Week 9: Even more stroke, part 4

#23: Malignant middle cerebral artery infarction: pathophysiology, diagnosis and management

  • Space occupying edema is the most common cause of early mortality in stroke; edema peaks at days 2-4
  • “Malignant MCA syndrome” really just refers to a big MCA stroke that swells a lot
  • Mechanism of cytotoxic edema is ischemia causing lack of oxygen and glucose, which leads to failure of the sodium/potassium ATPase; this results in sodium rushing in, osmotically drawing water in along with it, so the cell swells and dies
  • Vasogenic edema is caused by breakdown of the blood-brain barrier post stroke, the mechanism for which is not fully understood; proteins and ions leak out of the blood into the extracellular space
  • Radiographical predictors of poor outcome include more than 50% involvement of MCA territory, and pineal gland displacement
  • The article talks about 3 trials for decompressive surgery: DECIMAL and HAMLET showed improved survival but not improved mRS; DESTINY was stopped early
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