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Semin Neurol. 2013 Nov;33(5):448-55. doi: 10.1055/s-0033-1364211. Epub 2014 Feb 6.

Management of the malignant middle cerebral artery syndrome.

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Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Neuroscience Intensive Care Unit, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut.
Departments of Neurosurgery and Diagnostic Radiology, Neurovascular and Stroke Programs, Yale School of Medicine, New Haven, Connecticut.


The malignant middle cerebral artery syndrome, characterized by cerebral edema following large anterior circulation ischemic stroke, is a disease entity with high morbidity and mortality that is easy to recognize, but challenging to manage. In this review, we begin by discussing important aspects of the clinical presentation of the syndrome, including risk factors for deterioration. We then discuss medical measures that can be undertaken before symptomatic cerebral edema occurs and then outline both medical and surgical options for subsequent neurologic worsening. Shared decision making with patients' surrogates regarding decompressive craniectomy in the setting of available clinical trial data is addressed. The authors conclude with a brief discussion of promising novel therapies for preventing cerebral edema.

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