1. Recognition and Treatment of Large MCA Strokes Matthew S. Smith, MD, MS Director of Neurocritical Care Assistant Professor of Neurology Assistant Professor of Neurosurgery

2. Disclosures I have no disclosures.

3. Learning Objectives Know the epidemiology of large MCA strokes Recognize large MCA strokes on clinical and radiographic examinations Know the current effective acute treatments for large MCA strokes Know the long term sequelae and possible interventions

4. Epidemiology

5. Differing definitions Malignant stroke in 5-10% of all ischemic stroke patients About 30% of all MCA ischemic strokes The rate of decompression has doubled since the original European trials (will talk about later)

6. Recognizing a large hemispheric stroke

7. Clinical Presentation

8. Figure 1. NIHSS (median, first and third quartile, and range) on admission and location of the vessel occlusion as seen on DSA. No oc indicates no occlusion. Urs Fischer et al. Stroke. 2005;36:2121-2125 Copyright © American Heart Association, Inc. All rights reserved.

9. Radiographic Findings CT acute signs of stroke Dense MCA Sign Loss of Grey White differentiation, particularly on 40/40 window Cortical swelling

10. Radiographic Findings CT acute signs of stroke Dense MCA Sign Loss of Grey White differentiation, particularly on 40/40 window Insular Ribbon Lentiform Cortical swelling

11. Radiographic Findings CT acute signs of stroke Dense MCA Sign Loss of Grey White differentiation, particularly on 40/40 window Insular Ribbon Lentiform Cortical swelling/ Hypodensity

13. Figure 2. ASPECTS and functional outcome Spearman correlation coefficient −0·69, p<0·001. Philip A Barber, Andrew M Demchuk, Jinjin Zhang, Alastair M Buchan Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy null, Volume 355, Issue 9216, 2000, 1670–1674 http://dx.doi.org/10.1016/S0140-6736(00)02237-6

14. CT Perfusion Findings

15. CT Angiographic Findings

16. Acute Treatments

17. IV tPA Remains only FDA approved treatment for ischemic stroke Earlier studies showed potentially equal efficacy with endovascular techniques New studies have shown a clear role of IV tPA as an addition to endovascular techniques. Recanalization rates from IV tPA for large vessel occlusion are not as good as we would like.

18. Endovascular Therapy Recent Trials

19. Secondary Injury

20. Pathophysiology of Swelling

21. Sequlae of Big Strokes

22. To Decompress or Not to Decompress

29. 2000 - 2003

34. 2007-2009 European Trials

35. Netherlands

40. French

47. Germany

55. Example Case

56. Presentation 38 yo male transferred from outside hospital as a stroke page. Last normal at 11pm when he spoke to his wife. At approximately 12:30pm the patient was found in the parking lot confused. OSH plain CT shows a dense MCA sign on the right IV TPa was started. NIHSS Baseline: 12 Started on Mannitol and 3% NS

57. Presentation CT

58. HD 1 CT

59. HD #1 POD 0 Being that this patient is right-handed, this was felt to be the nondominant side and the patient, aside from the expected neurologic deficits of left-sided hemiplegia, was thought to be a good candidate for decompressive hemicraniectomy Hypertonic saline and mannitol seemed to be inadequate

60. HD 1 POD 0 CT Scan Interval craniectomy for decompression of worsening cytotoxic edema from right MCA infarction. No evidence of hemorrhage.

61. HD 3 POD 2 CT Redemonstration of right MCA distribution evolving infarction with interval increase in mass effect and right-to-left midline shift. No evidence of hemorrhagic transformation Midline shift appears slightly increased from the prior study and now measures approximately 9 mm at the level of the foramen of Monro.

62. Today Living independently Left spastic hemiparesis Seizure disorder

63. Summary Malignant stroke is uncommon up to 10% of all strokes 30% of all MCA strokes Patients do the best recanalization Best chance of recanalization with combination of IV tPA and endovascular therapy Hemicraniectomy may be effective in selected patients

64. Summary Salvage therapies medical or surgical are not as effective as acute therapy

65. Summary Local IV tPA Transfer to a higher level stroke center for continued care and evaluation for advanced therapies, that may not be available locally.

66. Questions/ Concerns