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.
Jay Khadpe MD
Latest posts by Jay Khadpe MD (see all)
- Morning Report: 7/30/2015 - July 30, 2015
- Morning Report: 7/28/2015 - July 28, 2015
- IN THE STRETCHER INSTEAD OF BESIDE IT - July 22, 2015
- Morning Report: 7/14/2015 - July 14, 2015
- Morning Report: 7/10/2015 - July 10, 2015