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(Stroke. 2003;34:2914.)
© 2003 American Heart Association, Inc.

Original Contributions

Editorial Comment—"Malignant" or Not: Is There a Role for In Vivo Neurochemistry?

Department of Neurology, University of Heidelberg, Heidelberg, Germany

An extract of the first 250 words of the full text is provided, because this article has no abstract.

Large infarctions of the middle cerebral artery (MCA) territory still represent a challenge for neurointensive care. Some patients may develop a space-occupying brain edema leading to raised intracranial pressure, midline shift, and, in the worst case, herniation with subsequent death. Clinical deterioration with decreasing levels of consciousness and evolvement of brain stem signs usually occurs within 2 to 5 days following symptom onset.¹ Prognosis of these so-called malignant MCA infarctions (MMI) is poor: In prospective case series, 80% died from herniation despite maximum conservative therapy.²

In order to prevent or reverse edema formation, to lower increased intracranial pressure, to improve cerebral perfusion, and to attenuate deleterious ischemic processes, more drastic rescue therapies such as craniectomy or therapeutic hypothermia have been applied. Moderate hypothermia initiated within 14 hours after stroke onset resulted in a mortality rate of 44% in an open case series.³ Decompressive surgery at a mean time of 39 hours after stroke onset reduced mortality to <35% in another case series,⁴ while earlier craniectomy at a mean time of 21 hours between stroke onset and surgery was associated with a further reduced mortality rate of 16% and improved clinical outcome.⁵ Early enough commencement of these strategies seems crucial for the prevention of a malignant stroke course. However, these therapeutic strategies are invasive, they may involve long-term sedation and ventilation on intensive care units, and they are associated with various serious side-effects.

Therefore, reliable data predicting MMI are required as early as possible in the course of stroke to make . . . [Full Text of this Article]