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Background and Purpose— The presence of intracranial artery calcification is associated with an increased risk for stroke. However, calcified atherosclerotic plaques are also known to be less vulnerable to rupture. Given this discrepancy, we investigated whether the vulnerability of intracranial arterial atherosclerosis differed based on the presence or absence of calcification. Methods— We considered consecutive patients with acute stroke in the unilateral middle cerebral artery (MCA) territory. Patients with any stenotic MCAs were included in this study. Symptomatic MCA was defined as the occurrence of infarctions relevant to the stenotic MCA. The presence of calcification in the MCA was evaluated on noncontrast thin-section computed tomography images using a 3dimensional software package. Generalized estimating equations were used to compare the frequency of calcification between symptomatic and asymptomatic stenosis. Results— Of the 1066 MCAs examined in 533 patients, 645 MCAs were stenotic and were included in the study. Among the 645 stenotic MCAs, 406 MCAs (62.9%) were symptomatic. Calcification was observed in 36 MCAs (5.6%). Calcification in the MCA was more frequently observed in the asymptomatic group (7.9% versus 4.2%; P =0.032). On multivariable analysis, the presence of calcification in MCA atherosclerosis was less frequent in the symptomatic group (odds ratio, 0.46; 95% confidence interval, 0.23–0.92; P =0.027). Conclusions— This study showed that calcified atherosclerosis in the MCA was less frequently symptomatic.

Optic nerve sheath diameter (ONSD) can predict intracranial hypertension and outcomes in severe traumatic brain injury. Its utility in middle cerebral artery (MCA) stroke is unknown.We reviewed serial radiological measurements, including ONSD, in patients with MCA stroke undergoing decompressive craniectomy (DC) for malignant MCA syndrome and compared demographic, clinical, and radiological data with an age- and gender-matched group of nonmalignant MCA stroke patients.Patients admitted to a large tertiary hospital in London, UK, between April 2012 and October 2016 with MCA infarction were identified through 2 data sources. We quantified ONSD, eyeball transverse diameter (ETD), ONSD/ETD ratio, midline shift (MLS), and infarct volume on computed tomography (CT).We identified 19 patients (mean age = 49.8 years [standard deviation = 12.5]) with malignant MCA stroke and 19 patients (47.8 years [16.0]) with nonmalignant MCA stroke. Mean ONSD, ONSD/ETD ratio, MLS, and infarct volume on initial CT all significantly increased after developing malignant MCA syndrome and decreased (except infarct volume, which increased) following DC (all Ps.05). ONSD and ONSD/ETD ratios in the malignant group did not correlate with functional outcomes but were significantly higher on initial CT compared with the nonmalignant group (mean ONSD: 5.66 mm [.6] versus 4.97 mm [.5], P = .001; mean ONSD/ETD ratio: .25 [.03] versus .22 [.02], P = .002).ONSD, ONSD/ETD ratio, MLS, and infarct volume change dynamically in patients with malignant MCA infarction who undergo DC. An ONSD of more than 5.25 mm and an ONSD/ETD ratio of more than .232 on initial CT may identify MCA stroke patients at high risk of developing malignant MCA syndrome.

This study used a role-play experience of stroke to improve student empathy for patients with neurological deficits. Participants were 4th- and 5th-year medical students (n = 62). Students worked in pairs, one as patient, and the other as carer/observer. To simulate middle cerebral artery infarction, the patient was fitted with a leg splint, their arm was placed in a sling with the hand taped closed, and they wore glasses that blocked half of their visual field in each eye to simulate homonymous hemianopia. The patient then attended to their daily duties and completed a list of tasks. All participants completed the Jefferson Scale of Physician Empathy (student version) before and after the role-play exercise and wrote a reflection about their experience. There was a statistically significant increase in mean empathy scores from baseline to post-participation. Students found the experience valuable and reported increased recognition of the time taken to complete tasks, receiving odd looks and stares, feeling judged, and greater understanding of stigma and of the experiences of people with disabilities. This role-play of a stroke experience improved medical-student empathy. Role-play experiences could be used more widely in clinical education.

Objective: To describe our experience implementing decompressive hemicraniectomy (DH) for eligible patients with malignant middle cerebral artery (MCA) infarcts. Methods: We retrospectively collected data of malignant MCA infarction patients requiring DH at King Abdulaziz University Hospital & King Faisal Specialist Hospital & Research Center, Jeddah, Kingdom of Saudi Arabia between October 2010 and July 2015. Clinical outcome was assessed immediately postoperatively using Glasgow Coma Score (GCS), and at 12 months using the modified Rankin scale (mRS) and Barthel index. Survival was evaluated at thirty-days and one year after surgery. Results: Six out of 10 patients diagnosed with malignant MCA infarction underwent DH. Among the surgically treated patients (n=6), 4 were males (66%), and the median age was 22.5 years. The median time from admission to surgery was 35.5 hours. The median post-operative GCS was 6.5. Three patients (50%) died within 30 days of DH. In those who survived, the median mRS was 4.5 and BI was 7.5. Conclusion: Decompressive hemicraniectomy saves life and has the potential of improving survival functional outcome when done fast and in carefully selected patients. We call for national awareness of the management of such cases and early intervention.

Malignant middle cerebral artery (MCA) infarction is associated with up to 80% mortality in the first week, despite maximal medical therapy. Decompressive craniectomy (DC) has been shown to improve survival rates in these patients. However, there are concerns that DC prolongs poor quality of life by increasing the number of survivors with major disability. This review will assess if DC in patients with malignant MCA infarction improves functional outcomes compared to maximal medical therapy. It will estimate the optimal time for surgery following stroke onset and ask if DC is effective in older patients (60 years).A literature search was conducted using Medline, Embase, PubMed and the Cochrane Library. Randomised controlled trials and meta-analysis that fulfilled the inclusion criteria and answered the clinical question were evaluated.Twelve papers were identified and considered appropriate to answer the clinical question. These included 8 prospective randomised controlled trials and 4 meta-analysis. A critical review of these papers was conducted.In patients 60 years of age or younger, DC within 48 hours of stroke onset significantly reduced risk of death and major disability (mRS 3) compared to maximal medical therapy only. In older patients (60 years) DC also significantly improved survival but the majority of survivors were left with major disability (mRS 4-5). DC performed more than 48 hours after symptom onset does not appear to be superior to best medical management. The decision to perform decompressive surgery needs to be made on a case-by-case basis, taking into account the degree of disability patients and their carers are willing to accept.

Background Several studies have evaluated the use of decompressive hemicraniectomy (DHC) in malignant middle cerebral artery infarction (MMCAI). In the United Kingdom, the National Institute for Health and Care Excellence (NICE) has set criteria for selection of patients for DHC in MMCAI. We set out to survey the attitudes and practice of neurosurgeons and stroke physicians within the United Kingdom towards DHC in MMCAI. Methods An electronic survey of questions on management of MMCAI in various clinical scenarios was submitted to the academic committees of the Society of British Neurological Surgeons and the British Association of Stroke Physicians for approval before dissemination through the consultant members. Responses were collected over 2 months. Results A total of 78 responses, from 51 neurosurgeons and 27 stroke physicians, were included in final analysis. A total of 54% and 24% of all respondents would recommend DHC in patients aged 60–70 and 70–80 years, respectively; 60% would advocate surgery between 48 and 72 hours and 27% beyond 72 hours. A total of 36% indicated DHC with preoperative Glasgow Coma Scale 15/15. These findings do not conform to current NICE guidelines. Stroke physicians were statistically more likely to recommend DHC in patients older than 60 years ( P = 0.032) and in those with dominant multiterritorial infarcts ( P = 0.042) and accept a greater postoperative modified Rankin Scale ( P = 0.034) compared with neurosurgeons. Conclusions In view of evidence from recent trials and differences in NICE guidelines and current clinical practice within the United Kingdom, based on our survey results, it is important to reevaluate NICE guidelines.

Objective: The activation of different physiopathological pathways (neuroinflammation, apoptosis, and oxidation) can lead to secondary brain injury in ischemic stroke, and in animal models the administration of melatonin has reduced that secondary injury. Lower levels of serum melatonin were found at the time of admission of cerebral infarction in surviving patients than in non-surviving patients. Thus, we carried out this prospective and observational study with the aim of exploring serum melatonin levels in the first week of a malignant middle cerebral artery infarction (MMCAI) in surviving and non-surviving patients, and to explore the capacity of those levels to predict mortality. Methods: Patients with severe MMCAI, defined as computed tomography showing acute infarction in more than 50% of the territory and Glasgow Coma Scale (GCS) lower than 9, were included in the study. We measured serum melatonin concentrations at days 1, 4, and 8 of MMCAI. Mortality at 30 days was the endpoint of our study. Results: Non-surviving patients (n = 34) compared to surviving patients (n = 34) showed higher serum melatonin levels at days 1 (p &lt, 0.001), 4 (p &lt, 0.001), and 8 (p = 0.001) of MMCAI. Serum melatonin concentrations at days 1, 4, and 8 of MMCAI had an area under the curve (AUC) (95% confidence interval (CI)) in the prediction of mortality of 0.89 (0.80&ndash, 0.96, p &lt, 0.001), 0.81 (0.68&ndash, 0.91, 0.001), and 0.82 (0.68&ndash, 0.92, 0.001), respectively. Conclusions: The novel findings of our study were that serum melatonin levels in the first week of MMCAI were higher in non-surviving patients, and were able to predict mortality.

Background: Pathological yawning is a compulsive, frequent, repetitive yawning triggered by a specific reason besides fatigue or boredom. It may be related to iatrogenic, neurologic, psychiatric, gastrointestinal, or metabolic disorders. Moreover, it could also be seen in the course of an ischemic stroke. Aims: To determine whether pathological yawning is a prognostic marker of middle cerebral artery stroke and evaluate its relationship with the infarct location. Study Design: Cross-sectional study. Methods: We examined 161 patients with acute middle cerebral artery stroke, consecutively admitted to emergency department. Demographic information, stroke risk factors, stroke type according to Trial of Org 10172 in Acute Stroke Treatment classification, blood oxygen saturation, body temperature, blood pressure, heart rate, glucose levels, daytime of stroke onset, National Institutes of Health Stroke Scale score (National Institutes of Health Stroke Scale score, at admission and 24 h), modified Rankin scale (at 3 months), and infarct locations were documented. Pathological yawning was defined as ?3 yawns/15 min. All patients were observed for 6 hours to detect pathological yawning. National Institutes of Health Stroke Scale score >10 was determined as severe stroke. The correlation between the presence of pathological yawning and stroke severity, infarct location, and the short-and long-term outcomes of the patients were evaluated. Results: Sixty-nine (42.9%) patients had pathological yawning and 112 (69.6%) had cortical infarcts. Insular and opercular infarcts were detected in 65 (40.4%) and 54 (33.5%) patients, respectively. Pathological yawning was more frequently observed in patients with cortical, insular, and opercular infarcts (p

Objective Previously there have been found higher circulating malondialdehyde levels during the first week of ischemic stroke in patients with worst neurological functional outcome, and at moment of ischemic stroke in non-survivor patients. Thus, the aim of our study was to determine the potential role of serum malondialdehyde levels during the first week of a severe cerebral infarction to mortality prediction. Methods This study was observational, prospective, and multicenter. We included patients with a severe malignant middle cerebral artery infarction (MMCAI) defined as patients with computed tomography showing acute infarction in more than of 50% of the territory and Glasgow Coma Scale (GCS) lower than 9. We determined serum concentrations of malondialdehyde on days 1, 4 and 8 of MMCAI. Results Serum malondialdehyde concentrations at days 1 (p p p = 0.001) of MMCAI in non-survivor patients (n = 34) were higher than in survivor patients (n = 34). ROC curve analyses showed that serum malondialdehyde concentrations at days 1, 4, and 8 of MMCAI had an AUC (95% CI) to predict 30-day mortality of 0.77 (0.65–0.86; p p p Conclusions The new findings of our study were that serum malondialdehyde levels during the first week of MMCAI could be used as biomarkers to mortality prediction.

Gangliogliomas are a relatively rare neoplasm with a major incidence in the pediatric population. As the temporal lobes are the most common site, patients usually present with seizures. We report the case of a 9-year-old child with an extensive suprasellar ganglioglioma presenting with a cerebral infarction due to direct compression of the medium cerebral artery. Suprasellar lesions can compress adjacent vascular structures, so an accurate diagnosis is necessary for an early treatment.

Circulating caspase-3 levels at 24 h of ischemic stroke were found to be associated with poorer functional neurological outcome in a previous study. The aim of this study was to determine whether there is an association between serum caspase-3 levels and early mortality in patients with malignant middle cerebral artery infarction (MMCAI). We included patients with MMCAI defined as computer tomography showing ischemic changes in more than 50% of the middle cerebral artery territory and Glasgow Coma Scale ≤ 8. Serum caspase-3 levels at days 1, 4, and 8 of MMCAI were determined. Non-surviving MMCAI (n = 34) showed higher serum caspase-3 levels at days 1 (p

Previously our team found higher serum substance P concentrations at day 1 of a malignant middle cerebral artery infarction (MMCAI) in non-surviving than in surviving patients. Thus, the objective of this study was to determine whether serum substance P levels during the first week of MMCAI could predict mortality.We included patients with MMCAI defined as computed tomography findings of acute infarction in at least of 50% of the territory and Glasgow Coma Scale ≤8. We determined serum concentrations of substance P on days 1, 4 and 8 of MMCAI. Thirty-day mortality was the study end-point.Serum substance P concentrations at days 1 (p .001), 4 (p .001), and 8 (p = .001) of MMCAI in non-surviving (n = 34) were higher than in surviving patients (n = 34). Receiver operating characteristic analyses showed that serum substance P concentrations at days 1, 4, and 8 of MMCAI had an area under curve (95% confidence intervals) to predict 30-day mortality of 0.77 (0.66-0.87; p .001), 0.82 (0.69-0.91; p .001) and 0.85 (0.72-0.94; p .001) respectively.The two new findings of our study are that non-surviving MMCAI patients showed higher serum substance P levels at day 1, 4 and 8 than surviving, and that those levels could predict 30-day mortality.

Introduction: Malignant middle cerebral artery infarction (MMI) is a severe complication of ischaemic stroke (IS), with a mortality rate up to 80%. Diffusion-weighted imaging (DWI) lesion volume larger than 82 millilitres on cerebral MRI performed within the six first hours is known to be predictive of MMI. These patients, with “malignant profile”, were mostly excluded of endovascular therapy (EVT) randomised trials. The aim of our study was to evaluate whether successful reperfusion after EVT in patients presenting IS with large DWI lesion decreased occurrence of malignant stroke. Methods: We analysed data collected between 2014 and 2018, in a monocentric prospective IS patients registry treated with EVT. Patients were selected if they had a malignant profile and could be eligible to a craniectomy. Thus, selected patients were less than 65-years old, with a severe stroke defined by National Institutes of Health Stroke Scale (NIHSS) score > 15 and with DWI lesion larger than 82ml. We compared patients with successful recanalization (defined by Thrombolysis in Cerebral Ischemia (TICI) 2b or 3) and poor recanalization (TICI 0, 1 or 2A). Primary end point was malignant stroke rate. Secondary end points were craniectomy, haemorrhagic complications, 90-days all-cause mortality rates and 90-days favourable outcome (defined by modified Rankin Scale 0-2). Results: From 2014 to 2018, 66 patients were selected. MMI occurred in 27 patients (42%), and 22 (33%) had effectively craniectomy. Successful recanalization was observed for 46 patients (69.7%). MMI occurrence was significantly lower in the latter patients compared to the poor recanalization group (14/44(31.8%) vs 13/20(65.0%); OR=0.25 (0.08-0.77), p = 0.015). Less craniectomies were performed in the successful recanalization group (12/46 (26.1%) vs 10/20 (50.0%); OR=0.35 (011-1.06), p=0.063).There was no significant difference in symptomatic intracranial haemorrhage rate; in 90-days favourable outcome and all causes mortality rate between the two groups. Conclusion: Successful recanalization performed in IS patients with large DWI lesion decreases the occurrence of malignant strokes and the need for craniectomy procedure. Further data with a larger sample or from randomized studies are needed.

Background - Decompressive surgery (hemicraniectomy) for large hemispheric stroke reduces the risk of death and increases the chance of a favorable outcome. We aim to evaluate the outcome in patien...

Background: Although associated with controversy, decompressive craniotomy (DC) for malignant middle cerebral artery infarction (MMCAI) is an unequivocally lifesaving intervention. DC for MMCAI is rarely performed in lower- to middle-income countries. Methods: A systemic review was performed in attempt to determine the rates of utilization and outcomes of DC on the African continent. Results: Only two African studies describing DC for MMCAI were found. Conclusion: DC for MMCAI is rarely performed and/or reported on the African continent. The African perspective for this needs to be urgently broadened.

Amaç:Bu çalışmanın amacı, merkezimizde geniş orta serebal arter enfarktı nedeni ile dekompresif cerrahi uygulanan veya yalnızca medikal tedavi ile takip edilen hastaların morbidite ve mortalite özelliklerini değerlendirmektir. Gereç ve Yöntem: Pamukkale Üniversitesi Nöroloji Kliniğinde malign orta serebral arter enfarktı nedeni ile takip edilen ve dekompresyon cerrahisi veya medikal tedavi uygulanan 28 hasta geriye dönük dosya incelemesi şeklinde taranarak değerlendirmeye alındı. Dekompresif cerrahi uygulanan hastalar aynı sayı ve yaş grubundaki yalnızca medikal tedavi alan hastalar ile fonksiyonel durum, prognoz ve sağ kalım açısından karşılaştırıldı. Bulgular:Dekompresif cerrahi yapılan hastalarda bir aylık izlemde 4 hasta yaşarken 10 hastanın kaybedildiği, yalnızca medikal tedavi uygulanan hastalarda ise 7 hasta yaşarken, 7 hastanın kaybedildiği görüldü. 65 yaş ve altındaki 13 hastanın 7' si yaşamını kaybetmiş, 6' sı sağ kalmışken, 65 yaş üzerindeki 15 hastanın 10' u yaşamını kaybetmiş, 5' i sağ olarak kaldığı belirlendi. Birden fazla risk faktörü olan 15 hastadan 9' unun dekompresif cerrahiye alındığı, bu hastalardan da bir aylık izlemde 2 hastanın sağ kaldığı saptandı. 1 ve daha az risk faktörü olan 13 hastadan ise 7 hastanın sağ kaldığı, bu hastalardan 5' inin yalnızca medikal tedavi ile takip edildiği saptandı (p: 0,011). Sonuç:Malign orta serebral arter enfarktı olan, özellikle 65 yaş altında, 1' den fazla risk faktörü olmayan uygun hastalarda ilk 48 saatte yapılan dekompresif kraniyektominin sağ kalım açısından faydalı olabileceği saptanmıştır., Purpose:The purpose of this study is to compare the morbidity and mortality properties of patients with decompressive surgery or medical treatment in malignant middle cerebral artery infarcts. Materials and Methods:28 patients with malignant middle cerebral artery infarct treated with decompressive surgery or medical therapy in Pamukkale University Neurology clinic enrolled in the study. Patients treated with decompressive surgery were compared with patients treated with medical theraphy alone on functional status, prognosis and survival rates. Results:In one month follow up, 4 patient survived and 10 patients were exitus in decompressive surgery group and 7 patients survived and 7 patients were exitus in medical therapy group. 6 patients survived and 7 patients were exitus of 13 patients who were under the age of 65 and 5 patients survived and 10 patients were exitus of 15 patients who were over the age of 65. 9 of the 15 patients with more than 1 risk factor were in decompressive surgery group and 2 patients survived in one month follow up. 7 of the 13 patients with 1 or less risk factor survived and 5 of this 7 patients were in medical therapy group (p: 0,011). Conclusion:Decompressive craniectomy should be considered in patients under the age of 65 with 1 or less risk factor when surgery performed within 48 hours for less mortality.

Background: Decompressive hemicraniectomy reduces secondary brain injury related to brain edema and increased intracranial pressure (ICP) in patients with malignant middle cerebral artery infarction (MMI). However, a substantial proportion of patients still die despite hemicraniectomy due to refractory brain swelling. Objective: We aim to investigate whether ICP measured immediately after hemicraniectomy may indicate decompression effects and predict survival in patients with MMI. Methods: We included 25 patients with MMI who underwent ICP monitoring and brain computed tomography within the first hour of hemicraniectomy. Midline shifts were measured as radiological surrogates of decompression. The Glasgow Coma Scale and pupillary enlargements during the first day after hemicraniectomy were assessed as clinical surrogates of decompression. Long-term survival status at 6 months was used as the final outcome. We analyzed the relationships between early ICP and findings of midline shift, Glasgow Coma Scale, pupillary enlargement, and survival. Results: Initial ICP was correlated with mean ICP ( P < .001) and maximal ICP ( P < .001) during the first postoperative day. Intracranial pressure was associated with midline shifts ( P = .009), lower Glasgow Coma Scale scores ( P = .025), and the pupillary enlargement ( P = .015). Sixteen (64.0%) patients survived at 6 months. In a Cox proportional hazard model, elevated ICP was associated with mortality at 6 months (hazard ratio: 1.13; 95% confidence interval: 1.03-1.24; P = .008). Conclusion: Increase in ICP soon after hemicraniectomy was associated with midline shift, poor neurological status, and mortality in patients with MMI. Measurements of ICP soon after hemicraniectomy may permit earlier interventions as well as more refined clinical assessments.

We evaluated the clinical outcomes of malignant middle cerebral artery (MCA) infarction (MMI) and determined an infarcted brain volume (BV) threshold value for accurate MMI prediction in elderly patients.We analyzed 69 consecutive patients (mean, 75.6 ± 11.7) with internal carotid artery or MCA infarction within 48 hours from onset. Diffusion-weighted high-intensity volume (DHV) and BV were measured in all patients. The percentage of DHV within BV (DHV/BV ratio) was calculated to standardize the DHV difference for each individual BV. Patients were stratified based upon their MMI status and age, compared with the following: (1) MMI versus non-MMI groups and (2) age ≥75 years group versus age75 years group, based on DHV values, DHV/BV ratio, Glasgow Coma Scale (GCS) scores on admission, and modified Rankin Scale (mRS) scores at 3 months after onset.The MMI group (n = 14) showed significantly larger DHV values (P .001), larger DHV/BV ratios (P .001), lower GCS scores on admission (P .01), and higher mRS scores at 3 months (P .001) than the non-MMI group. The DHV threshold value predicting MMI was 102 cm(3) (sensitivity 85%, specificity 91%, P .01) and DHV/BV threshold ratio was 7.8% (sensitivity 86%, specificity 87%, P .01). Both the age ≥75 years group and the age 75 years group with MMI showed equally poor outcomes (mRS 5.7 ± .7 versus 5.3 ± 1.3).DHV and DHV/BV can provide reliable information for MMI prediction in elderly patients.

Background and aim: Malignant middle cerebral artery infarction (MMCAI) usually leads to brain edema that may result in transtentorial herniation and brainstem compression. The prognosis of MMCAI is generally poor. The aim of this study was to discuss our experience with surgical decompression for MMCAI, and determine the association between timing of craniectomy and neurological outcomes. Methods: We identified consecutive patients diagnosed with MMCAI who underwent decompressive craniectomy (DC). Clinical and demographic data were obtained from electronic medical records, including: age, sex, preoperative Glasgow Coma Scale (GCS) score, surgery timing, postoperative GCS scores, and modified Rankin Scale (mRS) scores. Results: This study included 27 stroke patients (aged 38&ndash, 80 years) operated within 72 h of the onset of neurological symptoms. Sixteen, five, and six patients underwent DC within 24 h, between 24 and 48 h, and after 48 h after onset of symptoms, respectively. Five patients died after the surgery. Patients who underwent DC within 24 h and 24&ndash, 48 h had better mean GCS scores than those who underwent DC after 48 h (p = 0.000, p = 0.015). In addition, patients who underwent DC within 24 h had better mean postoperative mRS scores (p = 0.000) than other patients. Patients older than 60 years had significantly lower GCS scores (p = 0.027) and higher mRS scores (p = 0.033) than younger patients. Conclusion: Our findings support that DC had satisfying outcomes in patients who underwent DC within 24 h. Older age and lower Glasgow Coma Scale scores among DC patients with MMCAI are associated with high morbidity and mortality.

Background The prognosis of one hemisphere malignant infarction creates doubt among neurosurgeons about decompressive hemicraniectomy indication. What results are achieved in the short to medium term? Are families satisfied with the surgery once the patient is at home? In the present study, we analyze our experience in this matter during the last thirteen years. Methods In our review, twenty-one patients were included from 2004 to 2017, according to the protocol for the management of ischaemic stroke that is implemented in our institution. The relatives were interviewed by telephone. The functional outcome at discharge, 3 months, 1 year, and at present was measured using the modified Rankin scale (mRS). Results Patient age was shown to be directly related to the mRS (r = 0.56; p = 0.035) and 37.5% achieved a good outcome (mRS≤3). 78.9% of the interviewed relatives would repeat the surgical decision. Conclusion We present a 21 patients group where the best outcome was achieved in patients ≤60 years old. The severe neurological sequelae in patients with malignant infarction subjected to decompressive hemicraniectomy are tolerated and accepted by most families to the benefit of survival. We must not let this family satisfaction hide the prognosis, having to contextualize it within the real ambulatory situation of the patients.

Background Ischaemic stroke accounts for 87% of strokes and occurs when a clot or a thrombus blocks a blood vessel, cutting off blood flow to a part of the brain. If large areas of brain are affected, space-occupying oedema may result, leading to rapid neurological deterioration, coma and death. Malignant middle cerebral artery infarction (MMCAI) is a life-threating ischaemic stroke involving the whole middle cerebral artery (MCA) territory and comprises up to 10% of MCA infarctions. Methods We report the case of a 62 year old female ‘Mary’ who presented with a MMCAI together with a summary of the most recent and relevant evidence for treatment options in terms of survival and quality of life for her. We also focus on the vital role of the nurse in Mary’s care and treatment. Results Intravenous thrombolysis and endovascular clot retrieval (ECR) during the hyperacute phase have been shown to improve outcomes but Mary did not meet the criteria for thrombolysis and received unsuccessful ECR. Her neurological condition deteriorated so she underwent surgical decompression, which is one of the major advances for MMCAI treatment together with expert neuro critical care nursing. Mary made a good functional recovery, returning home to live independently. Conclusion This case highlights the need to consider all contextual and patient preferences in relation to treatment options. In addition the case emphases the vital role the neuro critical care nurse specialist plays in the complex assessment and treatment of this patient who experienced a MMCAI and underwent complex interventions.

Background and purpose Data from randomly controlled trials have indicated that a decompressive hemicraniectomy is more clinically effective than medical treatment in the management of space-occupying brain oedema post middle cerebral artery infarction. This economic evaluation compares the impact of the two options in the UK. No recent study has conducted an economic evaluation on this topic for the UK. Method A cost-utility analysis over a time period of 1 year was used, measuring benefits in terms of quality adjusted life years (QALYs) and costs in pound sterling, discounted to 2015 prices. The evaluation was from the perspective of the National Health Service, the largest healthcare provider in the UK. Results The cost-utility analysis found an incremental cost effectiveness of £116 595.10 for every QALY gained if patients were offered a decompressive hemicraniectomy compared to the best medical treatment. Discussion This is above the National Institute for Health and Care Excellence (NICE) 'cost-effective' threshold of £20 000-£30 000 per QALY, but lower mortality rates associated with the surgical alternative raises ethical considerations for healthcare providers in the UK.

Background This study aimed to evaluate the efficacy and safety of stereotactic aspiration of necrotic brain tissue for treating malignant middle cerebral artery infarction (MMI) in patients older than 60 years of age. Case Description A total of 13 consecutive patients with MMI (mean age, 67 ± 6.62 years) were enrolled in the study. These patients were treated with stereotactic aspiration of necrotic brain tissue within 72 hours from stroke onset between January 2016 and June 2017. The surgical results and clinical outcomes were evaluated in response to stereotactic aspiration of necrotic brain tissue. The mean preoperative infarction volume in the patients was found to be 153.46 ± 9.39 mL according to the latest computed tomography scan. The 30-day mortality was 2 out of 13 patients (15.4%). Patients were followed-up for 6 months to evaluate the efficacy of stereotactic aspiration of necrotic brain tissue using the modified Rankin Scale (mRS). Among the 11 surviving surgical patients, 6 (54.5%) had an mRS score of 3 (defined as moderate disability), 4 (36.4%) had an mRS score of 4 (defined as moderate to severe disability), and 1 (9.1%) had an mRS score of 5 (defined as severe disability). The probability of 6-month unfavorable outcome, defined as an mRS score of 5 or 6 (death), was 3 out of 13 (23.1%). Conclusions Our results suggest the stereotactic aspiration of necrotic brain tissue is an effective and safe method in patients with MMI who are over 60 years of age.

Der maligne Mediainfarkt (MMI) ist eine Erkrankung, fur die neben der einzig nachgewiesenermasen effektiven Therapie, der fruhen Hemikraniektomie (HC), eine Vielzahl von intensivmedizinischen Therapien zur Verfugung steht. Wie mit der HC und den konservativen Therapien an deutschen Kliniken im Detail verfahren wird und welche Strukturen an den einzelnen Kliniken zur Behandlung des MMI vorhanden sind, ist nicht bekannt. Es wurden anonyme Fragebogen an 297 neurologische und 133 neurochirurgische Akutkliniken in Deutschland versandt. Der Rucklauf betrug 24,7 %. Die meisten teilnehmenden Kliniken gaben an, personliche Erfahrung in der Behandlung des MMI zu haben (83,8 %). Eine HC kann meist fruhzeitig vor Ort durchgefuhrt werden (65,1 %). Die Indikationsstellung erfolgt in der Regel auf hoher fachlicher und hierarchischer Ebene anhand klinischer und bildgebender Kriterien (78,2 %). Ein fester Behandlungsalgorithmus ist in 70,8 % der Kliniken etabliert. 74,5 % der mittels HC behandelten Patienten und 42,5 % der konservativ behandelten Patienten werden auf einer Intensivstation behandelt. Eine Uberwachung des intrakraniellen Drucks erfolgt nicht regelhaft. Die Ergebnisse hinsichtlich Diagnosestellung und Therapie des MMI sind allerdings sehr heterogen und ohne erkennbaren klaren Konsens. In den teilnehmenden Kliniken sind die Strukturen fur die Behandlung des MMI prinzipiell vorhanden. Andererseits ist die Heterogenitat in der Versorgung des MMI auffallend. Eine Optimierung der Versorgung des MMI durch die Implementierung fester Behandlungsalgorithmen und die Adharenz an bestehende Leitlinien ist notwendig.