Malignant Hemispheric Infarction

Abstract

A previously healthy, right-handed 43-year-old man was found lying on the floor in his apartment. His relatives had been unable to contact him for more than a day. On admission, he was somnolent but attempted to obey commands and had a right-sided hemiplegia, dense sensory loss, severe word-finding difficulty, and anisocoria with miosis and ptosis in left eye (National Institutes of Health Stroke Scale, 21). Emergent computerized tomographic scan revealed an extensive left-hemispheric infarction (Figure [A]). Computerized tomographic angiography showed a left carotid dissection. The neurosurgeon recommended medical management; hypertonic saline was initiated. Fifteen hours after admission, his level of consciousness had deteriorated (Glasgow coma score, 10), his left pupil was enlarged and fixed, and increased midline shift was visible on computerized tomography (Figure [B]). The patient was referred to decompressive hemicraniectomy (DHC), which was performed 20 hours after admission. By 72 hours, the patient was more alert and his left pupil was reactive (still enlarged). Because of ventilatory problems, he required intermediate care for subsequent 2 weeks. After tracheostomy removal 18 days after admission, the patient was alert but hemiplegic and hemianopic, obeying commands, and able to communicate with single words and short phrases. He was discharged to a rehabilitation hospital 10 days later and thereafter to a supported residential home. Six years later, he was able to walk with a cane, go shopping unaided, communicate reasonably, and read short sentences with difficulty. His right arm remained plegic, and the left arm has restricted movement because of a fracture at the time of stroke. Therefore, he needs help with dressing and grooming but not every day (modified Rankin scale, 3). DiscussionThe case typifies a malignant middle cerebral artery infarction, which usually results from an internal carotid or middle cerebral artery stem occlusion. Middle cerebral artery infarction may be accompanied with anterior cerebral artery infarction (especially in internal carotid occlusions) but also with posterior cerebral artery infarction (internal carotid occlusion in patients with prominent posterior communicating artery or as a result of transtentorial compression during the expansive stage, like in our patient). Such concomitant involvement is often fatal within the first week if managed conservatively (transtentorial herniation). The downward spiral of symptoms is marked with increasing drowsiness, reduced level of consciousness, pupillary enlargement, and coma. Approximately 1 of 20 strokes has a malignant course, which occurs more commonly in younger adults with less brain atrophy (less ability to accommodate edema). Life-saving treatment by DHC has been available for >25 years. Pooled major trials show a marked effect in reducing mortality and the most severe dependency in patients aged <60 years.1 The number-neededto-treat is striking: in patients aged <60 years, number-neededto-treat is 2 in reduction of...

Decompressive craniectomy for the treatment of malignant infarction of the middle cerebral artery

“…Decompressive craniectomy (DC) has been shown to be effective in lowering mortality in patients with malignant MCA infarction. DC is aimed to remove part of the ipsilateral cranium to allow outward herniation of the infarcted brain tissue before compression of formerly healthy brain tissue occurs, decrease the ICP and improve cerebral perfusion pressure, thereby aiding the blood flow to the ischemic penumbra 10 11 12 . Recently, three randomized controlled trials (RCTs) and their pooled analyses suggested that early DC significantly reduced mortality and improved favorable outcome defined as modified Rankin scale (mRS) ≤ 4 13 14 15 16 .…”