Clinical Course and Treatment of Severe Stroke
after Occlusion of the Middle Cerebral Artery
In 10% of the cases of hemispheric ischemic stroke, extended cerebral ischemia is caused by embolic occlusion of the middle cerebral artery. The patients present in the period between the second and fifth day after ischemia onset the typical clinical features of major stroke, mainly due to brain edema and elevated intracranial pressure. Typical clinical findings (alteration of consciousness, hemiplegia with conjugated head and gaze deviation) as well as early neuroradiological signs (extended hypotense ischemic lesion of >50% of the MCA territory, signs of cerebral edema and midine shift) make diagnosis and prognosis within the first hours after symptom onset possible. Despite intensive basic- (regulation of blood pressure, body temperature and glucose levels) and specific treatment (pharamacological regulation of intracranial hypertension) under optimal conditions the mortality remains with 80% extremely high. Different new therapeutical approaches seem to be able to significantly reduce mortality rate and also improve the malignant natural clinical course. Moderate hypothermia (<29 °C) reduces mortality down to 40%. Serious complications during the rewarm phase are observed. Therefore mild hypothermia (<34 °C) seems to be a preferable and more promising therapeutic method. The mortality reduction (17%) as well as the clinical benefit for the patients after early decompressive craniotomy within 24 hours after symptom onset are impressive. Due to malignant clinical course and the bad prognostic aspects, early diagnosis of MCA occlusion, based on the clinical and neuroradiological findings is of great importance. It allows the early therapeutic intervention. Novel promising therapeutic approaches, such as hypothermia and early decompressive craniotomy seem to significantly improve the prognosis of patients with extended ischemic lesions in the MCA territory.
Key Words: Severe stroke, Hypothermia, Decompressive craniotomy.