Neurointensive Care Unit, Martin-Luther-University, Halle-Wittenberg, Halle, Germany.
Curr Opin Crit Care. 2012 Apr;18(2):152-63. doi: 10.1097/MCC.0b013e32835075c5.
This review will report on the new aspects of management of 'malignant' middle cerebral artery (MCA) infarctions.
Large MCA infarctions have been associated with high death rates for years. The most reliable predictors of a 'malignant' course are hypodensity in more than 50% of the MCA territory on computed tomography as well as stroke volume greater than 145 ml on diffusion-weighted imaging. Real-time neuromonitoring may be helpful in the detection of development of cerebral edema. The attempt of recanalization of the affected artery utilizing a combination of intravenous and intra-arterial thrombolysis and mechanical thrombectomy is crucial. Monitoring of intracranial pressure has not been proven helpful. Decompressive surgery within 48 h after symptom onset in patients less than 60 years old reduces mortality and severe disability. The quality of life perceived by the survivors is variable and deserves further study. The neuroprotective effect of hypothermia requires additional investigation.
The era of decompressive hemicraniectomy has changed the prospects of patients with large infarctions in the MCA or internal carotid artery territory who are at risk of development of 'malignant' cerebral edema. Timing of surgery and appropriate patient selection based on age and other criteria need to be refined.
本综述将报告“恶性”大脑中动脉（MCA）梗死治疗的新进展。
多年来，大面积 MCA 梗死与高死亡率相关。最可靠的“恶性”病程预测因子是 CT 上 MCA 供血区 50%以上的低密度影和弥散加权成像上的梗死体积大于 145ml。实时神经监测有助于发现脑水肿的发生。尝试联合静脉内和动脉内溶栓及机械取栓开通闭塞动脉至关重要。颅内压监测尚未被证明有效。症状发作后 48 小时内对年龄小于 60 岁的患者进行减压性颅切除术可降低死亡率和严重残疾。幸存者的生活质量各不相同，值得进一步研究。亚低温的神经保护作用需要进一步研究。
去骨瓣减压术的时代改变了有发生“恶性”脑水肿风险的大面积 MCA 或颈内动脉区域梗死患者的预后。手术时机和基于年龄和其他标准的适当患者选择需要进一步细化。
