title: Malignant hemispheric infarction of the middle cerebral artery. Diagnostic considerations and treatment options.
abstract: BACKGROUND
  Malignant hemispheric infarction (MHI) is a specific and devastating type of ischemic stroke. It usually affects all or part of the territory of the middle cerebral artery although its effects may extend to other territories as well. Its clinical outcome is frequently catastrophic when only conventional medical treatment is applied.
  
  
  OBJECTIVE
  The purpose of this review is to analyse the available scientific evidence on the treatment of this entity.
  
  
  METHODS
  MHI is associated with high morbidity and mortality. Its clinical characteristics are early neurological deterioration and severe hemispheric syndrome. Its hallmark is the development of space-occupying cerebral oedema between day 1 and day 3 after symptom onset. The mass effect causes displacement, distortion, and herniation of brain structures even when intracranial hypertension is initially absent. Until recently, MHI was thought to be fatal and untreatable because mortality rates with conventional medical treatment could exceed 80%. In this unfavourable context, decompressive hemicraniectomy has re-emerged as a therapeutic alternative for selected cases, with reported decreases in mortality ranging between 15% and 40%.
  
  
  CONCLUSIONS
  In recent years, several randomised clinical trials have demonstrated the benefit of decompressive hemicraniectomy in patients with MHI. This treatment reduces mortality in addition to improving functional outcomes.
authors.affiliation: Unidad de Terapia Intensiva, Hospital San Juan Bautista, Catamarca, Argentina; Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, Catamarca, Argentina. Electronic address: dagodoytorres@yahoo.com.ar.
authors.forename: D
authors.initials: D
authors.lastname: Godoy
authors.affiliation: Unidad de Terapia Intensiva, Hospital Municipal Leonidas Lucero, Bahía Blanca, Buenos Aires, Argentina.
authors.forename: G
authors.initials: G
authors.lastname: Piñero
authors.affiliation: Department of Neurology & Psychiatry, Saint Louis University School of Medicine, Saint Louis, Estados Unidos.
authors.forename: S
authors.initials: S
authors.lastname: Cruz-Flores
authors.affiliation: Facultad de Medicina, Universidad de Cartagena, Cartagena, Colombia.
authors.forename: G
authors.initials: G
authors.lastname: Alcalá Cerra
authors.affiliation: Neuroscience ICU and Regional Acute Stroke Program Mayo Clinic, Rochester, MN, Estados Unidos.
authors.forename: A
authors.initials: A
authors.lastname: Rabinstein
mesh_terms: D001929:Brain Edema / Q000209:etiology*; D019299:Decompression, Surgical / Q000379:methods*; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D019586:Intracranial Hypertension; D008279:Magnetic Resonance Imaging; D014057:Tomography, X-Ray Computed
keywords: Cerebral infarction; Cerebral oedema; Decompressive hemicraniectomy; Edema cerebral; Hemicraniectomía descompresiva; Ictus isquémico; Infarto cerebral; Infarto maligno; Ischaemic stroke; Malignant infarction