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Malignant middle cerebral artery infarction

A 55-year-old man with hypertension was referred from a rural hospital. Two days before, he had developed a cardioembolic ischaemic stroke, which resulted in left-sided hemiparesis and hemianaesthesia. On the day of referral, he developed repeated vomiting and severe headache, followed by progressive obtundation and coma. There was papilloedema. Both planter reflexes were extensors. A non-contrast CT brain scan was done (figure 1). The initial CT brain scan was not available for comparison. The patient was outside the international guidelines on timing of decompressive hemicraniectomy (DCH) for ischaemic stroke and was extremely unwell. After a few hours, he died from ‘malignant middle …