An aggressive approach to massive middle cerebral artery infarction

We report favorable outcome after surgical decompression, or strokectomy, guided by xenon-enhanced computed tomographic studies of cerebral blood flow in the setting of potentially fatal swelling from massive cerebral infarction.

Retrospective analysis with 3 months to 3 years of follow-up.

University of Pittsburgh (Pa) Medical Center, a tertiary care university referral center.

Four patients, aged 14 to 46 years, presented with focal neurologic deficits appropriate for a massive middle cerebral artery infarction (two dominant and two nondominant). In spite of medical therapy, all patients deteriorated to at least a decreased level of consciousness.

Using xenon-enhanced computed tomographic studies of cerebral blood flow in three patients, areas of severely ischemic (blood flow, < 5 mL/100 g per minute), nonviable brain were identified and resected.

Outcome was measured by survival and ability to perform activities of daily living.

Postoperatively, all patients recovered rapidly (< 6 hours) to the level of function at admission and were able to perform the activities of daily living with minimal or no assistance.

Despite deficits appropriate to the area of infarction, prompt management of life-threatening postinfarction swelling by surgical decompression can yield favorable outcome.