Malignant brain oedema treated in a complex and effective way – case reports

Klaudyna Kojder, Bartosz Limanówka



Introduction: Malignant ischaemic stroke is a rapidly progressing cerebral oedema following stroke, which is most commonly associated with poor prognosis.

Case reports: We present two case reports of patients aged 27 and 64 who were successfully treated for malignant ischaemic stroke caused by different primary issues. The patients were treated in a complex way, including craniectomy and intensive care methods. Treatment outcomes differed in both patients concerning survival time, but at the end of treatment both patients remained conscious, and communicated by gestures.

Conclusions: Regardless of the aetiology of malignant brain oedema, the treatment should be personalized and based on the cooperation of multi-specialist teams. The methods of treatment used for malignant stroke are discussed.


malignant brain oedema; ischaemic stroke; traumatic brain injury

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Lindsay P, Furie KL, Davis SM, Donnan GA, Norrving B. Worlds Stroke Organization global stroke services guidelines and action plan. Int J Stroke 2014; Suppl A100:4-13. doi: 10.1111/ijs.12371.

Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R. ‘Malignant’ middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol 1996;53(4):309-15.

Bounds JV, Wiebers DO, Whisnant JP, Okazaki H. Mechanisms and timing of deaths from cerebral infarction. Stroke 1981;12(4):474-7.

Berrouschot J, Sterker M, Bettin S, Köster J, Schneider D. Mortality of space-occupying (‘malignant’) middle cerebral artery infarction under conservative intensive care. Intensive Care Med 1998;24(6):620-3.

Hoehn-Berlage M, Norris DG, Kohno K, Mies G, Leibfritz D, Hossmann KA. Evolution of regional changes in apparent diffusion coefficient during focal ischemia of rat brain: the relationship of quantitative diffusion NMR imaging to reduction in cerebral blood flow and metabolic disturbances. J Cereb Blood Flow Metab 1995;15(6):1002-11.

Kniesel U, Wolburg H. Tight junctions of the blood-brain barrier. Cell Mol Neurobiol 2000;20(1):57-76.

Nielsen TH, Ståhl N, Schalén W, Reinstrup P, Toft P, Nordström CH. Recirculation usually precedes malignant edema in middle cerebral artery infarcts. Acta Neurol Scand 2012;126(6):404-10.

Wang CX, Shuaib A. Critical role of microvasculature basal lamina in ischemic brain injury. Prog Neurobiol 2007;83(3):140-8.

Krieger DW, Demchuk AM, Kasner SE, Jauss M, Hantson L. Early clinical and radiological predictors of fatal brain swelling in ischemic stroke. Stroke 1999;30(2):287-92.

von Kummer R, Meyding-Lamadé U, Forsting M, Rosin L, Rieke K, Hacke W, et al. Sensitivity and prognostic value of early CT in occlusion of the middle cerebral artery trunk. AJNR Am J Neuroradiol 1994;15(1):9-15; discussion 16-8.

Ryoo JW, Na DG, Kim SS, Lee KH, Lee SJ, Chung CS, et al.: Malignant middle cerebral artery infarction in hyperacute ischemic stroke: evaluation with multiphasic perfusion computed tomography maps. J Comput Assist Tomogr 2004;28(1):55-62.

Schwab S, Spranger M, Schwarz S, Hacke W. Barbiturate coma in severe hemispheric stroke: useful or obsolete? Neurology 1997;48(6):1608-13.

Tu PH, Liu ZH, Chuang CC, Yang TC, Wu CT, Lee ST. Postoperative midline shift as secondary screening for the long-term outcomes of surgical decompression of malignant middle cerebral artery infarcts. J Clin Neurosci 2012;19(5):661-4.

Torbey MT, Bösel J, Rhoney DH, Rincon F, Staykov D, Amar AP. Evidence-based guidelines for the management of large hemispheric infarction: a statement for health care professionals from the Neurocritical Care Society and the German Society for Neuro-intensive Care and Emergency Medicine. Neurocrit Care 2015;22(1):146-64.

Dohmen C, Bosche B, Graf R, Reithmeier T, Ernestus RI, Brinker G, et al. Indentification and clinical impact of impaired cerebrovascular autoregulation in patients with malignant middle cerebral artery infarction. Stroke 2007;38(1)56-61.

Paldor I, Rosenthal G, Cohen JE, Leker R, Harnof S, Shoshan Y, et al. Intracranial pressure monitoring following decompressive hemicraniectomy for malignant cerebral infarction. J Clin Neurosci 2015;22(1):79-82.

Poca MA, Benejam B, Sahuquillo J, Riveiro M, Frascheri L, Merino MA, et al. Monitoring intracranial pressure in patients with malignant middle cerebral artery infarction: is it useful? J Neurosurg 2010;112(3):648-57.

Simard JM, Tsymbalyuk N, Tsymbalyuk O, Ivanova S, Yurovsky V, Gerzanich V. Glibenclamide is superior to decompressive craniectomy in a model of malignant stroke. Stroke 2010;41(3):531-7.

Steiner T, Mendoza G, De Georgia M, Schellinger P, Holle R, Hacke W. Prognosis of stroke patients requiring mechanical ventilation in a neurological critical care unit. Stroke 1997;28(4):711-5.

Imberti R, Bellinzona G, Langer M. Cerebral tissue PO2 and SjvO2 changes during moderate hyperventilation in patients with severe traumatic brain injury. J Neurosurg 2002;96(1):97-102.

Schwarz S, Georgiadis D, Aschoff A, Schwab S. Effects of body position on intracranial pressure and cerebral perfusion in patients with large hemispheric stroke. Stroke 2002;33(2):497-501.

Simard JM, Sahuquillo J, Sheth KN, Kahle KT, Walcott BP. Managing malignant cerebral infarction. Curr Treat Options Neurol 2011;13(2):217-29. doi: 10.1007/s11940-010-0110-9.

Bereczki D, Fekete I, Prado GF, Liu M. Mannitol for acute stroke. Cochrane Database Syst Rev 2007(3):CD001153.

Bereczki D, Mihálka L, Szatmári S, Fekete K, Di Cesar D, Fülesdi B, et al. Mannitol use in acute stroke: case fatality at 30 days and 1 year. Stroke 2003;34(7):1730-5.

Palestrant D, Frontera JA, Mayer SA. Treatment of massive cerebral infarction. Curr Neurol Neurosci Rep 2005;5(6):494-502.

Qizilbash N, Lewington SL, Lopez-Arrieta JM. Corticosteroids for acute ischaemic stroke. Cochrane Database Syst Rev 2002(2):CD000064.

Schwarz S, Georgiadis D, Aschoff A, Schwab S. Effects of hypertonic (10%) saline in patients with raised intracranial pressure after stroke. Stroke 2002;33(1):136-40.

Singh V, Edwards NJ. Advances in the critical care management of ischemic stroke. Stroke Res Treat 2013. doi: 10.1155/2013/510481.

Schwab S, Schwarz S, Spranger M, Keller E, Bertram M, Hacke W. Moderate hypothermia in the treatment of patients with severe middle cerebral artery infarction. Stroke 1998;29(12):2461-6.

Jaramillo A, Illanes S, Díaz V. Is hypothermia useful in malignant ischemic stroke? Current status and future perspectives. J Neurol Sci 2008;266(1-2):1-8.

Kollmar R, Schwab S. Hypothermia and ischemic stroke. Curr Treat Options Neurol 2012;14(2):188-96.

Westendorp WF, Nederkoorn PJ, Vermeij JD, Dijkgraaf MG, van de Beek D. Post-stroke infection: a systematic review and meta-analysis. BMC Neurol 2011;11:110. doi: 10.1186/1471-2377-11-110.

Scarcella G. Encephalomalacia simulating the clinical and radiological aspects of brain tumor; a report of 6 cases. J Neurosurg 1956;13(4):278-92.

Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp HB, et al. Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol 2009;8(4):326-33.

Jüttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, et al. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke 2007;38(9):2518-25.

Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 2007;38(9):2506-17.

Taylor B, Appelboom G, Connolly ES Jr. Age selection for decompressive craniectomy in malignant middle cerebral artery infarction. World Neurosurg 2015;83(3):301-2. doi: 10.1016/j.wneu.2014.05.012.

Frank JI, Schumm LP, Wroblewski K, Chyatte D, Rosengart AJ, Kordeck C, et al. Hemicraniectomy and durotomy upon deterioration from infarction-related swelling trial: randomized pilot clinical trial. Stroke 2014;45(3):781-7.

Jüttler E, Unterberg A, Woitzik J, Bösel J, Amiri H, Sakowitz OW, et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 2014;370(12):1091-100.

Zhao J, Su YY, Zhang Y, Zhang YZ, Zhao R, Wang L, et al. Decompressive hemicraniectomy in malignant middle cerebral artery infarct: a randomized controlled trial enrolling patients up to 80 years old. Neurocrit Care 2012;17(2):161-71.

Back L, Nagaraja V, Kapur A, Eslick GD. Role of decompressive hemicraniectomy in extensive middle cerebral artery strokes: a meta-analysis of randomised trials. Intern Med J 2015;45(7):711-7.

Rastogi V, Lamb DG, Williamson JB, Stead TS, Penumudi R, Bidari S, et al. Hemispheric differences in malignant middle cerebral artery stroke. J Neurol Sci 2015;353(1-2):20-7.

Neugebauer H, Fiss I, Pinczolits A, Hecht N, Witsch J, Dengler NF, et al. Large size hemicraniectomy reduces early herniation in malignant middle cerebral artery infarction. Cerebrovasc Dis 2016;41(5-6):283-90.

Miller K, Eljamel S. Does size and site matter in therapeutic decompressive craniectomy? A laboratory-based experimental study. World Neurosurg 2016;95:441-6.

Wang YS, Wang Y, Shi XW, Zhang JD, Ma YY. Size of bone flap and bone window area may impact the outcome of decompressive craniectomy using standard bone flap. Eur Rev Med Pharmacol Sci 2016;20(17):3679-82.

Fletcher TL, Wirthl B, Kolias AG, Adams H, Hutchinson PJ, Sutcliffe MP. Modelling of brain deformation after decompressive craniectomy. Ann Biomed Eng 2016;44(12):3495-509.

Kurzbuch AR. Does size matter? Decompressive surgery under review. Neurosurg Rev 2015;38(4):629-40.

Poncyljusz W. Endovascular treatment of acute ischemic stroke. Pol J Radiol 2010;75(1):51.

Treadwell SD, Thanvi B. Malignant middle cerebral artery (MCA) infarction: pathophysiology, diagnosis and management. Postgrad Med J 2010;86(1014):235-42.


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