Malignant MCA Syndrome

Thanks to Dr. Corburn for presenting today’s Morning Report!

Malignant MCA Syndrome

Stats

-Space occupying cerebral edema resulting after MCA stroke

-Occurs in 10% of all strokes

-About 13% of proximal MCA strokes experience severe cerebral edema

Pathophysiology

-Cytotoxic edema begins within hours of the stroke and increases for 3-5 days

-For a large MCA stoke, the first 24-48 hours is greatest risk for developing fatal brain edema

Determining Patients at Risk

-Early hypodensity of >50% of MCA territory

-Early nausea/vomiting

-NIHSS greater than or equal to 20 for left sided infarcts

-NIHSS greater than or equal to 15 for right sided infarcts

Medical treatment:

-Intubation

-Tight blood pressure control

-Intra cranial pressure reduction: Mannitol, hypothermia, hyperventilation

*Despite medical therapy, mortality rates are reportedly as high as 80%

Surgical treatment: Decompressive hemicraniectomy

-Since 2000, there have been three European trials to address the role of hemicraniectomy

-Pooled analysis had an absolute risk reduction for mortality at 12 months of 51.2%

-Even though mortality was reduced, a greater number of survivors were left with moderately severe disability (modified Rankin score = 4)

-Outcomes are more favorable in patients younger than 50 and if surgery is performed within 48 hours of onset of stroke

Interesting Facts: Harvey Cushing

-Father of modern day neurosurgery

-The name for many medical eponyms: Cushing reflex, Cushing’s disease, Cushing forceps

-Introduced measuring systolic blood pressure with a sphygmomanometer to the United States (from Italy)

Resources:

• Bernardini, G.Malignant middle cerebral artery infarction: new approaches. Albany Medical Center, Neurology lecture. Accessed 2015 Feb. <https://www.neurocriticalcare.org/sites/default/files/pdfs/1100Bernardini.pdf>
• Gupta, R., et al. Decompressive hemicraniectomy for malignant middle cerebral artery territory infarction. Uptodate. 2015 Feb <http://www.uptodate.com.newproxy.downstate.edu/contents/decompressive-hemicraniectomy-for-malignant-middle-cerebral-artery-territory-infarction?source=search_result&search=decompressive+hemicraniectomy&selectedTitle=1%7E12>
• Johnson, R., et al. Decompressive craniectomy for malignant middle cerebral artery infarction: Evidence and controversies. Journal of Clinical Neuroscience. 2011 Aug; 18(8): 1018-1022.

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Jay Khadpe MD

• Editor in Chief of "The Original Kings of County"
• Assistant Professor of Emergency Medicine
• Assistant Residency Director
• SUNY Downstate / Kings County Hospital

Latest posts by Jay Khadpe MD (see all)

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