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From the APHP, Department of Neuropathology Raymond Escourolle (A.J., F.G.-R., P.A., J.-J.H.), Salpetrière Hospital, Pierre and Marie Curie University, and Department of Neurology and Stroke Centre (A.J., F.G-R., J.L., P.A.), Bichat University Hospital, Denis Diderot University and Medical School, Paris, France.
Address correspondence and reprint requests to Dr. P. Amarenco, Department of Neurology and Stroke Centre, Bichat University Hospital, 46 rue Henri Huchard, 75018 Paris, France; e-mail: pierre.amarenco{at}bch.aphp.fr
Background: Early detection of malignant infarction of the middle cerebral artery (MI-MCA) is important because of possible treatment by hemicraniectomy.
Objective: To investigate the anatomic and vascular predictors of MI-MCA.
Method: The authors evaluated 192 consecutive autopsies of patients with nonlacunar cerebral infarction affecting the MCA territory. MI-MCA was defined by an infarct with temporal or central brain herniation and brain swelling. The autopsy protocol included a systematic analysis of intracranial arteries (including the bony segments of carotid and vertebral arteries and the circle of Willis), extracranial arteries, the aortic arch, and the heart.
Results: A total of 45 patients with MI-MCA were identified. Their median (range) survival time was 6 (0 to 20) days as compared with 18 (0 to 2,040) days for non-MI-MCA patients. Compared with non-MI-MCA, MI-MCA cases more frequently involved the superficial and deep MCA territory and were more frequently associated with anterior cerebral and anterior choroidal artery territory infarcts. Hemorrhagic transformation, Duret hemorrhages, carotid occlusion, and ipsilateral abnormalities of the circle of Willis were also more frequent (p < 0.05). Multivariable analysis showed that younger age, female sex, absence of stroke history, higher heart weight, carotid artery occlusion, and abnormal circle of Willis ipsilaterally were all independently associated with MI-MCA (p < 0.03).
Conclusions: Typical pathologic pattern for development of malignant infarction of the middle cerebral artery is a carotid occlusion with abnormal ipsilateral circle of Willis in a young patient who had a first-ever large hemispheric stroke including the superficial territory with possibly a slight predominance of female sex.
Supported by the SOS-Attaque Cerebrale Association.
Disclosures: Dr. Jaramillo has received honoraria for clinical research from Hospital Clínico de la Universidad Católica in Santiago, Chile. Dr. Góngora has received a neurovascular research scholarship from FUNSALUD and Sanofi-Synthelabo Mexico (ADEMASS) with the support of the Instituto Nacional de Neurología y Neurocirugía in México. This funding source played no part in the preparation of the article.
Received October 11, 2005. Accepted in final form December 2, 2005.
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Neurology 2006 66: 790-791.
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