• About 10% of ischemic strokes are labeled malignant due to the extent of cerebral edema leading to elevated intra-cranial pressure; the most common cause is a large middle cerebral artery infarct
•  Risk factors include young age, carotid occlusion, no prior history of stroke, and female sex
• Standard of care includes medical interventions such as osmotic therapy (e.g., hypertonic saline) to reduce elevated ICP
• May need emergent decompressive hemicraniectomy if patient clinically worsens and develops signs of somnolence or pupillary changes although not proven yet to change ultimate neurologic prognosis or extent of disability
• Poor prognosis and high mortality rate (up to 78-80%) due brainstem herniation

References

• Simard JM, Sahuquillo J, Sheth KN, Kahle KT, Walcott BP. Managing Malignant Cerebral Infarction. Current treatment options in neurology. 2011;13(2):217-229.