Opinion statement
Malignant infarction implies a large middle cerebral artery (MCA) stroke that leads to rapid clinical deterioration and edema formation, and can be associated with hemorrhagic transformation, herniation, and poor functional outcomes, including death. Malignant edema is brain edema formation that occurs in the setting of large territory infarction. This review discusses the most recent efforts in diagnosis, prevention, and management of malignant edema in acute ischemic strokes.
Similar content being viewed by others
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance
Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R. 'Malignant' middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol. 1996;53(4):309–15.
Moulin DE, Lo R, Chiang J, Barnett HJ. Prognosis in middle cerebral artery occlusion. Stroke. 1985;16(2):282–4.
Silver FL, Norris JW, Lewis AJ, Hachinski VC. Early mortality following stroke: a prospective review. Stroke. 1984;15(3):492–6.
Kaste M, Waltimo O. Prognosis of patients with middle cerebral artery occlusion. Stroke. 1976;7(5):482–5.
Huttner HB, Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol. 2009;8(10):949–58.
Jaramillo A, Góngora-Rivera F, Labreuche J, Hauw JJ, Amarenco P. Predictors for malignant middle cerebral artery infarctions: a postmortem analysis. Neurology. 2006;66(6):815–20.
Hofmeijer J, Kappelle LJ, Algra A, et al. Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicenter, open, randomized trial. Lancet Neurol. 2009;8(4):326–33.
Jüttler E, Schwab S, Schmiedek P, et al. Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY): a randomized, controlled trial. Stroke. 2007;38(9):2518–25.
Vahedi K, Vicaut E, Mateo J, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke. 2007;38(9):2506–17.
Frank JI. Large hemispheric infarction, deterioration, and intracranial pressure. Neurology. 1995;45(7):1286–90.
Donkin JJ, Vink R. Mechanisms of cerebral edema in traumatic brain injury: therapeutic developments. Curr Opin Neurol. 2010;23(3):293–9.
Walcott BP, Kahle KT, Simard JM. Novel treatment targets for cerebral edema. Neurotherapeutics. 2012;9(1):65–72. Outlines the pathophysiology of cerebral edema and discusses novel strategies for treating it.
Simard JM, Kent TA, Chen M, Tarasov KV, Gerzanich V. Brain oedema in focal ischaemia: molecular pathophysiology and theoretical implications. Lancet Neurol. 2007;6(3):258–68.
Yan Y, Dempsey RJ, Flemmer A, Forbush B, Sun D. Inhibition of Na(+)-K(+)-Cl(-) cotransporter during focal cerebral ischemia decreases edema and neuronal damage. Brain Res. 2003;961(1):22–31.
Badaut J, Lasbennes F, Magistretti PJ, Regli L. Aquaporins in brain distribution, physiology, and pathophysiology. J Cereb Blood Flow Metab. 2002;22(4):367–78.
Simard JM, Geng Z, Silver FL, et al. Does inhibiting Sur1 complement rt-PA in cerebral ischemia? Ann N Y Acad Sci. 2012;1268:95–107.
Hofmeijer J, Algra A, Kappelle LJ, van der Worp HB. Predictors of life-threatening brain edema in middle cerebral artery infarction. Cerebrovasc Dis. 2008;25(1–2):176–84.
Walcott BP, Miller JC, Kwon CS, et al. Outcomes in severe middle cerebral artery ischemic stroke. Neurocrit Care. 2013.
Toni D, Fiorelli M, Gentile M, et al. Progressing neurological deficit secondary to acute ischemic stroke. A study on predictability, pathogenesis, and prognosis. Arch Neurol. 1995;52(7):670–5.
Serena J, Blanco M, Castellanos M, et al. The prediction of malignant cerebral infarction by molecular brain barrier disruption markers. Stroke. 2005;36(9):1921–6.
Kernagis DN, Laskowitz DT. Evolving role of biomarkers in acute cerebrovascular disease. Ann Neurol. 2012;71(3):289–303. Provides an excellent review of the potential of biomarkers for the early detection of stroke.
Minnerup J, Wersching H, Ringelstein EB, et al. Prediction of malignant middle cerebral artery infarction using computed tomography-based intracranial volume reserve measurements. Stroke. 2011;42(12):3403–9.
Bektas H, Wu TC, Kasam M, et al. Increased blood-brain barrier permeability on perfusion CT might predict malignant middle cerebral artery infarction. Stroke. 2010;41(11):2539–44.
Hom J, Dankbaar JW, Soares BP, et al. Blood-brain barrier permeability assessed by perfusion CT predicts symptomatic hemorrhagic transformation and malignant edema in acute ischemic stroke. Am J Neuroradiol. 2011;32(1):41–8.
Thomalla G, Cheng B, Ebinger M, et al. DWI-FLAIR mismatch for the identification of patients with acute ischaemic stroke within 4 · 5 hours of symptom onset (PRE-FLAIR): a multicenter observational study. Lancet Neurol. 2011;10(11):978–86.
Mangla R, Ekhom S, Jahromi BS, Almast J, Mangla M, Westesson PL. CT perfusion in acute stroke: know the mimics, potential pitfalls, artifacts, and technical errors. Emerg Radiol. 2013.
O'Collins VE, Macleod MR, Donnan GA, Horky LL, van der Worp BH, Howells DW. 1,026 experimental treatments in acute stroke. Ann Neurol. 2006;59(3):467–77.
Young AR, Ali C, Duretête A, Vivien D. Neuroprotection and stroke: time for a compromise. J Neurochem. 2007;103(4):1302–9.
Ramos-Fernandez M, Bellolio MF, Stead LG. Matrix metalloproteinase-9 as a marker for acute ischemic stroke: a systematic review. J Stroke Cerebrovasc Dis. 2011;20(1):47–54.
Switzer JA, Hess DC, Ergul A, et al. Matrix metalloproteinase-9 in an exploratory trial of intravenous minocycline for acute ischemic stroke. Stroke. 2011;42(9):2633–5.
Fagan SC, Waller JL, Nichols FT, et al. Minocycline to improve neurologic outcome in stroke (MINOS): a dose-finding study. Stroke. 2010;41(10):2283–7.
Kono S, Deguchi K, Morimoto N, et al. Intravenous thrombolysis with neuroprotective therapy by edaravone for ischemic stroke patients older than 80 years of age. J Stroke Cerebrovasc Dis. 2013.
Feng S, Yang Q, Liu M, et al. Edaravone for acute ischaemic stroke. Cochrane Database Syst Rev. 2011;12, CD007230.
Kunte H, Schmidt S, Eliasziw M, et al. Sulfonylureas improve outcome in patients with type 2 diabetes and acute ischemic stroke. Stroke. 2007;38(9):2526–30.
Kunte H, Busch MA, Trostdorf K, et al. Hemorrhagic transformation of ischemic stroke in diabetics on sulfonylureas. Ann Neurol. 2012;72(5):799–806.
Li H, Wang D. Mild hypothermia improves ischemic brain function via attenuating neuronal apoptosis. Brain Res. 2011;1368:59–64.
Wu TC, Grotta JC. Hypothermia for acute ischaemic stroke. Lancet Neurol. 2013;12(3):275–84.
Hemmen TM, Raman R, Guluma KZ, et al. Intravenous thrombolysis plus hypothermia for acute treatment of ischemic stroke (ICTuS-L): final results. Stroke. 2010;41(10):2265–70.
Horn CM, Sun CH, Nogueira RG, et al. Endovascular Reperfusion and Cooling in Cerebral Acute Ischemia (ReCCLAIM I). J Neurointerv Surg. 2013.
Sandercock PA, Soane T. Corticosteroids for acute ischaemic stroke. Cochrane Database Syst Rev. 2011;9, CD000064.
Wright DW, Kellermann AL, Hertzberg VS, et al. ProTECT: a randomized clinical trial of progesterone for acute traumatic brain injury. Ann Emerg Med. 2007;49(4):391–402. 402.e391–2.
Stein DG. Progesterone exerts neuroprotective effects after brain injury. Brain Res Rev. 2008;57(2):386–97.
Zador Z, Stiver S, Wang V, Manley GT. Role of aquaporin-4 in cerebral edema and stroke. Handb Exp Pharmacol. 2009;190:159–70.
Martins AP, Marrone A, Ciancetta A, et al. Targeting aquaporin function: potent inhibition of aquaglyceroporin-3 by a gold-based compound. PLoS One. 2012;7(5):e37435.
Chu H, Tang Y, Dong Q. Protection of vascular endothelial growth factor to brain edema following intracerebral hemorrhage and its involved mechanisms: effect of Aquaporin-4. PLoS One. 2013;8(6):e66051.
O'Donnell ME, Tran L, Lam TI, Liu XB, Anderson SE. Bumetanide inhibition of the blood-brain barrier Na-K-Cl cotransporter reduces edema formation in the rat middle cerebral artery occlusion model of stroke. J Cereb Blood Flow Metab. 2004;24(9):1046–56.
Jauch EC, Saver JL, Adams HP, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870–947.
Chesnut RM, Temkin N, Carney N, et al. A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med. 2012;367(26):2471–81.
Donato T, Shapira Y, Artru A, Powers K. Effect of mannitol on cerebrospinal fluid dynamics and brain tissue edema. Anesth Analg. 1994;78(1):58–66.
Bereczki D, Fekete I, Prado GF, Liu M. Mannitol for acute stroke. Cochrane Database Syst Rev. 2007;3, CD001153.
Lazaridis C, Neyens R, Bodle J, DeSantis SM. High-osmolarity saline in neurocritical care: systematic review and meta-analysis. Crit Care Med. 2013;41(5):1353–60.
Kamel H, Navi BB, Nakagawa K, Hemphill JC, Ko NU. Hypertonic saline vs mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Crit Care Med. 2011;39(3):554–9.
Diringer MN, Scalfani MT, Zazulia AR, Videen TO, Dhar R. Cerebral hemodynamic and metabolic effects of equi-osmolar doses mannitol and 23.4 % saline in patients with edema following large ischemic stroke. Neurocrit Care. 2011;14(1):11–7.
Walcott BP, Kuklina EV, Nahed BV, et al. Craniectomy for malignant cerebral infarction: prevalence and outcomes in US hospitals. PLoS One. 2011;6(12):e29193. Provides large-scale epidemiologic data of the incidence in craniectomy surgeries in the past decade. It shows an increase in decompressive surgeries after the publication of the three randomized controlled trials that came out in favor of surgery in 2007-2009.
Vahedi K, Hofmeijer J, Juettler E, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol. 2007;6(3):215–22.
McKenna A, Wilson CF, Caldwell SB, Curran D. Functional outcomes of decompressive hemicraniectomy following malignant middle cerebral artery infarctions: a systematic review. Br J Neurosurg. 2012;26(3):310–5. The first systematic review that examines functional outcome following decompressive surgery in patients with malignant cerebral edema.
Zhao J, Su YY, Zhang Y, et al. Decompressive hemicraniectomy in malignant middle cerebral artery infarct: a randomized controlled trial enrolling patients up to 80 years old. Neurocrit Care. 2012;17(2):161–71.
Jüttler E, Bösel J, Amiri H, et al. DESTINY II: DEcompressive surgery for the treatment of malignant INfarction of the middle cerebral arterY II. Int J Stroke. 2011;6(1):79–86.
Compliance with Ethics Guidelines
Conflict of Interest
Dr. Allison E. Arch declares that she has no conflicts of interest. Dr. Kevin N. Sheth reported received grants from Remedy Pharmaceuticals and NIH.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Author information
Authors and Affiliations
Corresponding author
Additional information
This article is part of the Topical Collection on Cerebrovascular Disease and Stroke
Rights and permissions
About this article
Cite this article
Arch, A.E., Sheth, K.N. Malignant Cerebral Edema After Large Anterior Circulation Infarction: A Review. Curr Treat Options Cardio Med 16, 275 (2014). https://doi.org/10.1007/s11936-013-0275-0
Published:
DOI: https://doi.org/10.1007/s11936-013-0275-0