Malignant MCA syndrome
Related Subjects:
|Acute Stroke Assessment (ROSIER&NIHSS)
|Causes of Stroke
|Ischaemic Stroke
|Cancer and Stroke
|Cardioembolic stroke
|CT Basics for Stroke
🧠 Introduction
- ⚡ Malignant MCA syndrome occurs after a large MCA territory infarct with massive cerebral oedema.
- 🕐 Typically presents 2–5 days post-stroke, but may occur earlier (within 24h).
- 🔍 Characterised by cytotoxic oedema, midline shift, raised ICP, and risk of herniation.
- 📊 Trials show surgery reduces mortality and improves outcomes, though survival may include significant disability.
🧬 Aetiology
- 🫀 Atheroembolism from large vessel disease.
- 💓 Cardioembolism (AF, structural heart disease).
- 🩸 Carotid dissection → embolism to MCA.
🩺 Clinical Presentation
- Hemiparesis, hemianopia, hemisensory loss ± aphasia/neglect (depending on hemisphere).
- Progressive ↓ consciousness (due to mass effect).
- Late signs: Pupillary dilatation, Cheyne-Stokes respiration, herniation syndromes.
🖼️ Imaging
- CT: May be normal initially; later → hyperdense MCA, hypodensity >50% territory, mass effect, midline shift.
- MRI: DWI shows infarct volume;>145 cm³ predicts poor prognosis.
📑 RCP Guidance 2016
Patients with MCA infarction should be considered for decompressive hemicraniectomy if:
- Pre-stroke mRS <2.
- Clinical MCA territory syndrome, NIHSS >15.
- Reduced consciousness (NIHSS 1a ≥1).
- Imaging: >50% MCA territory infarct or DWI volume >145 cm³.
💊 Management
- 🎯 Supportive ICP measures: intubation, osmotherapy (mannitol, hypertonic saline), hyperventilation → not sufficient alone.
- 🔪 Decompressive hemicraniectomy + durotomy: Large bone flap + dural opening → allows oedematous brain expansion, prevents herniation.
- 👥 Patient selection: consider age, baseline function, comorbidities, wishes.
- ⚠️ Poor prognosis: infarct extends into ACA/PCA territories, infarct volume >145 cm³.
- 📊 Trials:
- HAMLET → best outcomes if surgery <48h.
- DESTINY I → clear survival benefit in younger patients.
- DESTINY II → survival benefit also in >60 yrs, but many survivors had mRS 4–5 (dependent).
📚 References
| 🧪 Neurosurgical Trials |
👨⚕️ Authors |
📊 Key Outcome |
| HAMLET (Lancet Neurol. 2009) |
HAMLET investigators |
Hemicraniectomy within 48h ↓ mortality & poor outcomes. No functional benefit if delayed >96h. |
| DESTINY (Stroke 2007) |
DESTINY Study Group |
Surgery markedly ↓ mortality. Trial stopped early after joint analysis with DECIMAL & HAMLET. |
| DESTINY II (NEJM 2014) |
DESTINY II Investigators |
In >60 yrs, surgery ↑ survival, but many had severe disability (mRS 4–5). |
