====== Malignant middle cerebral artery territory infarction ====== {{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1ncuFVMRo4HsVSCTmDlVckLlZKjicfk4QiTeOLAIsPbUgaks8W/?limit=15&utm_campaign=pubmed-2&fc=20230826061551}} ---- ---- The term [[Malignant]] [[middle cerebral artery]] [[infarction]] was coined in [[1996]], describing a severe [[hemisphere syndrome]] with characteristic symptoms and a predictable clinical course including [[hemiparesis]], eye, and head deviation, a progressive decline in [[consciousness]], [[pupillary dilatation]], and increased [[intracranial pressure]] ((Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R. ‘Malignant’ middle cerebral artery territory infarction: clinical course and prognostic signs.Arch Neurol. 1996; 53:309–315. doi: 10.1001/archneur.1996.00550040037012)). ===== General information ===== The malignant [[middle cerebral artery]] territory [[infarction]] is a distinct [[syndrome]] that occurs in up to 10% of [[stroke]] patients, ((Moulin DE, Lo R, Chiang J, et al. Prognosis in Middle Cerebral Artery Occlusion. Stroke. 1985;16:282–284)) ((Hacke W, Schwab S, Horn M, et al. Malignant Middle Cerebral Artery Territory Infarction: Clinical Course and Prognostic Signs. Arch Neurol. 1996; 53:309–315)) which carries a mortality of up to 80% (mostly due to severe postischemic [[cerebral edema]] → increased [[ICP]] → [[herniation]] ((Hacke W, Schwab S, Horn M, et al. Malignant Middle Cerebral Artery Territory Infarction: Clinical Course and Prognostic Signs. Arch Neurol. 1996; 53:309–315)) Patients usually present with findings of severe hemispheric [[stroke]] ([[hemiplegia]], forced eye and head deviation) often with [[CT]] findings of major [[infarct]] within the first 12 hours. Most develop [[drowsiness]] shortly after [[admission]]. There is progressive deterioration during the first 2 days, and subsequent [[transtentorial herniation]] usually within 2–4 days of stroke. Fatalities are often associated with: severe drowsiness, dense hemiplegia, age > 45–50 yrs, ((Wijdicks EFM, Diringer MN. Middle Cerebral Artery Territory Infarction and Early Brain Swelling: Progression and Effect of Age on Outcome. Mayo Clin Proc. 1998; 73:829–836)) early parenchymal hypodensity involving > 50% of the [[MCA]] distribution on CT scan,23 midline shift > 8–10 mm, early sulci effacement, and [[hyperdense artery sign]] (p. 1354) ((Wijdicks EFM, Diringer MN. Middle Cerebral Artery Territory Infarction and Early Brain Swelling: Progression and Effect of Age on Outcome. Mayo Clin Proc. 1998; 73:829–836)) in MCA. Neurosurgeons may become involved in caring for these patients because aggressive therapies in these patients may reduce morbidity and mortality. Options include: 1. conventional measures to control ICP (with or without ICP monitor): mortality is still high in this group and elevated ICP is not a common cause of initial neurologic deterioration in large hemispheric stroke 2. [[hemicraniectomy]] ([[decompressive craniectomy]]): 3. ✖ to date, the following treatments have not improved outcome: agents to lyse clot, [[hyperventilation]], [[mannitol]], or [[barbiturate coma]]. ---- In patients with severe [[middle cerebral artery]] (MCA), intracranial atherosclerotic disease (ICAD), the mechanism of stroke is multifactorial, but hemodynamic insufficiency plays a significant role. This finding is important in selecting a subgroup of patients who may benefit from revascularization ((Dubow JS, Salamon E, Greenberg E, Patsalides A. Mechanism of Acute Ischemic Stroke in Patients with Severe Middle Cerebral Artery Atherosclerotic Disease. J Stroke Cerebrovasc Dis. 2014 Jan 11. pii: S1052-3057(13)00425-4. doi: 10.1016/j.jstrokecerebrovasdis.2013.10.015. [Epub ahead of print] PubMed PMID: 24424333.)). ===== Clinical features ===== see [[Malignant middle cerebral artery syndrome]]. ===== Diagnosis ===== [[Malignant middle cerebral artery territory infarction diagnosis]]. ===== Treatment ===== [[Malignant middle cerebral artery territory infarction treatment]]. ===== Complications ===== [[Malignant Cerebral Edema]] ===== Outcome ===== [[Malignant middle cerebral artery territory infarction outcome]]. ===== Retrospective cohort studies ===== Patients with acute ischemic stroke (AIS) of the MCA territory were retrospectively enrolled between January 2019 and July 2022. Patients were divided into two groups according to the follow-up CT after 24-48 hours: malignant and nonmalignant infarction. NWUs were measured on diverse ASPECT regions on admission non-contrast CT, namely affected ASPECTS-NWU (af-ASPECTS-NWU), subcortical ASPECTS-NWU (sc-ASPECTS-NWU), and cortical ASPECTS-NWU (c-ASPECTS-NWU). Baseline characteristics were collected for univariate analyses and multivariate regression analyses to explore the independent risk factors for malignant infarction. Receiver operating characteristic (ROC) curves were plotted and compared. Results: patients were included in the final analysis. Malignant MCA infarction was achieved in 42 (27.45%) patients and nonmalignant was 111 (72.55%). Compared with the nonmalignant infarction group, higher baseline National Institute of Health stroke scale (NIHSS) score, af-ASPECTS-NWU, c-ASPECTS-NWU, sc-ASPECTS-NWU, and lower ASPECTS were noted in the malignant infarction group (all P < 0.001). Multivariate logistic regression showed that only baseline sc-ASPECTS-NWU (>3.6%) was a positive factor for malignant MCA infarction. The ROC analysis indicated the highest predictive value of sc-ASPECTS-NWU for indicating malignant infarction with the area under ROC curve (AUC) 0.91. Conclusion: Higher baseline sc-ASPECTS-NWU was a quantitative predictor for malignant MCA infarction in patients with AIS, which could be helpful for treatment decisions ((Wang J, Xiong X, Ma Y, Yin Y, Ye J, Fu J. Higher baseline subcortical net water uptake in computed tomography predicts malignant middle cerebral artery infarction in patients with acute ischemic stroke. Clin Radiol. 2024 Aug 6:S0009-9260(24)00411-2. doi: 10.1016/j.crad.2024.08.001. Epub ahead of print. PMID: 39198107.)) ---- Rodríguez-Vázquez et al. retrospectively analyzed 253 patients from a single-center registry presenting with acute, severe, proximal large vessel occlusion studied with [[Whole-brain CT perfusion imaging]] at hospital arrival within the first 24 h of symptoms-onset. MCI was defined by clinical and imaging criteria, including decreased level of consciousness, anisocoria, death due to cerebral edema, or need for decompressive craniectomy, together with midline shift ⩾6 mm, or infarction of more than 50% of the MCA territory. The predictive accuracy of baseline ASPECTS and CTP quantifications for MCI was assessed by receiver operating characteristic (ROC) area under the curve (AUC) while F-score was calculated as an indicator of precision and sensitivity. Results: Sixty-three out of 253 patients (25%) fulfilled MCI criteria and had worse clinical and imaging results than the non-MCI group. The capacity to predict MCI was lower for baseline ASPECTS (AUC 0.83, F-score 0.52, Youden's index 6), than with perfusion-based measures: relative cerebral blood volume threshold <40% (AUC 0.87, F-score 0.71, Youden's index 34 mL) or relative cerebral blood flow threshold <35% (AUC 0.87, F-score 0.62, Youden's index 67 mL). CTP based on rCBV measurements identified twice as many MCI as baseline CT ASPECTS. Discussion and conclusion: CTP-based quantifications may offer enhanced predictive capabilities for MCI compared to non-contrast baseline CT ASPECTS, potentially improving the monitoring of severe ischemic stroke patients at risk of life-threatening edema and its treatment ((Rodríguez-Vázquez A, Laredo C, Reyes L, Dolz G, Doncel-Moriano A, Llansó L, Rudilosso S, Llull L, Renú A, Amaro S, Torné R, Urra X, Chamorro Á. Computed tomography perfusion as an early predictor of malignant cerebral infarction. Eur Stroke J. 2024 Jun 13:23969873241260965. doi: 10.1177/23969873241260965. Epub ahead of print. PMID: 38872264.)) ===== Case series ===== A total of 17 patients, aged between 34 and 70 years, diagnosed with malignant MCA infarction with radiological edema and mid-line shift, who underwent decompressive surgery, were eligible. From the records, we collected data on age, sex, preoperative and postoperative Glasgow Coma Scale (GCS) scores, National Institutes of Health Stroke Scale (NIHSS) score, the degree of disability in the preoperative period and three months postoperatively through the scores on the Modified Rankin Scale (MRS), and the preoperative and postoperative midline shift measured by computed tomography (CT) scans of the brain. Results: Preoperatively, the mean GCS score was of 8 (range: 7.7-9.2), whereas it was found to be of 12 (range 10-14) on the first postoperative day (p = 0.001). The mean preoperative NIHSS score was of 21.36 ± 2.70 and, on the first postoperative day, it was of 5.30 ± 0.75 (p < 0.001). As for the midline shift, the mean preoperative value was of 1.33 ± 0.75 cm, and, on the first postoperative day, 0.36 ± 0.40 cm (p < 0.001). And, regarding the ONSD, the mean preoperative measurement was of 5.5 ± 0.1 mm, and, on the first postoperative day, it was of 5 ± 0.9 mm (p < 0.001). Conclusion: The ocular US measurement of the ONSD for the preoperative and postoperative monitoring of the ICP seems to be a practical and useful method ((Senol O, Cosgun Z, Dagistan E, Demiryurek BE, Cancan SE. Role of the optic nerve sheath diameter in the assessment of the effectiveness of decompressive surgery after malignant middle cerebral artery infarction. Arq Neuropsiquiatr. 2022 Jul;80(7):671-675. English. doi: 10.1055/s-0042-1754345. Epub 2022 Sep 29. PMID: 36254438.)). ===== Case reports ===== A case of a child with serological evidence of [[SARS-CoV-2]] infection whose onset was a massive right cerebral artery ischemia that led to a malignant [[cerebral infarction]]. The patient underwent a life-saving [[decompressive hemicraniectomy]], with good functional [[recovery]], except for residual [[hemiplegia]]. During [[rehabilitation]], the patient also developed a lower extremity [[peripheral nerve]] [[neuropathy]], likely related to a long-Covid syndrome ((Scala MR, Spennato P, Cicala D, Piccolo V, Varone A, Cinalli G. [[Malignant cerebral infarction]] associated with [[COVID-19]] in a [[child]]. Childs Nerv Syst. 2021 Jun 26. doi: 10.1007/s00381-021-05273-x. Epub ahead of print. PMID: 34175976.)). ---- A 39-year-old woman in the 24th week of pregnancy who suffered a right malignant MCA infarction that eventually required DC. The patient delivered a healthy baby and underwent a second surgery for cranioplasty 7 months later. ((Fernández García A, Jiménez Zapata HD, de Lera Alfonso MC, Sánchez Fernández C, Jiménez Arribas P, Rodríguez Arias CA. Decompressive Craniectomy in Pregnant Women. J Neurol Surg A Cent Eur Neurosurg. 2021 Jun 2. doi: 10.1055/s-0041-1726108. Epub ahead of print. PMID: 34077979.)). ===== References =====