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Table of Contents    
Year : 2016  |  Volume : 64  |  Issue : 3  |  Page : 442-443

Malignant middle cerebral artery infarction: An unusual but severe neurovascular condition

1 Department of Neurology, Cerebrovascular Division, University of Barcelona, Barcelona, Catalonia, Spain
2 Library Department, Sagrat Cor University Hospital, University of Barcelona, Barcelona, Catalonia, Spain

Date of Web Publication3-May-2016

Correspondence Address:
Adrià Arboix
Department of Neurology, Cerebrovascular Division, Sagrat Cor University Hospital, University of Barcelona, Barcelona, Catalonia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.181586

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How to cite this article:
Arboix A, Sánchez MJ. Malignant middle cerebral artery infarction: An unusual but severe neurovascular condition. Neurol India 2016;64:442-3

How to cite this URL:
Arboix A, Sánchez MJ. Malignant middle cerebral artery infarction: An unusual but severe neurovascular condition. Neurol India [serial online] 2016 [cited 2020 Oct 20];64:442-3. Available from:

Malignant middle cerebral artery (MCA) infarction is a severe form of ischemic hemispheric stroke which is characterized by the large extent of the ischemic lesion that occupies more than 50% of the MCA territory and may extend to other adjacent territories as well.[1] Malignant MCA infarction develops a space-occupying mass effect due to the associated cytotoxic edema and shows a devastating clinical outcome. The patients show a high rate of early mortality, which varies from 25% to 80% and serious neurological sequelae may occur in the surviving patients. Due to their high morbidity as well as mortality rates despite appropriate medical treatment, these infarctions are referred to as being “malignant.”[1],[2] Conversely, lacunar infarcts (LIs) represent the ischemic stroke subtype and are associated with a better prognosis. The short-term prognosis is favorable because in-hospital mortality rate is very low, case-fatality at 1 year is <2.8%, and recovery of the deficit is generally good in the first few weeks after the onset of infarction.[3] Malignant MCA infarction and LI are, therefore, the two neurovascular entities that have the worst and best prognosis on the short term evaluation, respectively.

Malignant MCA infarction is a subgroup of unusual cerebral infarcts accounting for 2.3% of all cases of Sylvian infarctions in the Sagrat Cor Hospital of Barcelona Stroke Registry.[4] This figure is in accordance with other studies reporting that these infarctions account for <10% of all ischemic supratentorial strokes.[5]

Conventional medical treatment with tissue plasminogen activator is often unsatisfactory in malignant MCA infarction although several clinical trials have demonstrated the benefits of decompressive hemicraniectomy and some authors have proposed the beneficial and neuroprotective effects of moderate hypothermia.[5],[6] Actually, we can establish, based on strong published evidence that early decompressive hemicraniectomy is effective in patients with malignant MCA infarction younger than 65 years.[5]

Although malignant MCA infarction is a well-described entity, there are some clinical features of its natural history that remain unclear. Due to the poor prognosis of patients with malignant MCA infarction, efforts have been made to identify clinical features that predict the development of a “malignant infarction;” or conversely, predict a favorable outcome in smaller infarctions of the MCA.[7],[8] In the study published in this issue of Neurology India,[9] the authors report a favorable outcome in one-fourth of the patients with a large MCA infarct and they identify younger age, less severe stroke, recombinant tissue plasminogen activator (rtPA) treatment, and large artery atherosclerosis subtypes as features related to a lesser degree of disability (based on the modified Rankin scale being 2 or less) at the final follow-up (average of 13 months).

In conclusion, malignant MCA infarction is an unusual but severe neurovascular condition. The current evidence shows that an early decompressive hemicraniectomy may be clinically indicated in younger patients. However, this encouraging study shows that clinical benefits may be achieved in one-fourth of the patients. This good functional recovery occurs mainly among the subgroup of younger patients, with lesser initial neurological deficits, presenting with atherothrombotic stroke, and receiving early thrombolytic therapy with rtPA.

 » References Top

Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R. 'Malignant' middle cerebral artery territory infarction: Clinical course and prognostic signs. Arch Neurol 1996;53:309-15.  Back to cited text no. 1
Simard JM, Sahuquillo J, Sheth KN, Kahle KT, Walcott BP. Managing malignant cerebral infarction. Curr Treat Options Neurol 2011;13:217-29.  Back to cited text no. 2
Arboix A, Massons J, Oliveres M, García L, Titus F. An analysis of 1000 consecutive patients with acute cerebrovascular disease. The registry of cerebrovascular disease of La Alianza-Hospital Central of Barcelona. Med Clin (Barc) 1993;101:281-5.  Back to cited text no. 3
Arboix A, García-Plata C, García-Eroles L, Massons J, Comes E, Oliveres M, et al. Clinical study of 99 patients with pure sensory stroke. J Neurol 2005;252:156-62.  Back to cited text no. 4
von Sarnowski B, Kleist-Welch Guerra W, Kohlmann T, Moock J, Khaw AV, Kessler C, et al. Long-term health-related quality of life after decompressive hemicraniectomy in stroke patients with life-threatening space-occupying brain edema. Clin Neurol Neurosurg 2012;114:627-33.  Back to cited text no. 5
Dohmen C, Galldiks N, Bosche B, Kracht L, Graf R. The severity of ischemia determines and predicts malignant brain edema in patients with large middle cerebral artery infarction. Cerebrovasc Dis 2012;33:1-7.  Back to cited text no. 6
Arboix A, Garcia-Eroles L, Massons JB, Oliveres M, Pujades R, Targa C. Atrial fibrillation and stroke: Clinical presentation of cardioembolic versus atherothrombotic infarction. Int J Cardiol 2000;73:33-42.  Back to cited text no. 7
Beck C, Kruetzelmann A, Forkert ND, Juettler E, Singer OC, Köhrmann M, et al. A simple brain atrophy measure improves the prediction of malignant middle cerebral artery infarction by acute DWI lesion volume. J Neurol 2014;261:1097-103.  Back to cited text no. 8
Dharmasaroja PA, Muengtaweepongsa S, Pattaraarchachai J. Clinical course, prognostic factors and long-term outcomes of malignant middle cerebral artery infarction patients in the modern era. Neurol India 2016;64:435-40.  Back to cited text no. 9


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