Malignant Middle Cerebral Artery (MCA) infarct and surgical decompression: Pre-op and post-op CT brain findings

B. Mahendrasamy

Physician Assistant, Department of Neurosurgery, Kauvery Hospital, Cantonment, Trichy

Introduction

Malignant MCA infarct usually denotes a large MCA infarct, with or without the involvement of anterior and posterior cerebral arteries, which causes acute brain swelling within the first 48 hr after stroke, resulting in elevated intracranial pressure (ICP), brain herniation and even death. Clinically the patient usually has rapidly worsening sensorium, anisocoria, progressive neurological deficit, aphasia, and coma, ultimately causing death.

Radiologically large volumes of MCA hemispheric infarction, midline shift and mass effect, uncal herniation, brainstem compression and FLAIR miss match suggest a malignant MCA infarct. Emergency treatment is intubation and hyperventilation and antioedema measures (mannitol/3% NACL) or steroids which can serve as a temporising measure. Usually, decompressive craniotomy is the definitive treatment suggested.

Without surgical treatment for malignant MCA infarct mortality rates can cross 80%. Surgery can be a life saving measure; very early aggressive case selection can decrease morbidity and improve functional outcomes.

Case presentation

A 63 years old female, with Type 2 DM on regular medication, presented with complaints of chest pain. She was initially taken to the nearby hospital, diagnosed as unstable angina/acute coronary syndrome, and planned for a primary angiogram. After 48 hr she had a drop in GCS with right upper and lower limb weakness.

On Examination

On arrival to our ER, her GCS was E2V1M5, both pupils equally reacting to light, right hemiplegia.

Emergency MRI stroke protocol showed acute infarct in left MCA territory, basal cistern normal and no brainstem compression. Carotid and Vertebral Doppler showed low-velocity flow in the left carotid system (S/O Distal obstruction). The patient was intubated: given poor GCS, he was put on mechanical ventilation.

Management

Dual antiplatelet were started (Ecosprin 75 mg and Clopilet 75 mg), statin and anticonvulsants were given.

Within another 24 hr, she had a drop in sensorium and developed anisocoria along with early bradycardia. Emergency repeat CT brain showed uncal herniation, midline shift, loss of brainstem cisternal spaces, increased mass effect, brainstem compression and early hydrocephalus.

Emergency left decompressive craniotomy was done along with basal cisternostomy. She was managed with aggressive ICU care. Post op CT brain was taken and it showed uncal herniation released, brainstem compression released, midline shift and mass effect decreased. Gradual weaning was started after sensorium improved.

Pre-op CT Findings

  • Increased edema
  • Uncal herniation leading to midbrain compression
  • Brainstem pushed to contralateral side leading to cisterns space increased in the ipsilateral side
  • Early ventriculomegaly as evidenced by dilating temporal horn
  • Midline shift and mass effect increased

Post-op CT Findings

  • Uncal herniation released
  • Brainstem compression released
  • Midline shift and mass effect decreased.

Conclusion

Early identification and treatment of a malignant MCA infarct are crucial. Early imaging and clinical assessment determine the best course, potentially improving outcomes for affected individuals.

Mr. B. Mahendrasamy
Physician Assistant

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