Massive Middle Cerebral Artery 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.

Strokectomy and Extensive Cisternal CSF Drain for Acute Management of Malignant Middle Cerebral Artery Infarction: Technical Note and Case Series.

Background and Purpose: Ischemic stroke is a major cause of death and disability worldwide. Large MCA stroke may evolve as malignant space occupying lesion and mortality rate reaches 80% despite maximal medical therapy. Early decompressive craniectomy is effective in reducing mortality and improving the functional outcome but is an extended and invasive surgical approach burdened with a significant complication rate. We report a surgical treatment based on partial strokectomy and basal cisterns opening with massive CSF drain.Materials and Methods: We retrospectively collected 15 cases of massive middle cerebral artery stroke treated with strokectomy between 2010 and 2017: nine males and six females, mean age 61.73 ± 9.5 years. The right side was affected in 66.7%. All patients show clinical deterioration despite standard medical therapy and indication for surgery was placed after collegiate evaluation by neurologists and neurosurgeons based on clinical and radiological data.Results: Surgical procedure was performed 24–96 h after the stroke onset. All the 15 patients survived the intervention, one patient died 20 days after the admission for massive lung embolism. Mean GCS and NIHSS at admission were 12.6 ± 1.18 (range 9–15) and 19.7 ± 2.3 (range 18–23), respectively. Mean mRS at 12 months was 3.6 ± 1.1 (range 2–6). Mean follow-up was 18.1 months (range 12–34). The outcome was evaluated as satisfactory (mRs ≤ 3) in 8 patients (53.3%). Mortality at 1 year was 6.7%. No patients developed hydrocephalus and 1 presented seizures. According to mRs outcome evaluation (mRs ≤ 3 vs. mRs ≥ 4) no quantitative variable resulted significantly different between the two groups, whereas the concomitant use of iv rTPA significantly differed (P < 0.05).Conclusion: Supratentorial strokectomy seems to be safe and could be a potential alternative to decompressive craniectomy for the acute management of malignant MCA stroke. Advantages of this approach could be low complication rate, avoidance of bone reconstruction procedure, and reduced occurrence of hydrocephalus or seizures. A co-operative multicentric, prospective pilot study will be necessary to validate this technical approach.

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

Timing of Symptomatic Infarct Swelling Following Intravenous Thrombolysis in Acute Middle Cerebral Artery Infarction: A Case–Control Study

The risk of symptomatic infarct swelling has been reported to be higher in patients treated with recombinant tissue plasminogen activator (rt-PA). The aim of this study was to evaluate the timing of symptomatic infarct swelling after rt-PA treatment. We retrospectively analyzed 14 868 patients with acute ischemic stroke from a stroke registry databank. We recruited patients with massive middle cerebral artery (MCA) infarction and symptomatic infarct swelling and excluded those with parenchymal or symptomatic hemorrhage. Multiple linear regression and multivariate logistic regression analyses were used to estimate the impact of rt-PA on the timing of symptomatic infarct swelling. A total of 23 patients with rt-PA treatment and 117 patients without rt-PA treatment were included. The rt-PA treatment group had a lower rate of coronary artery disease (8.7% vs 32.5%; P = .023), lower severity of baseline National Institutes of Health Stroke Scale score (19 vs 23; P = .014), shorter duration of infarct swelling (27.6 vs 45.4 hours; P < .001), and higher rate of hemicraniectomy surgery (65.2% vs 28.2%; P =.001) than those without rt-PA treatment. After adjusting for variables in multiple linear regression analysis, rt-PA treatment and an elevated C-reactive protein level were associated with early symptomatic infarct swelling ( P = .014 and P = .041, respectively). The rt-PA treatment was an independent factor related to early symptomatic infarct swelling within 36 hours ( P = .005; odds ratio [OR]: 5.3; confidence interval [CI]: 1.65-17.0) or 48 hours ( P = .009; OR: 16.4; CI: 2.00-134). Intravenous rt-PA treatment may hasten the onset of cerebral edema and subsequent cerebral herniation in large MCA territory infarction.

Malignant middle-cerebral artery territory infarction in tuberculous vasculitis

Intracranial large vessel involvement is an unusual complication of tuberculous meningitis. The authors report a 39-year-old female presenting with an episode of seizure, followed by rapid decline in sensorium without prominent systemic features. An initial cranial magnetic resonance imaging revealed tuberculomata and patchy infarcts. Despite antituberculous therapy, she progressively worsened. A cranial computed tomography scan done following the worsening revealed a massive middle-cerebral artery (MCA) infarct. Unfortunately, the patient died in spite of decompressive craniotomy. Malignant MCA territory infarct is a rare and potentially fatal complication of tuberculous meningitis.

An Unusual Association between Unilateral Intracranial Vessels Occlusion with Iron Deficiency Anaemia and Alpha-Thalassemia Trait: A Case Report

We report a 33-year-old Malay woman presented with acute left dense hemiparesis and an NIHSS score of 11/15. Computed tomography (CT) scan brain showed a massive right middle cerebral artery (MCA) territory infarct. The right internal carotid artery (ICA) and right proximal MCA were shown occluded from digital substraction angiography (DSA). Carotid dissection, carotid canal anomaly, and intercavernous communication were systematically ruled out. She had no risk factors for atherosclerosis. The connective tissue screening and thrombophilic markers were negative. However, she was anaemic on admission and subsequent investigations revealed that she had alpha-thalassemia and iron deficiency anaemia. The right ICA remained occluded from a repeat CT cerebral angiogram after one year, but otherwise she was neurologically stable. This case illustrates an unusual association between intracranial vessel occlusion with iron deficiency anaemia and alpha-thalassemia trait.

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.

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.

Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review.

Hemicraniectomy and durotomy have been proposed in many small series to relieve intracranial hypertension and tissue shifts in patients with large hemispheric infarcts, thereby preventing death from herniation. Our objective was to review the literature to identify patients most likely to benefit from hemicraniectomy. All available individual cases from the English literature were reviewed and analyzed to determine whether age, vascular territory of infarction, side of infarction, reported time to surgery, and signs of herniation predict outcome in patients after hemicraniectomy. All studies included were retrospective and uncontrolled; there were no randomized controlled trials. Of 15 studies screened, 12 studies describing 129 patients met the criteria for analysis; 9 patients treated at our institution were added, for a total of 138 patients. After a minimum follow-up of 4 months, 10 patients (7%) were functionally independent, 48 (35%) were mildly to moderately disabled, and 80 (58%) died or were severely disabled. Of 75 patients who were >50 years of age, 80% were dead or severely disabled compared with 32% of 63 patients <or=50 years of age (P<0.00001). The timing of surgery, hemisphere infarcted, presence of signs of herniation before surgery, and involvement of other vascular territories did not significantly affect outcome. Age may be a crucial factor in predicting functional outcome after hemicraniectomy in patients with large middle cerebral artery territory infarction.

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.

Multimodal Monitoring in MCA Stroke

Patients with massive middle cerebral artery (MCA) infarction often develop malignant cerebral edema, which is heralded by clinical deterioration with

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.