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To the Editor:In Stroke , we read with great interest the original article by Serena et al1 on prediction of malignant middle cerebral artery (MCA) infarction. As a group working experimentally and clinically on malignant MCA infarction,2–4⇓⇓ we would like to comment on their competent study on molecular blood-brain barrier (BBB) disruption markers in patients who developed a malignant MCA infarction, because their work establishes a new point of view in the understanding of this life-threatening disease.The approach of Serena and colleagues to detect matrix metalloproteinases (MMPs) and basal lamina decomposition products like cellular fibronectin in plasma of patients allows a quite precise prediction of malignant MCA infarction.1 Cerebral ischemia leads to an up-regulation of MMPs, which degrade elements of the extracellular matrix and of the basal lamina.5,6⇓ BBB disruption may result from this process because the basal lamina is part of the blood-brain barrier system. Thus, substances involved in this process are of substantial interest not only for diagnostic purposes but also for investigations of the mechanisms resulting in malignant infarction and associated complications like hemorrhagic transformation.7–9⇓⇓ Recently, studies using various imaging techniques have emphasized that the size of the initial infarct volume3,10,11⇓ …

There Is More to it Than: the Greater the Infarction Volume, the More Probable Is a Malignant MCA Infarction