An Aggressive Approach to Massive Middle Cerebral Artery Infarction

OBJECTIVE: We report favorable outcome after surgical decompression, or strokectomy, guided by xenon-enhanced computed tomographic studies of cerebral blood flow in the setting of potentially fatal swelling from massive cerebral infarction. DESIGN: Retrospective analysis with 3 months to 3 years of follow-up. SETTING: University of Pittsburgh (Pa) Medical Center, a tertiary care university referral center. PATIENTS: Four patients, aged 14 to 46 years, presented with focal neurologic deficits appropriate for a massive middle cerebral artery infarction (two dominant and two nondominant). In spite of medical therapy, all patients deteriorated to at least a decreased level of consciousness. INTERVENTION: Using xenon-enhanced computed tomographic studies of cerebral blood flow in three patients, areas of severely ischemic (blood flow, < 5 mL/100 g per minute), nonviable brain were identified and resected. OUTCOME MEASURE: Outcome was measured by survival and ability to perform activities of daily living. RESULTS: Postoperatively, all patients recovered rapidly (< 6 hours) to the level of function at admission and were able to perform the activities of daily living with minimal or no assistance. CONCLUSION: Despite deficits appropriate to the area of infarction, prompt management of life-threatening postinfarction swelling by surgical decompression can yield favorable outcome.