Massive stroke definition
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Definition and Clinical Criteria of Massive Stroke
Massive stroke, often referred to as "massive ischemic stroke" or "massive cerebral infarction," is typically defined by the severity of neurological impairment and the extent of brain tissue affected. In adults, a massive ischemic stroke is commonly identified by a high score on the National Institutes of Health Stroke Scale (NIHSS), with a threshold of NIHSS ≥ 20 on admission indicating a severe or "massive" stroke presentation . This definition is supported by clinical studies that associate such high scores with extensive neurological deficits and a high risk of mortality and disability .
Pathophysiology and Imaging Features of Massive Stroke
Massive strokes are characterized by large areas of brain infarction, often involving the entire vascular territory of a major artery such as the middle cerebral artery (MCA) or carotid artery. These strokes frequently result in significant brain swelling (cerebral edema), midline shift, and can progress to life-threatening complications like herniation syndrome and brain death 236. Neuroimaging, such as CT or MRI, typically reveals extensive infarct volume, space-occupying mass effect, and signs of increased intracranial pressure 36.
In neonates, a similar entity called massive neonatal arterial ischemic stroke (M-NAIS) is defined by MRI findings of large infarct volume (often involving the M1 segment of the MCA), midline shift, and collapse of brain spaces, leading to severe neurodevelopmental outcomes .
Clinical Presentation and Outcomes
Patients with massive stroke often present with rapid neurological deterioration, decreased consciousness, and severe deficits. In some cases, such as with bilateral large vessel occlusion, the clinical course can be especially rapid and fatal . The prognosis for massive stroke is generally poor, with high rates of mortality and severe disability, although a subset of patients may achieve favorable outcomes depending on factors like age, prior cerebrovascular events, and early recanalization of the blocked artery .
Management and Treatment Considerations
The management of massive stroke focuses on preventing and treating complications from brain swelling and increased intracranial pressure. Decompressive surgical procedures, such as hemicraniectomy for malignant MCA infarction or suboccipital craniectomy for massive cerebellar infarction, have been shown to reduce mortality and improve outcomes in selected patients 267. Medical management includes sedation, ventilatory support, osmotherapy (mannitol or hypertonic saline), and measures to optimize cerebral perfusion pressure . Early identification and intervention are critical for improving survival and quality of life 67.
Conclusion
Massive stroke is defined by severe neurological impairment (NIHSS ≥ 20 in adults) and extensive brain infarction, often with significant cerebral edema and risk of herniation. It is a life-threatening condition with high morbidity and mortality, requiring prompt recognition and aggressive management, including surgical decompression in appropriate cases. Early intervention and supportive care can improve outcomes for some patients, but the overall prognosis remains guarded 12367.
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