Decompressive Craniectomy in Middle Cerebral Artery Infarction

Andrew Chow gives a rapid breakdown of malignant cerebral artery (MCA) infarction and the utility of decompressive craniectomy. An MCA infarction is an ischaemic stroke, affecting the total or subtotal area of the MCA. It involves the basal ganglia (at least partially) and may involve the adjacent territories. The incidence is 10-20 per 100 000 and there is a high mortality rate of up to 80%. Early clinical symptoms of MCA infarction are contralateral hemiparesis, gaze deviation and hemisensory neglect. A malignant infarction will then progress to severe headache, nausea and vomiting, papilloedema and reduced consciousness. The pathophysiology underlying these clinical signs is complex and involves a failure of sodium pumps, leading to cellular swelling, metabolic failure, tissue necrosis and breakdown of serum products. So, how do you predict who progresses to a malignant MCA infarction? Andrew will guide you through the three domains to consider: Radiological, clinical and pathological. From there, the management. Medical management is grounded in methods to reduce the intracranial pressure. This includes admissions to a stroke unit, high dependency unit or intensive care unit. Elevating the head to greater than 30 degrees and maintenance of normal clinical variables are other considerations. Surgical management involves decompressive craniectomy. This procedure first described in 1935. It is not a benign treatment and there are a number of complications. Andrew discusses the risks, and the preferred methods of the procedure to enhance outcome. He also describes the risk benefit analysis that should be undertaken before recommending this treatment to a patient with a malignant MCA infarction. In doing so, Andrew takes you through the landmark trials looking at the use of decompressive craniectomy.

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