Treatment of Malignant Cerebral Edema in Acute Ischemic Stroke

Purpose of review: To provide an updated summary on the diagnosis and treatment of patients with malignant cerebral edema after ischemic stroke. Recent findings: The risk of malignant middle cerebral artery (MCA) stroke is highest in young patients with large vessel occlusion and unsuccessful revascularization. Several scores are available for risk stratification. Treatment includes supportive care, close neurologic monitoring, and hyperosmolar therapy. Yet, the main therapeutic decision is whether to proceed with decompressive craniectomy. Multiple randomized clinical trials and several meta-analyses have demonstrated that decompressive hemicraniectomy is the single most important intervention associated with survival. Survivors may face severe disability regardless of surgical treatment, and the definition of acceptable outcome in this context remains elusive. Summary: Malignant MCA infarcts are life-threatening and invariably cause disability, most often severe. Neurologic deterioration requires airway management and hyperosmolar therapy. Decompressive hemicraniectomy is a lifesaving procedure; approximately 50% of surgically treated patients younger than 60 years can regain independent ambulation, and one nearly in five may become functionally independent at 1 year. Older patients face a much worse functional prognosis; surgical decisions in these patients should be assessed case by case.