Predictors for malignant middle cerebral artery infarctions: a postmortem analysis.
BACKGROUND
Early detection of malignant infarction of the middle cerebral artery (MI-MCA) is important because of possible treatment by hemicraniectomy.


OBJECTIVE
To investigate the anatomic and vascular predictors of MI-MCA.


METHODS
The authors evaluated 192 consecutive autopsies of patients with nonlacunar cerebral infarction affecting the MCA territory. MI-MCA was defined by an infarct with temporal or central brain herniation and brain swelling. The autopsy protocol included a systematic analysis of intracranial arteries (including the bony segments of carotid and vertebral arteries and the circle of Willis), extracranial arteries, the aortic arch, and the heart.


RESULTS
A total of 45 patients with MI-MCA were identified. Their median (range) survival time was 6 (0 to 20) days as compared with 18 (0 to 2,040) days for non-MI-MCA patients. Compared with non-MI-MCA, MI-MCA cases more frequently involved the superficial and deep MCA territory and were more frequently associated with anterior cerebral and anterior choroidal artery territory infarcts. Hemorrhagic transformation, Duret hemorrhages, carotid occlusion, and ipsilateral abnormalities of the circle of Willis were also more frequent (p < 0.05). Multivariable analysis showed that younger age, female sex, absence of stroke history, higher heart weight, carotid artery occlusion, and abnormal circle of Willis ipsilaterally were all independently associated with MI-MCA (p < 0.03).


CONCLUSIONS
Typical pathologic pattern for development of malignant infarction of the middle cerebral artery is a carotid occlusion with abnormal ipsilateral circle of Willis in a young patient who had a first-ever large hemispheric stroke including the superficial territory with possibly a slight predominance of female sex.
APHP, Department of Neuropathology Raymond Escourolle, Salpetrière Hospital, Pierre and Marie Curie University, Paris, France. pierre.amarenco@bch.aphp.fr
A
A
Jaramillo
F
F
Góngora-Rivera
J
J
Labreuche
J-J
JJ
Hauw
P
P
Amarenco
D000368:Aged; D000369:Aged, 80 and over; D001929:Brain Edema / Q000453:epidemiology / Q000473:pathology; D002545:Brain Ischemia / Q000453:epidemiology / Q000473:pathology; D002941:Circle of Willis / Q000473:pathology; D016208:Databases, Factual / Q000706:statistics & numerical data; D003933:Diagnosis; D005260:Female; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000453:epidemiology* / Q000473:pathology*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D018709:Statistics, Nonparametric