Makindo Medical Notes

Related Subjects: |Acute Stroke Assessment (ROSIER&NIHSS) |Causes of Stroke |Ischaemic Stroke |Cancer and Stroke |Cardioembolic stroke |CT Basics for Stroke

Introduction

• Malignant MCA syndrome may occur following a large MCA territory infarct.
• Typically presents 2-5 days post-onset of stroke but can occur earlier, within 24 hours.
• Characterized by localized cytotoxic oedema, swelling, and often midline shift.
• Trials have shown that surgery can reduce mortality and improve functional status, though it may increase survival among patients with severe disabilities.

Aetiology

• MCA occlusion may result from atheroembolism.
• Cardioembolism, often due to atrial fibrillation (AF) or structural cardiac disease.
• Carotid dissection may also cause embolism to the MCA.

Clinical Presentation

• Presents with left/right MCA syndrome.
• Progressive reduction in level of consciousness.
• Pupillary changes and Cheyne-Stokes respiration may be observed.

Images

Investigations

• CT Scan: May initially appear normal or show a hyperdense artery. Over time, progressive hypodensity, cytotoxic oedema, and midline shift may become evident.
• MRI: Provides a detailed view of infarct volume and extent.

RCP Guidance 2016

• Patients with middle cerebral artery (MCA) infarction meeting the criteria below should be considered for decompressive hemicraniectomy:
  • Pre-stroke modified Rankin Scale score of less than 2
  • Clinical deficits indicating infarction in the territory of the MCA
  • NIHSS score greater than 15
  • Decreased level of consciousness (NIHSS score of 1 or more on item 1a)
  • CT evidence of infarct in at least 50% of the MCA territory, or infarct volume > 145 cm³ on diffusion-weighted MRI

Management

• Despite interventions for intracranial pressure (ICP), such as intubation, osmotherapy, and hyperventilation, mortality can reach up to 80% without surgical intervention.
• Decompressive hemicraniectomy with durotomy involves removing a large skull flap and dura, allowing the brain to expand beyond the skull and reducing brainstem compression.
• Patient selection should consider the patient’s wishes, baseline functional status, and comorbidities. Poor functional baseline may suggest that surgery is not in the patient's best interests.
• Imaging showing involvement of the posterior cerebral artery (PCA) or anterior cerebral artery (ACA), or an infarct volume > 145 cm³, is associated with poorer outcomes.
• The DESTINY II trial demonstrated survival benefits for patients over 60, comparable to younger patients, though decisions should be individualized and not based on age alone.

References