Malignant middle cerebral artery infarction

Case contributed by Dr Benedikt Beilstein


Acute onset of left sided hemiplegia. No loss of conscience, patient is agitated and anxious. Cardio-vascular risk factors: hypertension, obesity, hyperlipidaemia, prior stroke and heart attack.

Patient Data

Age: 55 years
Gender: Male

Findings: Non-contrast CT of the head shows a hyperdense middle cerebral artery on the right side, the insular ribbon sign, hypodensity of the right middle cerebral artery (MCA) territory and loss of gray- white matter differentiation.

Other, non-acute findings include an old, right anterior cerebral artery infarction and extensive arteriosclerosis. No intracerebral hemorrhage. Mild to moderate microangiopathic changes.

Correspondingly, the CT angiography demonstrates a complete occlusion of the terminal segment of the right internal carotid artery (ICA) with complete lack of opacification of the proximal M1 segment of the right MCA. There is collateral reperfusion of the right MCA in the distal M1 segment. Very poor perfusion of the distal MCA branches compared to the contralateral side. Mild to moderate stenosis of the right vertebral artery in segment V4. The other intracerebral vessels appear patent.

Conclusion: Acute, right MCA infarction with complete occlusion of the terminal ICA / proximal M1 segment and poor collateralisation of the periphery. Hyperdense middle cerebral artery sign and insular ribbon sign are visualized on the non-contrast CT.

Patient received intravenous thrombolysis and was transferred to another hospital for clot retrieval. The next day, the patient developed a haemorrhagic transformation and space-occupying cerebral oedema, which was treated by decompressive hemicraniectomy (DHC). 10 days later, he was re-transferred to our clinic and a follow-up CT was performed.

Findings: Non-contrast follow-up CT shows status post decompressive hemicraniectomy on the right side. Extensive infarction in the MCA and ACA territory is visualized with large, diffuse areas of encephalomalacia and decreased density. No acute hemorrhage is seen. Expansion of brain parenchyma way beyond the former course of the right calvaria, in keeping with a space-occupying infarction due to extensive vasogenic edema.No signs of acute raised intracranial pressure, no midline shift, no other acute findings.

Conclusion:  Status post decompressive hemicraniectomy. Large MCA/ ACA infarction with extensive encephalomalacia, no acute hemorrhage. No signs of acute raised intracranial pressure, no midline shift, no other acute findings.

Case Discussion

This case demonstrates features of a "malignant MCA infarction", a term which is used to describe the rapid aggravation of neurological symptoms following an MCA infarction that are attributed to space-occupying vasogenic edema and/or hemorrhagic transformation with consecutive raised intracranial pressure. Malignant infarction has, if left untreated, a very high mortality due to compression of vital brain structures 1.

Prognostic factors for developing a malignant infarction are affection of 50 % or more of the MCA territory, a small penumbra and a large infarcted core as well as early signs of midline shift.

Therapeutic options are limited, with decompressive hemicraniectomy being the best option and hence, is the mainstay of treatment 2.

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Case information

rID: 59787
Published: 25th Apr 2018
Last edited: 16th Jul 2018
Inclusion in quiz mode: Included

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