Malignant MCA Syndrome

Clinical

In patients presenting with a MCA territory stroke:

• Drop in GCS
• Change in Level of Consciousness score(NIHSS)
• Worsening of NIHSS score
• New headache, nausea, or vomiting

Patients with MCA territory stroke presenting with any of the above features need an urgent senior review and repeat imaging with a non-contrast CT brain.

Patients at risk of developing malignant MCA syndrome need prompt and early discussion with the neurosurgical team if they are a candidate for treatment with decompressive hemicranectomy.

Investigations (CT)

• Cytotoxic oedema, swelling and often midline shift
• Loss of Grey white matter distinction

Treatment options

Admit under joint care Stroke/Neurosurgery

Decompressive hemicranectomy should be considered in patients who present with Malignant MCA Syndrome and:

• A pre-stroke modified rankin score (mRS) of 0-1
• Clinical deficits indicating infarct in the territory of the MCA
• NIHSS score of more than 15
• A decrease in the level of consciousness score to 1 or more on item 1a on the NIHSS
• Signs of an infarct of at least 50% of the MCA territory on CT, or infarct volume greater than 145ml on DWI MRI

Patient selection will depend upon the patient's known views and wishes as to how they would wish to be managed.

Patients should be referred to Neurosurgery within 24hr of stroke onset and if deemed appropriate treated within 48hr of stroke onset.

Prognosis

• Malignant MCA has a poor prognosis
• 80% mortality rate if treated conservatively
• Decompressive hemicranectomy can improve survival with a NNT of 2 to prevent 1 death, and functional outcomes in patients appropriately selected
• However it is important explain the high probability of residual moderate to severe stroke disability in patients following surgery
• Admit under joint care Stroke/Neurosurgery

Links / References

• https://doi.org/10.1136/pgmj.2009.094292
• https://doi.org/10.17712/nsj.2021.3.20200187