GCSGlasgow Coma Scale ICP Intracranial pressure MMCAI Malignant middle cerebral artery infarction AIM Mortality from malignant middle cerebral artery infarction (MMCAI) approaches 80% in adult series. Although decompressive craniectomy decreases mortality and leads to an acceptable outcome in selected adult patients, there are few data on MMCAI in children with stroke. This study evaluated the frequency of MMCAI and the use of decompressive craniectomy in children.METHOD We retrospectively reviewed cases of MMCAI from five pediatric tertiary care centers.RESULTS Ten children (two females, eight males; median age 9y 10mo, range 22mo-14y) had MMCAI, with a median Glasgow Coma Scale score of 6 (range 3-9). MMCAI represented fewer than 2% of cases of pediatric arterial ischemic stroke. Three patients who did not undergo decompression, all of whom had monitoring of intracranial pressure, developed intractable intracranial hypertension, and fulfilled criteria for brain death. In contrast, seven patients underwent decompressive craniectomy and survived, with rapid improvement in their level of consciousness postoperatively. All seven survivors now walk independently with mild to moderate residual hemiparesis and speak fluently, even though four had left-sided infarcts.INTERPRETATION Decompressive craniectomy can lead to a moderately good outcome for children with MMCAI and should be considered, even with symptomatic stroke and deep coma. Monitoring of intracranial pressure may delay life-saving treatment.Malignant middle cerebral infarction (MMCAI), characterized by space-occupying edema, intracranial hypertension, and eventual herniation, results in significant morbidity and mortality in adults. Medical management is associated with nearly 80% mortality, and many survivors remain moderately to severely disabled. 1 Early surgical intervention in adults has been associated with decreased mortality and improved outcome in survivors.2-4 Although the specific inclusion criteria for three recent randomized-controlled trials in adults varied somewhat, a meta-analysis that included individuals with infarction of more than 50% of the middle cerebral artery territory and decreased levels of consciousness demonstrated improved outcome. 4 An earlier review of the adult literature revealed that younger age (<50y) was a good prognostic factor, 5 although the use of decompressive craniectomy in children with MMCAI has not been extensively evaluated. We reviewed cases of MMCAI at our institutions and here report treatment and outcome.

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Intravenous fluids should be used with caution as regards the tonicity and volume administered, and with appropriate monitoring of serum electrolytes.

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