Morning Report: 3/17/2015

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.
The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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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

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