Malignant MCA Infarction: Pathophysiology and Imaging for Early Diagnosis and Management Decisions

Background: Malignant middle cerebral artery infarction is a devastating condition, with up to 80% mortality in conservatively treated patients. The pathophysiology of this stroke is characterized by a large core of severe ischemia and only a relatively small rim of penumbra. Due to the fast development of irreversible morphological damage, cytotoxic edema occurs immediately in a large portion of the ischemic territory. The subsequent damage of the tight junctions leads to the breakdown of the blood brain barrier and vasogenic brain edema, resulting in space-occupying brain swelling. The progressive vasogenic edema reaches its maximum after 1 to several days and exerts a mechanical force on surrounding tissue structures leading to midline shift and transtentorial herniation and finally brain stem compression and death. Summary: Early severe neurological symptoms – hemiparesis, gaze deviation, higher cortical signs – followed by headache, vomiting, papillo edema and reduced conReceived: July 22, 2015 Accepted: September 29, 2015 Published online: November 19, 2015 Wolf-Dieter Heiss, MD Max Planck Institute for Metabolism Research Gleueler Str. 50, DE–50931 Cologne (Germany) E-Mail wdh @ sf.mpg.de © 2015 S. Karger AG, Basel 1015–9770/15/0412–0001$39.50/0