General

Stroke - Malignant Middle Cerebral artery syndrome

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3 Jul 2016 - General
 

Malignant middle cerebral artery (MCA) syndrome can occur after middle cerebral artery stroke, with rapid neurological or conscious level deterioration, due to space occupying oedema. The symptoms that suggestive of malignannt middle cerebral artery infarction can be ranging from headache, vomiting, to rapid deterioration of consciousness level of Glascow Come Scale (GCS). Diagnosis will be support by radiology evidence of cerebral oedema , and mass effect. Its general prognosis is very poot, with high mortality (up to around 80%) and morbidity. The definite treatment option will be decompressive hemicraniectomy, by neurosurgical team. Pooled analysis from DECIMAL, DESTINY, and HAMLET trials showed mortaity benefit and favourable outcome, in surgery group. The reason behind decompressive hemicraniectomy is to relive the high intracranial pressure, allowing space for oedematous brain to expand.  Anyone has experience in this area ?

Hi Marinelle, yes I would agree with you to some extent. Age should be taking into account when considering this intervention. Age should not be the absolute contra-indication in offering decompressive hemicranectomy to patients with malignant MCA syndrome. As I mentioned before, all the RCTs looking at this particular intervention did not have any data for patients with ages above 60 years ago. Hence, we are not really able to base our decision on the level of evidence available. So I would say...
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Hi You! (Is this your nickname?) To be honest, in my own medical opinion, I don’t think age should matter. I think it should be broken down into two other categories: 1) Brain volume, 2) Expected functional outcome. For the brain volume, the entire principle of performing decompressive craniectomy relies on the Monro-Kellie doctrine, wherein brain volume plays a significant role. These days, using 256-slice CT scans; we can do 3D reconstructions making use of a software that translates DICOM fil...
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Hi Maria, thanks for the wonderful comments, great insight. I have encountered few cases of malignant MCA syndrome that have a great recover after the decompressive hemicranectomy. My centre does not has a Neuro-surgical department, hence will require transfer of patient to the other hospital, which is a centralised neuro-surgical centre. The main issues with regards to referral to neuro-surgical decompressive hemicraniectomy is age. None of the RCTs investigating hemicraniectomy in malignant M...
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Hi! I'm a senior neurosurgery resident and we do decompressive hemicraniectomy for selected candidates with Malignant infarcts. Candidate patients are those who are less than 60 years old with large MCA infarction (meaning more than 50percent of the MCA territory by visual inspection or 150ml by volumetric studies) as evidenced by an MRI/CT. To check for eligibility, we use the STATE criteria to determine who will most likely benefit from decompressive hemicraniectomy. 1 Score: NIHSS greate...
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Then, we tier patient into 3 categories: those who will MOST LIKELY benefit (meets all criteria) - proceed with hemicraniectomy, thos with UNCERTAIN benefit (meets many but not criteria) - offer hemicraniectomy as a compassionate therapy provided that there is a concensus among the treating teams anf family understands that benefit is uncertain, lastly those who will UNLIKELY benefit (actively herniating, >75 years of age with terminal illness), hemicraniectomy is no longer offered. Basically...
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