Acta Neurochirurgica

, Volume 160, Issue 6, pp 1115–1119 | Cite as

The Wessex modified Richmond Sedation Scale as a novel tool for monitoring patients at risk of malignant MCA syndrome

  • Tayyib T. A. Hayat
  • Matthew A. Myers
  • John Hell
  • Matthew Cordingly
  • Diederik O. Bulters
  • Nicolas Weir
  • George Pengas
Original Article - Vascular



The Wessex Modified Richmond Sedation Scale (WMRSS) has been developed with the aim of improving the early identification of patients requiring decompressive hemicraniectomy for malignant middle cerebral artery syndrome (MMS). The objective of this study was to evaluate the WMRSS against the Glasgow Coma Scale (GCS).


A retrospective study was conducted of patients admitted to our unit for observation of MMS. Data were obtained on WMRSS and GCS recordings from admission up to 120-h post-ictus. Patients’ meeting inclusion criteria were recommended for theatre based on subsequent deteriorations in consciousness on either WMRSS or GCS from a 6-h post-stroke baseline, after ruling out non-neurological causes.


Approximately, 60% of those eligible for monitoring were not recommended for theatre, and none died; however, these patients continued to demonstrate some variability in recorded conscious level. Patients requiring surgical intervention showed earlier drops in WMRSS compared to GCS. Neither the GCS nor the WMRSS on admission predicted the subsequent need for decompressive surgery. There was no increase in mortality with the introduction of WMRSS.


WMRSS adds value to monitoring MMS by indicating need for surgery prior to GCS. Early reduction in consciousness may not be sufficient for proceeding to surgical intervention, but subsequent reduction in consciousness may be a more appropriate criterion for surgery.


Malignant MCA syndrome Glasgow coma scale Stroke 


Compliance with ethical standards

Ethical approval

Approval for the study was obtained from Southampton University Hospitals NHS Trust Clinical Effectiveness Committee (Ref: ZUAD3316) and University of Southampton Ethics and Research Governance Committee (Ref: 14786). For this type of study formal consent is not required.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Beck C, Kruetzelmann A, Forkert ND et al (2014) A simple brain atrophy measure improves the prediction of malignant middle cerebral artery infarction by acute DWI lesion volume. J Neurol 261(6):1097–1103CrossRefPubMedGoogle Scholar
  2. 2.
    Ely EW, Truman B, Shintani A et al (2003) Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA 289(22):2983–2991CrossRefPubMedGoogle Scholar
  3. 3.
    Foerch C, Otto B, Singer OC, Neumann-Haefelin T, Yan B, Berkefeld J, Steinmetz H, Sitzer M (2004) Serum S100B predicts a malignant course of infarction in patients with acute middle cerebral artery occlusion. Stroke 35(9):2160–2164CrossRefPubMedGoogle Scholar
  4. 4.
    Frank JI (1995) Large hemispheric infarction, deterioration, and intracranial pressure. Neurology 45(7):1286–1290CrossRefPubMedGoogle Scholar
  5. 5.
    Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R (1996) “Malignant” middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol 53(4):309–315CrossRefPubMedGoogle Scholar
  6. 6.
    Hanley JA, McNeil BJ (1983) A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology 148(3):839–843CrossRefPubMedGoogle Scholar
  7. 7.
    Heinsius T, Bogousslavsky J, Van Melle G (1998) Large infarcts in the middle cerebral artery territory. Etiology and outcome patterns. Neurology 50(2):341–350CrossRefPubMedGoogle Scholar
  8. 8.
    Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp HB, investigators HAMLET (2009) Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol 8(4):326–333CrossRefPubMedGoogle Scholar
  9. 9.
    Jüttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, Witte S, Jenetzky E, Hacke W, DESTINY Study Group (2007) Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke 38(9):2518–2525CrossRefPubMedGoogle Scholar
  10. 10.
    Kamran S, Akhtar N, Salam A, Alboudi A, Kamran K, Ahmed A, Khan RA, Mirza MK, Inshasi J, Shuaib A (2017) Revisiting hemicraniectomy: late decompressive hemicraniectomy for malignant middle cerebral artery stroke and the role of infarct growth rate. Stroke Res Treat 2017:2507834PubMedPubMedCentralGoogle Scholar
  11. 11.
    Lammy S, Al-Romhain B, Osborne L, St George EJ (2016) 10-year institutional retrospective case series of decompressive craniectomy for malignant middle cerebral artery infarction (mMCAI). World Neurosurg 96:383–389CrossRefPubMedGoogle Scholar
  12. 12.
    Maciel CB, Sheth KN (2015) Malignant MCA stroke: an update on surgical decompression and future directions. Curr Atheroscler Rep 17(7):40CrossRefPubMedGoogle Scholar
  13. 13.
    Oppenheim C, Samson Y, Manaï R et al (2000) Prediction of malignant middle cerebral artery infarction by diffusion-weighted imaging. Stroke 31(9):2175–2181CrossRefPubMedGoogle Scholar
  14. 14.
    Poca MA, Benejam B, Sahuquillo J, Riveiro M, Frascheri L, Merino MA, Delgado P, Alvarez-Sabin J (2010) Monitoring intracranial pressure in patients with malignant middle cerebral artery infarction: is it useful? J Neurosurg 112(3):648–657CrossRefPubMedGoogle Scholar
  15. 15.
    Ronchetti G, Panciani PP, Stefini R, Spena G, Fontanella MM (2014) Acute supratentorial ischemic stroke: when surgery is mandatory. Biomed Res Int 2014:624126Google Scholar
  16. 16.
    Vahedi K, Vicaut E, Mateo J et al (2007) Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 38(9):2506–2517CrossRefPubMedGoogle Scholar
  17. 17.
    Varndell W, Elliott D, Fry M (2015) The validity, reliability, responsiveness and applicability of observation sedation-scoring instruments for use with adult patients in the emergency department: a systematic literature review. Australas Emerg Nurs J 18(1):1–23CrossRefPubMedGoogle Scholar
  18. 18.
    Wartenberg KE (2012) Malignant middle cerebral artery infarction. Curr Opin Crit Care 18(2):152–163CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2018

Authors and Affiliations

  • Tayyib T. A. Hayat
    • 1
  • Matthew A. Myers
    • 1
  • John Hell
    • 1
  • Matthew Cordingly
    • 1
  • Diederik O. Bulters
    • 1
  • Nicolas Weir
    • 1
  • George Pengas
    • 1
  1. 1.Wessex Neurological CentreUniversity Hospital SouthamptonSouthamptonUK

Personalised recommendations