Audit on the assessment of the care for patients with malignant middle cerebral artery (MCA) syndrome in a tertiary hospital

Kamara, J, Liu, WJ, Marigold, R, Monosuru-Oke, M, Ahmed, M and Haq, E (2025) Audit on the assessment of the care for patients with malignant middle cerebral artery (MCA) syndrome in a tertiary hospital. International Journal of Stroke, 20 (2(S)), 221. (doi:10.1177/17474930251371440).

Abstract

Background and Aims: Malignant middle cerebral artery(MCA) syndrome
carries a high mortality rate of up to 80%. If done within 48 hours
of the diagnosis, decompressive surgery reduces mortality and increases
the chance of a favourable outcome for patients with this condition. The
National Institute for Health and Care Excellence (NICE) recommends
that patients with large MCA infarction should be considered for decompressive
surgery. The audit aimed to assess whether NICE and local hospital
guidelines were followed when caring for these patients in a
hyperacute stroke unit in a tertiary neuro-surgical centre.
Methods: Adults aged 18 years and over admitted to a tertiary hospital
in the UK, with the diagnosis of malignant MCA syndrome, were included
in the audit. The audit was done against the local Malignant MCA protocol
and NICE recommendation. It was a retrospective data collection
from January 2019 to January 2024. Patients still in the hospital at the
time of data collection and those with infarcts involving the ACA or PCA
territories only were omitted.
Results: Only 62% of staff in HASU had good knowledge of the optimal
time for decompressive craniectomy. 50% of patients had hourly MRASS and
GCS monitoring as per protocol. 53% of patients had daily CT in the first 72
hours. Aspirin was held in 50% of patients on the malignant MCA watch.
Conclusions: Recommendation: Malignant MCA daily review sheet for
the first 72 hours. Educate resident doctors and nurses working on
HASU. Implement online stroke referral to neurosurgeons for malignant
MCA patients to keep track of timing.

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