included myocardial infarction (24%), congestive heart failure (20%), and dysrythmias (24%). A total of 16 patients had new cardiac events during hospitalization. These included atrial fibrillation (n=8), atrial flutter (n=1), ventricular fibrillation (n=1), ventricular tachycardia (n=2), myocardial infarction (n=2), and pulmonary edema (n=5); 3 patients had more than one event. Treatment was required for 10 of 16 (62%) events; 3 (19%) were fatal. Overall mortality was higher in patients who developed acute cardiac events during hospitalization (69%) compared to those who did not (40%, p&lt;0.05). The mean Glasgow outcome score was 4.4±1.1 and 3.7±1.1 in patients with or without cardiac events. Conclusions: Our study demonstrates the relatively high frequency of acute cardiac events in patients with massive MCA infarction and their impact on outcome. Patients with massive MCA infarctions should be managed in settings suited for effective monitoring and management of cardiovascular emergencies.

Cardiovascular complications in patients with massive middle cerebral artery infarction

P242 Background: Patients with cerebral infarction have a high frequency of underlying cardiac diseases. Acute cardiac events may be observed in patients with massive middle cerebral artery (MCA) infarction due to the severity of neurological insult. We performed this study to determine the frequency of acute cardiac events in this patient population and their impact on outcome and management. Methods: Patients with massive MCA infarction were identified at five university affiliated medical centers using ICD-9 codes or local stroke registries. The medical and neuroimaging records were reviewed at each center by a neurointensivist or stroke neurologist. Only patients who underwent neurological deterioration, defined as a decline in Glasgow Coma Scale (GCS) score of ≥2, attributable to cerebral edema were included. All cardiac events and treatment required during hospitalization were recorded. Outcome was determined at 1 month using Glasgow outcome scores and modified Rankin scale. Results: A total of 54 patients (mean age 62.5±18.0 years; 26 were men) were studied. Underlying cardiac diseases included myocardial infarction (24%), congestive heart failure (20%), and dysrythmias (24%). A total of 16 patients had new cardiac events during hospitalization. These included atrial fibrillation (n=8), atrial flutter (n=1), ventricular fibrillation (n=1), ventricular tachycardia (n=2), myocardial infarction (n=2), and pulmonary edema (n=5); 3 patients had more than one event. Treatment was required for 10 of 16 (62%) events; 3 (19%) were fatal. Overall mortality was higher in patients who developed acute cardiac events during hospitalization (69%) compared to those who did not (40%, p Conclusions: Our study demonstrates the relatively high frequency of acute cardiac events in patients with massive MCA infarction and their impact on outcome. Patients with massive MCA infarctions should be managed in settings suited for effective monitoring and management of cardiovascular emergencies.

An Aggressive Approach to Massive Middle Cerebral Artery Infarction

We report favorable outcome after surgical decompression, or strokectomy, guided by xenon-enhanced computed tomographic studies of cerebral blood flow in the setting of potentially fatal swelling from massive cerebral infarction. Retrospective analysis with 3 months to 3 years of follow-up. University of Pittsburgh (Pa) Medical Center, a tertiary care university referral center. Four patients, aged 14 to 46 years, presented with focal neurologic deficits appropriate for a massive middle cerebral artery infarction (two dominant and two nondominant). In spite of medical therapy, all patients deteriorated to at least a decreased level of consciousness. Using xenon-enhanced computed tomographic studies of cerebral blood flow in three patients, areas of severely ischemic (blood flow, < 5 mL/100 g per minute), nonviable brain were identified and resected. Outcome was measured by survival and ability to perform activities of daily living. Postoperatively, all patients recovered rapidly (< 6 hours) to the level of function at admission and were able to perform the activities of daily living with minimal or no assistance. Despite deficits appropriate to the area of infarction, prompt management of life-threatening postinfarction swelling by surgical decompression can yield favorable outcome.