Malignant middle cerebral artery infarction — FFICM MCQ

Correct answer: C — Urgent neurosurgical discussion for decompressive hemicraniectomy

The correct answer is C, urgent neurosurgical discussion for decompressive hemicraniectomy. This man has malignant MCA infarction: more than half the MCA territory infarcted, early midline shift, and a falling GCS at 30 hours, all classic markers of life-threatening cytotoxic oedema before irreversible herniation occurs. NICE NG128 recommends considering decompressive hemicraniectomy, to be performed within 48 hours of symptom onset, in patients with MCA territory deficits, reduced consciousness, and CT infarction of at least 50 percent of the MCA territory, with or without additional ACA or PCA involvement. Because he was previously independent, is within the 48 hour window, and is in a network with neurosurgical access, urgent referral now (before a fixed pupil develops) is the step that offers the only proven mortality and functional benefit, pooled from DECIMAL, DESTINY and HAMLET trial data. Why the other options are wrong: B. Therapeutic heparin infusion: anticoagulation does not treat mass effect or oedema and risks haemorrhagic transformation in a large infarct, offering no benefit for impending herniation. E. High-dose dexamethasone: steroids do not reduce cytotoxic oedema after ischaemic stroke and are not supported by any guideline for malignant MCA infarction; they may worsen glycaemic control and infection risk without survival benefit. D. Wait until a pupil becomes fixed: a fixed pupil signifies established transtentorial herniation, by which point surgery carries far higher mortality and poorer functional recovery; decision-making must precede this sign, not follow it. A. Lower sodium to reduce osmotic stress: hyponatraemia would worsen cerebral oedema; osmotherapy (hypertonic saline or mannitol) raises, not lowers, serum sodium and is only a temporising bridge, not definitive treatment. Key point: In malignant MCA infarction with early deterioration, decompressive hemicraniectomy discussed and performed within 48 hours of onset is the only intervention proven to reduce death and severe disability.

Reference: NICE NG128, Stroke and transient ischaemic attack in over 16s: diagnosis and initial management, recommendations on decompressive hemicraniectomy, https://www.nice.org.uk/guidance/ng128/chapter/recommendations