Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
Current Atherosclerosis Reports
Published in: Current Atherosclerosis Reports 7/2015

01-07-2015 | Cardiovascular Disease and Stroke (S Prabhakaran, Section Editor)

Malignant MCA Stroke: an Update on Surgical Decompression and Future Directions

Authors: Carolina B. Maciel, Kevin N. Sheth

Published in: Current Atherosclerosis Reports | Issue 7/2015

Login to get access

Abstract

Despite a decline over the past decade in overall stroke mortality, hemispheric strokes retain a strikingly high mortality due to their potential for malignant edema and herniation. The pathogenesis of ischemic cerebral edema is steered by disruption of ionic homeostasis in the neurogliovascular unit. Significant effort has been made to identify potential medical therapies targeting edema formation with promising results. To date, decompressive craniectomy remains the therapy with the most robust impact on mortality. Historically, patient selection for surgical treatment of malignant supratentorial strokes has focused on a strict age cutoff and hemispheric dominance. Recent evidence supports a significant mortality benefit in elderly population, although the impact in morbidity is modest. Careful patient selection for surgical treatment in conjunction with comprehensive neurocritical care and inclusion of family in the educated decision making process remain the mainstay of care for such shattering disease.
Literature
1.
Mozaffarian D, et al. Heart Disease and stroke statistics-2015 update: a report from the American Heart Association. Circulation. 2014.
2.
Heinsius T, Bogousslavsky J, Van Melle G. Large infarcts in the middle cerebral artery territory. Etiology and outcome patterns. Neurology. 1998;50(2):341–50.PubMedCrossRef
3.
Shimoyama T et al. The DASH score: a simple score to assess risk for development of malignant middle cerebral artery infarction. J Neurol Sci. 2014;338(1–2):102–6.PubMedCrossRef
4.
Huttner HB, Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol. 2009;8(10):949–58.PubMedCrossRef
5.
Hacke W et al. ‘Malignant’ middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol. 1996;53(4):309–15.PubMedCrossRef
6.
Beck C et al. A simple brain atrophy measure improves the prediction of malignant middle cerebral artery infarction by acute DWI lesion volume. J Neurol. 2014;261(6):1097–103.PubMedCrossRef
7.
Scarcella G. Encephalomalacia simulating the clinical and radiological aspects of brain tumor; a report of 6 cases. J Neurosurg. 1956;13(4):278–92.PubMedCrossRef
8.
Schwab S et al. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke. 1998;29(9):1888–93.PubMedCrossRef
9.
Delashaw JB et al. Treatment of right hemispheric cerebral infarction by hemicraniectomy. Stroke. 1990;21(6):874–81.PubMedCrossRef
10.
Young PH, Smith Jr KR, Dunn RC. Surgical decompression after cerebral hemispheric stroke: indications and patient selection. South Med J. 1982;75(4):473–5.PubMedCrossRef
11.
Wirtz CR et al. Hemicraniectomy with dural augmentation in medically uncontrollable hemispheric infarction. Neurosurg Focus. 1997;2(5):E3. discussion 1 p following.PubMedCrossRef
12.
Juttler E et al. Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY): a randomized, controlled trial. Stroke. 2007;38(9):2518–25.PubMedCrossRef
13.
Hofmeijer J et al. Hemicraniectomy after middle cerebral artery infarction with life-threatening Edema trial (HAMLET). Protocol for a randomised controlled trial of decompressive surgery in space-occupying hemispheric infarction. Trials. 2006;7:29.PubMedCentralPubMedCrossRef
14.
Vahedi K et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke. 2007;38(9):2506–17.PubMedCrossRef
15.
Holtkamp M et al. Hemicraniectomy in elderly patients with space occupying media infarction: improved survival but poor functional outcome. J Neurol Neurosurg Psychiatry. 2001;70(2):226–8.PubMedCentralPubMedCrossRef
16.
17.
18.
Menzies SA. Contributions of ions and albumin to the formation and resolution of ischemic brain edema. J Neurosurg. 1993;78(2):257–66.PubMedCrossRef
19.•
O’Donnell ME. Blood–brain barrier Na transporters in ischemic stroke. Adv Pharmacol. 2014;71:113–46. Provides a great overview of transporting mechanisms involved in edema formation in acute ischemic stroke.PubMed
20.
21.
Chechneva OV. Evidence for blood–brain barrier Na-K-Cl cotransport, Na/H exchange and Na-HCO3 cotransport involvement in hyperglycemia exacerbation of cerebral edema formation in ischemic stroke. FASEB J. 2014;27:A222.
22.
23.
Hertz L. Antagonists of the Vasopressin V1 Receptor and of the β(1)-adrenoceptor inhibit cytotoxic brain edema in stroke by effects on astrocytes—but the mechanisms differ. Curr Neuropharmacol. 2014;12(4):308–23.PubMedCentralPubMedCrossRef
24.
Huang LQ et al. Hypertonic saline alleviates cerebral edema by inhibiting microglia-derived TNF-alpha and IL-1beta-induced Na-K-Cl cotransporter up-regulation. J Neuroinflammation. 2014;11:102.PubMedCentralPubMedCrossRef
25.
O’Donnell ME et al. Intravenous HOE-642 reduces brain edema and Na uptake in the rat permanent middle cerebral artery occlusion model of stroke: evidence for participation of the blood–brain barrier Na/H exchanger. J Cereb Blood Flow Metab. 2013;33(2):225–34.PubMedCentralPubMedCrossRef
26.
Lee JH. Effect of propofol post-treatment on blood–brain barrier integrity and cerebral edema after transient cerebral ischemia in rats. Neurochem Res. 2013;38(11):2276–86.PubMedCrossRef
27.
Wang R, et al. Intra-artery infusion of recombinant human erythropoietin reduces blood–brain barrier disruption in rats following cerebral ischemia and reperfusion. Int J Neurosci. 2014.
28.
Yao X. Reduced brain edema and infarct volume in aquaporin-4 deficient mice after transient focal cerebral ischemia. Neurosci Lett. 2015;584:368–72.PubMedCrossRef
29.
Hedna VS et al. Treatment of stroke related refractory brain edema using mixed vasopressin antagonism: a case report and review of the literature. BMC Neurol. 2014;14:213.PubMedCentralPubMedCrossRef
30.
Panahpour H, Nekooeian AA, Dehghani GA. Candesartan attenuates ischemic brain edema and protects the blood–brain barrier integrity from ischemia/reperfusion injury in rats. Iran Biomed J. 2014;18(4):232–8.PubMedCentralPubMed
31.
Arch AE, Sheth KN. Malignant cerebral edema after large anterior circulation infarction: a review. Curr Treat Options Cardiovasc Med. 2014;16(1):275.PubMedCrossRef
32.
Qureshi AI et al. Timing of neurologic deterioration in massive middle cerebral artery infarction: a multicenter review. Crit Care Med. 2003;31(1):272–7.PubMedCrossRef
33.
Bosche B et al. Extracellular concentrations of non-transmitter amino acids in peri-infarct tissue of patients predict malignant middle cerebral artery infarction. Stroke. 2003;34(12):2908–13.PubMedCrossRef
34.
Oppenheim C et al. Prediction of malignant middle cerebral artery infarction by diffusion-weighted imaging. Stroke. 2000;31(9):2175–81.PubMedCrossRef
35.
Sheth KN. Early transfer of patients with stroke to comprehensive centers is necessary. Stroke. 2014;45(12):3748–9.PubMedCrossRef
36.
Battey TW et al. Brain edema predicts outcome after nonlacunar ischemic stroke. Stroke. 2014;45(12):3643–8.PubMedCrossRef
37.
Hofmeijer J et al. Predictors of life-threatening brain edema in middle cerebral artery infarction. Cerebrovasc Dis. 2008;25(1–2):176–84.PubMedCrossRef
38.
Dohmen C et al. Prediction of malignant course in MCA infarction by PET and microdialysis. Stroke. 2003;34(9):2152–8.PubMedCrossRef
39.
Kim H, et al. Predictors of malignant brain edema in middle cerebral artery infarction observed on CT angiography. J Clin Neurosci. 2014.
40.
Bektas H et al. Increased blood–brain barrier permeability on perfusion CT might predict malignant middle cerebral artery infarction. Stroke. 2010;41(11):2539–44.PubMedCentralPubMedCrossRef
41.
Thomalla G et al. Prediction of malignant middle cerebral artery infarction by magnetic resonance imaging within 6 hours of symptom onset: a prospective multicenter observational study. Ann Neurol. 2010;68(4):435–45.PubMedCrossRef
42.
Jaramillo A et al. Predictors for malignant middle cerebral artery infarctions: a postmortem analysis. Neurology. 2006;66(6):815–20.PubMedCrossRef
43.
Minnerup J et al. Prediction of malignant middle cerebral artery infarction using computed tomography-based intracranial volume reserve measurements. Stroke. 2011;42(12):3403–9.PubMedCrossRef
44.
Kasner SE et al. Predictors of fatal brain edema in massive hemispheric ischemic stroke. Stroke. 2001;32(9):2117–23.PubMedCrossRef
45.
Dohmen C et al. Identification and clinical impact of impaired cerebrovascular autoregulation in patients with malignant middle cerebral artery infarction. Stroke. 2007;38(1):56–61.PubMedCrossRef
46.
Burghaus L et al. Evoked potentials in acute ischemic stroke within the first 24 h: possible predictor of a malignant course. Neurocrit Care. 2008;9(1):13–6.PubMedCrossRef
47.
MacCallum C et al. Low Alberta Stroke Program Early CT score (ASPECTS) associated with malignant middle cerebral artery infarction. Cerebrovasc Dis. 2014;38(1):39–45.PubMedCrossRef
48.
Kummer RV. Sensitivity and prognostic value of early CT in occlusion of the middle cerebral artery trunk. Am J Neuroradiol. 1994;15(1):9–15. discussion 16–8.
49.
Lee SH. The effect of brain atrophy on outcome after a large cerebral infarction. J Neurol Neurosurg Psychiatry. 2010;81(12):1316–21.PubMedCrossRef
50.
Dohmen C et al. The severity of ischemia determines and predicts malignant brain edema in patients with large middle cerebral artery infarction. Cerebrovasc Dis. 2012;33(1):1–7.PubMedCrossRef
51.
Menon BK et al. Anterior temporal artery sign in CT angiography predicts reduced fatal brain edema and mortality in acute M1 middle cerebral artery occlusions. J Neuroimaging. 2012;22(2):145–8.PubMedCrossRef
52.
Schneweis S et al. Predictive value of neurochemical monitoring in large middle cerebral artery infarction. Stroke. 2001;32(8):1863–7.PubMedCrossRef
53.
Sykora M et al. Baroreflex sensitivity to predict malignant middle cerebral artery infarction. Stroke. 2012;43(3):714–9.PubMedCrossRef
54.
Burghaus L et al. Early electroencephalography in acute ischemic stroke: prediction of a malignant course? Clin Neurol Neurosurg. 2007;109(1):45–9.PubMedCrossRef
55.
Schneider AL. Regional attenuation without delta (RAWOD): a distinctive EEG pattern that can aid in the diagnosis and management of severe acute ischemic stroke. Am J Electroneurodiagnostic Technol. 2005;45(2):102–17.PubMed
56.
Foerch C et al. Serum S100B predicts a malignant course of infarction in patients with acute middle cerebral artery occlusion. Stroke. 2004;35(9):2160–4.PubMedCrossRef
57.
Burghaus L et al. Prognostic value of electroencephalography and evoked potentials in the early course of malignant middle cerebral artery infarction. Neurol Sci. 2013;34(5):671–8.PubMedCrossRef
58.••
Wijdicks EF et al. Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(4):1222–38. Provides an updated and comprehensive guideline for the management of acute ischemic strokes associated with edema and mass effect.PubMedCrossRef
59.
60.
Kirkman MA, Citerio G, Smith M. The intensive care management of acute ischemic stroke: an overview. Intensive Care Med. 2014;40(5):640–53.PubMedCrossRef
61.
Kaufmann AM, Cardoso ER. Aggravation of vasogenic cerebral edema by multiple-dose mannitol. J Neurosurg. 1992;77(4):584–9.PubMedCrossRef
62.
Grande PO, Romner B. Osmotherapy in brain edema: a questionable therapy. J Neurosurg Anesthesiol. 2012;24(4):407–12.PubMedCrossRef
63.
64.
Paczynski RP et al. Multiple-dose mannitol reduces brain water content in a rat model of cortical infarction. Stroke. 1997;28(7):1437–43. discussion 1444.PubMedCrossRef
65.
Bereczki D. Mannitol for acute stroke. Cochrane Database Syst Rev. 2007;3:CD001153.PubMed
66.
Sandercock PA, Soane T. Corticosteroids for acute ischaemic stroke. Cochrane Database Syst Rev. 2011;(9):Cd000064.
67.
Schwab S. The value of intracranial pressure monitoring in acute hemispheric stroke. Neurology. 1996;47(2):393–8.PubMedCrossRef
68.
Frank JI. Large hemispheric infarction, deterioration, and intracranial pressure. Neurology. 1995;45(7):1286–90.PubMedCrossRef
69.
Poca MA et al. Monitoring intracranial pressure in patients with malignant middle cerebral artery infarction: is it useful? J Neurosurg. 2010;112(3):648–57.PubMedCrossRef
70.
Ropper AH. Brain edema after stroke. Clinical syndrome and intracranial pressure. Archi Neurol (Chicago). 1984;41(1):26–9.CrossRef
71.
Polderman KH. Mechanisms of action, physiological effects, and complications of hypothermia. Crit Care Med. 2009;37(7 Suppl):S186–202.PubMedCrossRef
72.
Wan YH et al. Therapeutic hypothermia (Different Depths, Durations, and Rewarming Speeds) for acute ischemic stroke: a meta-analysis. J Stroke Cerebrovasc Dis. 2014;23(10):2736–47.PubMedCrossRef
73.
van der Worp HB et al. Hypothermia in animal models of acute ischaemic stroke: a systematic review and meta-analysis. Brain. 2007;130(Pt 12):3063–74.PubMedCrossRef
74.
Hong JM et al. Therapeutic hypothermia after recanalization in patients with acute ischemic stroke. Stroke. 2014;45(1):134–40.PubMedCrossRef
75.
Neugebauer H et al. DEcompressive surgery Plus hypoTHermia for Space-Occupying Stroke (DEPTH-SOS): a protocol of a multicenter randomized controlled clinical trial and a literature review. Int J Stroke. 2013;8(5):383–7.PubMedCrossRef
76.
Bendszus M et al. Hemodynamic effects of decompressive craniotomy in MCA infarction: evaluation with perfusion CT. Eur Radiol. 2003;13(8):1895–8.PubMedCrossRef
77.
Kenning TJ. A comparison of hinge craniotomy and decompressive craniectomy for the treatment of malignant intracranial hypertension: early clinical and radiographic analysis. Neurosurg Focus. 2009;26(6):E6.PubMedCrossRef
78.
Vahedi K et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol. 2007;6(3):215–22.PubMedCrossRef
79.
Cruz-Flores S, Berge E, Whittle IR. Surgical decompression for cerebral oedema in acute ischaemic stroke. Cochrane Database Syst Rev. 2012;1:Cd003435.PubMed
80.
Yu JW et al. Outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 70 years old. J Cerebrovasc Endovasc Neurosurg. 2012;14(2):65–74.PubMedCentralPubMedCrossRef
81.
Zhao J et al. Decompressive hemicraniectomy in malignant middle cerebral artery infarct: a randomized controlled trial enrolling patients up to 80 years old. Neurocrit Care. 2012;17(2):161–71.PubMedCrossRef
82.••
Juttler E et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med. 2014;370(12):1091–100. Most current randomized clinical trial of decompressive craniectomy for the treatment of malignant middle cerebral artery strokes in the elderly population.PubMedCrossRef
83.
Gupta R et al. Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review. Stroke. 2004;35(2):539–43.PubMedCrossRef
84.
Arac A et al. Assessment of outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 60 years of age. Neurosurg Focus. 2009;26(6), E3.PubMedCrossRef
85.
Maramattom BV, Bahn MM, Wijdicks EF. Which patient fares worse after early deterioration due to swelling from hemispheric stroke? Neurology. 2004;63(11):2142–5.PubMedCrossRef
86.
87.
Lucas C et al. Decompressive surgery for malignant middle cerebral artery infarcts: the results of randomized trials can be reproduced in daily practice. Eur Neurol. 2012;68(3):145–9.PubMedCrossRef
88.
Neugebauer H, Heuschmann PU, Juttler E. DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY - registry (DESTINY-R): design and protocols. BMC Neurol. 2012;12:115.PubMedCentralPubMedCrossRef
89.
Flechsenhar J et al. Hemicraniectomy in the management of space-occupying ischemic stroke. J Clin Neurosci. 2013;20(1):6–12.PubMedCrossRef
90.
Ozdemir O et al. Early decompressive surgery after combined intra-venous thrombolysis and endovascular stroke treatment. Clin Neurol Neurosurg. 2014;122:66–9.PubMedCrossRef
91.
Sundseth J, et al. Long-term outcome and quality of life after craniectomy in speech-dominant swollen middle cerebral artery infarction. Neurocrit Care. 2014
92.
Kastrau F et al. Recovery from aphasia after hemicraniectomy for infarction of the speech-dominant hemisphere. Stroke. 2005;36(4):825–9.PubMedCrossRef
93.
Wagner S et al. Suboptimum hemicraniectomy as a cause of additional cerebral lesions in patients with malignant infarction of the middle cerebral artery. J Neurosurg. 2001;94(5):693–6.PubMedCrossRef
94.
Creutzfeldt CJ et al. Seizures after decompressive hemicraniectomy for ischaemic stroke. J Neurol Neurosurg Psychiatry. 2014;85(7):721–5.PubMedCrossRef
95.
Pillai A et al. Decompressive hemicraniectomy in malignant middle cerebral artery infarction: an analysis of long-term outcome and factors in patient selection. J Neurosurg. 2007;106(1):59–65.PubMedCrossRef
96.
Ewald C et al. Bone flap necrosis after decompressive hemicraniectomy for malignant middle cerebral artery infarction. Neurocrit Care. 2014;20(1):91–7.PubMedCrossRef
97.
van Middelaar T, et al. Quality of life after surgical decompression for space-occupying middle cerebral artery infarction: systematic review. Int J Stroke. 2014.
98.
Schwarz S, Kuhner C. Prognosis and quality of life after decompressive hemicraniectomy: a nationwide survey in Germany on the attitudes held by doctors and nurses. Nervenarzt. 2012;83(6):731–40.PubMedCrossRef
99.
Geurts M et al. Surgical decompression for space-occupying cerebral infarction: outcomes at 3 years in the randomized HAMLET trial. Stroke. 2013;44(9):2506–8.PubMedCrossRef
100.
McKenna A et al. Decompressive hemicraniectomy following malignant middle cerebral artery infarctions: a mixed methods exploration of carer experience and level of burden. Disabil Rehabil. 2013;35(12):995–1005.PubMedCrossRef
101.
Caso V et al. High diastolic blood pressure is a risk factor for in-hospital mortality in complete MCA stroke patients. Neurol Sci. 2012;33(3):545–9.PubMedCrossRef
102.
Uhl E et al. Outcome and prognostic factors of hemicraniectomy for space occupying cerebral infarction. J Neurol Neurosurg Psychiatry. 2004;75(2):270–4.PubMedCentralPubMed
103.
Tu PH et al. Postoperative midline shift as secondary screening for the long-term outcomes of surgical decompression of malignant middle cerebral artery infarcts. J Clin Neurosci. 2012;19(5):661–4.PubMedCrossRef
Metadata
Title
Malignant MCA Stroke: an Update on Surgical Decompression and Future Directions
Authors
Carolina B. Maciel
Kevin N. Sheth
Publication date
01-07-2015
Publisher
Springer US
Published in
Current Atherosclerosis Reports / Issue 7/2015
Print ISSN: 1523-3804
Electronic ISSN: 1534-6242
DOI
https://doi.org/10.1007/s11883-015-0519-4

Other articles of this Issue 7/2015

Current Atherosclerosis Reports 7/2015 Go to the issue

Nonstatin Drugs (E deGoma, Section Editor)

Lipoprotein Apheresis

Vascular Biology (T Hla, Section Editor)

Prostanoids and NSAIDs in Cardiovascular Biology and Disease

Women and Ischemic Heart Disease (M Gulati, Section Editor)

Primary and Secondary Prevention of Ischemic Heart Disease in Women

Cardiovascular Disease and Stroke (S Prabhakaran, Section Editor)

Dual Antiplatelet Therapy in Acute Ischemic Stroke

Cardiovascular Disease and Stroke (S Prabhakaran, Section Editor)

Carotid Bypass for Carotid Occlusion
Live Webinar | 27-06-2024 | 18:00 (CEST)

Keynote webinar | Spotlight on medication adherence

Reserve your place

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

WHO estimates that half of all patients worldwide are non-adherent to their prescribed medication. The consequences of poor adherence can be catastrophic, on both the individual and population level.

Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.

Prof. Kevin Dolgin
Prof. Florian Limbourg
Prof. Anoop Chauhan
Developed by: Springer Medicine
Obesity Clinical Trial Summary

At a glance: The STEP trials

Read more

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.

Developed by: Springer Medicine
Image Credits