Malignant Middle Cerebral Artery (MCA) Syndrome

Patients presenting with large hemisphere stroke (TACS) should be carefully monitored during the first 48 hours, due to the risk of developing malignant MCA syndrome. Patients developing signs of neurological deterioration should have repeat CT brain and discussed with the neurosurgeons for potential decompressive hemicraniectomy as soon as possible – seek senior advice.  Warning signs to look out for are:

  • Younger patients (<60 years)
  • Patients with no previous co-morbidities
  • Headache
  • Vomiting
  • Reduced consciousness
  • Confusion
  • Abnormalities of eye movement

Referral to tertiary centre (QEUH) for neurological treatment or advice should be considered in the following circumstances:

  • Patients with neurosurgical emergencies such as extradural or subdural haematomas
  • Patients with intracerebral haematomas or secondary hydrocephalus who may require neurosurgical evacuation or drainage
  • Partial craniotomy for intracerebral swelling following a major middle cerebral artery infarct (Malignant MCA syndrome)
  • Posterior fossa haemorrhage with hydrocephalus
  • Patients with suspected arterial dissection or cerebral vasculitis
  • Suspected basilar artery occlusion within 12 hours of onset or with continuing progression over a longer time scale. These patients may present with progressive posterior circulation symptoms, episodic posterior circulation symptoms over several days to weeks or with acute occlusion with bilateral long tract signs and clonus that may mimic seizure activity
  • Cerebral or cerebellar infarction where the patient may benefit from decompression craniotomy. Patients should be considered if:
    • Generally fit and no previous co-morbidities
    • Decreasing conscious level or worsening headache
    • CT evidence of infarction with mass effect
    • Unilateral pupillary dilatation in hemispheric infarcts
    • Stroke has occurred 48 hours previously or less.
  • Patients with unusually sited intracranial haemorrhage especially if these are lobar or superficial. Consideration should be given to cerebral venous thrombosis, amyloid angiopathy, aneurysmal bleeding, arteriovenous malformations, infective endocarditis and intracerebral tumours in these circumstances
  • Subarachnoid haemorrhage – referral for intracranial vascular imaging and treatment of aneurysm.



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