Malignant Cerebral Edema after Large-Core Anterior Circulation Stroke in the Thrombectomy Era: Prediction and Neurocritical Care Pathways.

Large-core anterior circulation ischemic stroke (LCIS) complicated by malignant cerebral edema (MCE) remains a leading cause of early death and profound disability even in the era of endovascular thrombectomy (EVT). As EVT indications have expanded to include patients with large ischemic cores, more patients survive the initial ischemic insult but continue to face substantial risk of space-occupying edema, underscoring the need for standardized neurocritical care pathways. This narrative review summarizes evidence published between 2015 and 2025 from PubMed and Web of Science, emphasizing randomized trials, meta-analyses, high-quality observational cohorts, and major guidelines. Contemporary neurocritical care guidance increasingly treats LCIS as a distinct syndrome and recommends structured surveillance, timely osmotherapy, and consideration of decompressive hemicraniectomy (DHC). Recent large-core EVT trials show that, in carefully selected patients, EVT can improve functional outcomes, but it does not eliminate mortality or severe disability and is associated with higher risks of hemorrhage, while edema-related deterioration remains common after reperfusion. For patients who develop space-occupying middle cerebral artery infarction, early DHC consistently lowers mortality and increases the proportion of survivors with moderate disability. Meanwhile, predictive models and emerging deep-learning approaches are enhancing early risk stratification for MCE, supporting earlier escalation of monitoring and intervention. Overall, LCIS with MCE should be approached as a dynamic, time-sensitive condition that benefits from early recognition and a pragmatic, sequenced pathway integrating risk prediction, medical management, and surgical decompression when indicated. Future work should refine multimodal prediction tools, clarify DHC thresholds in reperfused patients, and develop more effective anti-edema therapies. An American Heart Association science advisory (published online 17 December 2024) synthesized the randomized evidence supporting EVT in selected large-core strokes and highlighted key implementation considerations.