Dramatic Reversal of the Uncal Syndrome and Brain Edema from Infarction in the Middle Cerebral Artery Territory

Abstract

Brain edema following ischemic stroke often results in significant morbidity and death. Decompressive craniotomy has been advocated and may result in a surprisingly satisfactory outcome. We present a 17-year-old patient who developed a right middle cerebral artery territory infarction associated with a cardiac myxoma. Five days after the ictus and two days after a thoracotomy to remove the obstructing tumor, he developed clinical signs of uncal herniation. CT scans showed massive cerebral edema and development of obstructive hydrocephalus. An intracranial pressure monitor measured 30 mmHg on insertion. Management with mannitol reversed the clinical and radiologic signs of uncal herniation. There is a renewed interest in decompressive craniotomy. Our patient indicates that conventional management of increased intracranial pressure may reverse brain edema when associated with hemispheric infarction. Decompressive craniotomy needs validation in a randomized trial.

Increased Blood–Brain Barrier Permeability on Perfusion CT Might Predict Malignant Middle Cerebral Artery Infarction

“…Patients that underwent HC were significantly younger than the NHC group. Wijdicks and colleagues 26 suggested that ICP in younger patients might rise rather quickly due to less reserve to compensate for the increase in volume. Certain degrees of age-related cerebral atrophy might protect older patients from space-occupying brain swelling.…”

Early Hemicraniectomy in Patients With Complete Middle Cerebral Artery Infarction

“…However, Frank 30 has demonstrated that elevated ICP is not a common cause of initial neurological deterioration from large hemispheric stroke. Because in most patients cerebral edema contributes to the gradual build-up of a mass, displacing the brain stem rather than globally increasing ICP, Wijdicks and colleagues 34 suggest that ICP in younger patients might rise rather quickly due to less reserve to compensate for the increase in volume. Our own data 35 from patients in whom ICP was monitored during severe MCA infarction showed a correlation of high ICP and poor clinical outcome.…”

Surgical Treatment of Patients with Ischemic Stroke Decompressive Craniectomy

“…In patients with malignant CVA, a large area of parenchymal hypodensity in the MCA territory is often visualized on the admission CT scans (Figure 1). (59,64,74,78) With progressive clinical deterioration, CT-demonstrated signs may also include mass effect, effacement of the basal cisterns, compression of the ventricular system, a shift of midline structures, (78,74) and herniation of tissue through the falx, foramen magnum, or tentorium. These patients present clinically with progressive deterioration of consciousness within the first 2 days.…”