Hemiparesis or hemiplegia of the lower half of the contralateral face> Hemiparesis or hemiplegia of the contralateral upper and lower extremities> Sensory loss of the contralateral face, arm and leg> Ataxia of contralateral extremities> Speech impairments/aphasia: Broca's, Wernicke's or Global aphasia as a result of a dominant hemisphere lesion (usually the left brain)> Perceptual deficits: hemispatial neglect, anosognosia, apraxia, and spatial disorganization as a result of a non-dominant hemi- sphere lesion (usually the right brain)> Visual disorders: deviation conjuguee, a gaze preference towards the side of the lesion; contralateral homonymous hemianopsia> Radiographic features:> Generally the features are those of cerebral infarction, similar to those seen in any other territory.> There are however certain features specific to middle cerebral artery infarct, and these are discussed below. For both CT and MRI it is worth dividing the features according to time course.> It should also be noted that middle cerebral artery infarcts are often incomplete affecting only perforator branches or one or more distal branches. As such in many cases only parts of the middle cerebral artery territory is affected.> CT: The earliest finding of middle cerebral artery occlusion is: Hyperdense middle cerebral artery sign 3 seen immediately and represents direct visualisation of the thromboembolism. Presence of calcification is important as it is a contraindication to angioplasty> Early parenchymal signs include subtle blurring, decreased attenuation and swelling of the grey-white matter junction of affected regions. It should be noted that deep grey matter structures are affected before the cortex due to lenticulostriate arteries being end arteries, and cytotoxic oedema (intracellular fluid accumulation) occurring earlier 2,4: lentiform nucleus; caudate nucleus as early as 1 hour after occlusion 4 visible in 75% of patients at 3 hours 4 insular ribbon although cortical it is the furthest cortex from collateral circulation and is therefore also affected early 4 the insular ribbon sign describes loss of normal grey-white differentiation surface cortex (including peri-rolandic cortex) collateral flow retards development of CT signs with only 20% of cases demonstrating changes at 3 hours 4> With time the hypo-attenuation and swelling become more marked, and in patients with the majority of the MCA territory affected the mass effect is often dramatic and life threatening, sometimes requiring a decompressive craniectomy.> As time passes the infarct undergoes gradual reduction in swelling and mass effect (see cerebral infarction).> Treatment and prognosis. Treatment of middle cerebral artery infarcts is the same as infarcts anywhere else (see cerebral infarction) except that due to the size of the involved territory the degree of mass effect resulting form infarction can be marked and life threatening. As such decompressive craniectomy is advocated by many as a life saving procedure.">