Makindo Medical Notes

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