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Cerebral stroke is the third cause of death in the world and is the most common cause of death among diseases of the central nervous system. Among cases of supratentorial infarction, 10 - 15% involve the entire middle cerebral artery (MCA) territory.
Journal of military pharmaco-medicine MIDDLE CEREBRAL ARTERY INFARCTION AND IPSILATERAL POSTERIOR CEREBRAL ARTERY INFARCTION: Case report: Successful hemicraniestomy in patient older than 60 years of age Truong Da*; Bui Quang Tuyen** Vu Van Hoe**; Bui Quang Dung** SUMMARY Cerebral stroke is the third cause of death in the world and is the most common cause of death among diseases of the central nervous system Among cases of supratentorial infarction, 10 - 15% involve the entire middle cerebral artery (MCA) territory The occlusion of MCA leads to a mortality of around 80% Over the last 10 years, decompressive hemicraniectomy for management of MCA infarction has been implemented at many neurosurgical centres all over the world Although the mortality rate in patients ≥ 60 years of age was high, the result of surgical decompression showed an improvement in functional outcome and mortality rate compared with medical management Of 75 patients who underwent decompressive craniectomy for middle cerebral artery infarction, one case suffered from MCA and ipsilateral posterior cerebral artery infarction This case was successfully operated We report the rare case and review the relevant literature * Keywords: Middle cerebral artery infarction; Cerebral stroke; Ipsilateral posterior cerebral artery infarction CASE REPORT A 61 year-old man (dwelled at 232 Nguyen Cong Tru street, Nguyen Thai Binh ward, district 1, Hochiminh City) was referred to the emergency unit of 115 Hospital in Hochiminh City on September 13, 2015 with symptoms of sudden weakness of the right hemibody On the image of the computer tomography scans (CT), there was an infarction of the left middle cerebral artery The patient received medical treatment with anticoagulant, fluid replacement and antibrain edema measures After days, the patient deteriorated with Glasgow Coma Scale (GOS) score dropped down points Repeated computer tomography (CT) showed evidence of the left middle cerebral artery infarct with infarction of ipsilateral posterior cerebral artery (fig.1) The patient was transferred to Choray Hospital on September 18, 2015 with symptoms of headaches, vomiting and right-side hemiparesis On general examination, his GCS was 9/15 (E3V1M5); the pupils were mm isocoria in size with good reaction to light There was no obvious facial nerve VII palsy * Choray Hospital ** 103 Military Hospital Corresponding author: Bui Quang Tuyen (buiquangtuyenb9@gmail.com) Date received: 26/06/2017 Date accepted: 28/08/2017 197 Journal of military pharmaco-medicine Muscle tone on the right side was reduced His heart rate was 88 beats per minute; a blood pressure of 170/100 mmHg CT brain scans revealed hypodense lesion in left MAC and posterior cerebral artery (PCA) territories with midline shift > mm (fig.1) A diagnosis of MCA infarction associated PCA infarction was made On September 18, he was operated on with large decompressive craniectomy on the left side A large craniotomy and a subtemporal craniectomy were made, A followed by a dural incision at the anterior temporal lobe region (fig 2) His bone flap, which had been saved in the bone bank, was replaced on January 6, 2016 Within to hours after operation, the patient began to wake up In the next morning, on September 19 the patient was alert and oriented with GCS 13/15, isocoria and normal respiration He was kept initially in a semi-sitting position On September 21, he was transferred back to 115 Hospital and discharged B Fig.1: CT images of patient Ng Van T 61 years old at 115 Hospital (A: Plain CT-scans obtained early after symptoms onset demonstrating only subtle hanges in the left middle cerebral artery territory B: CT-scans on the third day of medical treatment) A B Fig 2: A: Infarction secondary to left MCA and PCA occlusion (B: CT of the same patient following large decompressive craniectomy Complication of parenchymal hemorrhages) 198 Journal of military pharmaco-medicine A B Fig.3: A: Computed tomography images months following cranioplasty (reinsertion) (B: The patient made a good recovery) After months, the cranioplasty was done After 6-month follow-up, the patient was revisted and head CT was done (fig.3) DISCUSSION Middle cerebral artery infarction Middle cerebral artery (MCA) infarct occurs about 10 - 15% of ischaemic strokes They are the most devastating form of acute stroke and lead to a mortality of around 80% MCA infarction leads to acute brain swelling, elevated intracranial pressure (ICP) and brain herniation MCA infarction was termed “massive MCA infarction” or “spaceccupying MCA infarction” MCA infarction manifests itself with a severe hemispheric syndrome including hemiparesis, gaze deviation, headache, vomiting, papillo edema and reduced consciousness The life-threatening edema usually develops to several days after the stroke and may cause midline shift, transtentorial herniation and death in up to 80% within the first week MCA infarction associated with that of other arteries MCA infarction may also combine with anterior cerebral artery or posterior cerebral artery infarction, which constitutes up to 10% of supra-tentorial strokes According to Scott C Robertson (2004), among 12 patients with MCA infarction, two patients had associated anterior cerebral artery (ACA) and one had a posterior cerebral artery (PCA) infarction According to Eugene Lee (2009), among 205 patients, 126 patients (61.5%) had infarction limited to the PCA territory (“PAC territory only”), while 79 patients (38.5%) had concomitant infarcts in other territories (“PCA territory plus”) including ACA (6.3%); middle cerebral artery territory infarcts were the most frequent (17.6%) MCA infarction associated with PAC infarction is very rare and had severe prognosis Decompressive surgery and results According to Dimitre Staykov et al (2011), the decompressive hemicraniectomy (DHC) for treatment of ischemic brain edema had been reported in 1956 Since then, DHC has been increasingly studied 199 Journal of military pharmaco-medicine in the setting of different conditions, including traumatic brain injury, subarachnoid hemorrhage and middle cerebral artery (MCA) infarction All European trials (DECIMAL, DESTINY and HAMLET) showed a significant reduction in mortality rate in surgically treated patients compared with the conservatively treated groups Decompressive surgery in patient older than 60 years of age In 2009, Arac et al published a review of 19 studies, which included 273 patients undergoing decompressive craniectomy for malignant cerebral infarction There were 73 of 273 patients (26.7%) over 60 years of age The mortality rate was significantly higher (50.68% = 37/73 patients) in the group > 60 years old compared with 20.8% (41/200 patients) in the group of ≤ 60 years old (p < 0.0001) Similarly, patients who survived in the group > 60 years of age had significantly higher rate of poor outcomes (81.8% compared with 33.1% in the group of ≤ 60 years (p < 0.0001) Although the mortality rate and neurological functional outcome were significantly worse in patients > 60 years of age following decompressive craniectomy for middle cerebral artery infarction, age should not be a contraindication to surgery and the decision should be made on an individualized basis Surgical management in older patients increases the survival without severe disability CONCLUSION Decompressive hemicraniectomy as a surgical treatment for the brain stroke has been performed for many years 200 Decompressive craniectomy can significantly reduce the mortality rate and improve the neurological outcome in older patients with middle cerebral artery infarction REFERENCES Ahmet Arac et al Assessment of outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 60 years of age Neurosurgical Focus 2009, June, Vol 26, No.6, p.E3 Brandt T et al Posterior cerebral artery territory infarcts: Clinical features, Infarct topography, causes and outcome Multicenter results and review of literature Cerebrovasc Dis 2000, 20, pp.170-182 Dimitre Staykov, Rishi Gupta Hemicraniectomy in malignant middle cerebral artery infarction https://doi.org/10.1161/ STROKEAHA.110.605642 Download PDF Stroke 2011, 42, pp.513-516 Jennifer C.V.Gwyn, Tonny Veenith Management of malignant middle cerebral artery infarction EMJ Neurol 2015, (1), pp.57-62 Klaus Zweckberger et al Surgical aspects of decompression craniectomy in malignant stroke: Review Cerebrovasc Dis 2014, 38, pp.313-323 Scott C Robertson et al Clinical Course and surgical management of massive cerebral infarction Neurosurgery 2004, 55, pp.55-62 Wolf-Dieter Heiss Malignant MCA Infarction: Pathophysiology and imaging for early diagnosis and management decisions Cerebrovasc Dis 2016, 41, pp.1-7 Xiao Cheng Lu et al Decompressive craniectomy for the middle cerebral artery Scientific Reports 4, Article number: 7070 doi: 10.1038/screp 07070 2014 ... cerebral artery infarction REFERENCES Ahmet Arac et al Assessment of outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 60 years of age... MCA infarction leads to acute brain swelling, elevated intracranial pressure (ICP) and brain herniation MCA infarction was termed “massive MCA infarction or “spaceccupying MCA infarction MCA infarction. .. surgery in patient older than 60 years of age In 2009, Arac et al published a review of 19 studies, which included 273 patients undergoing decompressive craniectomy for malignant cerebral infarction