Malignant middle cerebral artery infarction.
OBJECTIVE
This review will report on the new aspects of management of 'malignant' middle cerebral artery (MCA) infarctions.


RESULTS
Large MCA infarctions have been associated with high death rates for years. The most reliable predictors of a 'malignant' course are hypodensity in more than 50% of the MCA territory on computed tomography as well as stroke volume greater than 145  ml on diffusion-weighted imaging. Real-time neuromonitoring may be helpful in the detection of development of cerebral edema. The attempt of recanalization of the affected artery utilizing a combination of intravenous and intra-arterial thrombolysis and mechanical thrombectomy is crucial. Monitoring of intracranial pressure has not been proven helpful. Decompressive surgery within 48  h after symptom onset in patients less than 60 years old reduces mortality and severe disability. The quality of life perceived by the survivors is variable and deserves further study. The neuroprotective effect of hypothermia requires additional investigation.


CONCLUSIONS
The era of decompressive hemicraniectomy has changed the prospects of patients with large infarctions in the MCA or internal carotid artery territory who are at risk of development of 'malignant' cerebral edema. Timing of surgery and appropriate patient selection based on age and other criteria need to be refined.
Neurointensive Care Unit, Martin-Luther-University, Halle-Wittenberg, Halle, Germany. katja.wartenberg@medizin.uni-halle.de
Katja E
KE
Wartenberg
D001929:Brain Edema / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D002545:Brain Ischemia / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D019299:Decompression, Surgical / Q000379:methods; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D018810:Magnetic Resonance Angiography; D008297:Male; D017131:Thrombectomy; D015912:Thrombolytic Therapy; D014057:Tomography, X-Ray Computed
D005343:Fibrinolytic Agents