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Hemorrhagic transformation following a malignant middle cerebral artery infarction

Salah Sehweil¹, Zoya Goncharova¹, Prashanth Nataraj¹

¹Department of Neurology and Neurosurgery, Rostov State Medical University, Rostov Region, Russia.

Journal of Cerebrovascular and Endovascular Neurosurgery

|January 20, 2026

Abstract

Objective:

This study aimed to determine the frequency of hemorrhagic transformation (HT) and evaluate its impact on the clinical course and outcomes of patients with malignant middle cerebral artery (MCA) infarction.

Methods:

A retrospective review was conducted of 74 patients with malignant MCA infarction, aged 44 to 92 years (mean age 71.5±2.0 years; 54.0% female), admitted between 2017 and 2025. Conservative therapy was administered to 77.0% of patients, while 22.9% underwent decompressive hemicraniectomy. All cases of HT were assessed using computed tomography according to the ECASS I classification.

Results:

In the study cohort, 15% of patients received intravenous thrombolysis (IVT). Significantly, among this group, 100% developed HT as a complication. Hemorrhagic infarction (HI) occurred in 81.8% of these cases and was asymptomatic, not worsening the clinical condition or neurological deficits. Parenchymal hemorrhage (PH) occurred in 18.2% and was associated with clinical deterioration and fatal outcomes. In patients not receiving IVT, HT was observed in 66.6% of cases: HI type 1 occurred in 33.3%, HI type 2 in 47.6%, and PH type 1 in 19.0%. No cases of PH type 2 were reported.

Conclusions:

HT is highly prevalent in malignant MCA infarction, regardless of IVT administration, with the majority of cases asymptomatic. Consequently, these findings suggest that asymptomatic HT may represent a natural progression of large infarcts rather than a treatment complication. The results underscore the need for early diagnostic markers and improved management strategies for HT in malignant MCA infarction.

Insights

Hemorrhagic transformation (HT) is common in malignant middle cerebral artery (MCA) infarction, often asymptomatic. This suggests HT may be a natural infarct progression, not solely a treatment complication, necessitating better diagnostic tools.

Area of Science:

Neurology
Radiology
Critical Care Medicine

Background:

Malignant middle cerebral artery (MCA) infarction is a severe condition with high mortality.
Hemorrhagic transformation (HT) is a known complication of ischemic stroke, but its frequency and impact in malignant MCA infarction require further elucidation.

Purpose of the Study:

To determine the frequency of hemorrhagic transformation (HT) in patients with malignant MCA infarction.
To evaluate the impact of HT on the clinical course and outcomes of these patients.

Main Methods:

Retrospective review of 74 patients with malignant MCA infarction.
Assessment of HT using computed tomography (CT) according to the ECASS I classification.
Analysis of clinical data, including intravenous thrombolysis (IVT) administration and decompressive hemicraniectomy.

Main Results:

HT occurred in 100% of patients receiving IVT, with most cases being asymptomatic hemorrhagic infarction (HI).
In patients not receiving IVT, HT occurred in 66.6%, with varying types of HI and parenchymal hemorrhage (PH).
Parenchymal hemorrhage (PH) was associated with clinical deterioration and fatal outcomes, irrespective of IVT.

Conclusions:

Hemorrhagic transformation (HT) is highly prevalent in malignant MCA infarction, often asymptomatic.
Asymptomatic HT may represent a natural progression of large infarcts rather than a treatment complication.
There is a need for early diagnostic markers and improved management strategies for HT in malignant MCA infarction.

Read full analysis

Keywords:

Decompressive craniectomy Hemorrhage Intravenous thrombolysis Middle cerebral artery stroke

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