Malignant MCA Stroke in a 4-Year-Old Child: Early Decompressive Surgery as a Life-Saving Intervention

Malignant middle cerebral artery (MCA) infarction is a rare but life-threatening condition in children. We report a case of a previously healthy 4-year-old who developed malignant left MCA infarction following bronchopneumonia. One week into bronchopneumonia, the child experienced a prolonged right-sided focal motor seizure and a reduced level of consciousness (GCS 11/15). Brain CT revealed a large left MCA infarct with mild oedema. Seventy-two hours later, the child clinically deteriorated, and repeat imaging showed midline shift with signs of impending uncal herniation. Emergency decompressive hemicraniectomy and durotomy were performed. Postoperatively, cerebral oedema and midline shift improved. At discharge, the child could sit independently but had persistent neurological deficits requiring long-term neurorehabilitation. This case highlights the importance of early recognition and timely surgical intervention in managing paediatric malignant MCA infarction to improve survival and neurological outcomes.