International circulation; Are there biomarkers which can tell the clinician before imaging that the patient is having a stoke?
　　Dr Edward Manno: There are biomarkers such as neuron- specific-enolase and some other biomarkers for glial breakdown. However there has not been any studies as of yet that have been able to characterize the degree of these in relation to neurological deterioration.
　　International Circulation: In terms of malignant MCA what factors are important when deciding whether to perform surgery or more conservative treatments?
　　Dr Edward Manno: It depends on which patients are going to require surgery are there are a number of factors which we can get from the literature. One is the initial size of the infarct， whether it is greater than 50% of MCA territory. There have been other notable markers in relation to diffusion and perfusion MRI that suggests that these patients with malignant cerebral edema have worsening neurological deterioration. Our study from the Mayo clinic retrospectively suggested that hyper-dense MCA sign found after a stroke was predicted with neurological deterioration. Similarly， if you have MCA greater than 50% territory on an early CAT scan was also a very positive predictor of neurological deterioration.
　　International Circulation: How do we optimize patient selection for craniectomy?
　　Dr Edward Manno; It appears that younger patients do better which is defined as those who are less than 50 years old. There is currently a trial enrolling older patients between the 50 and 60 age range. If you go beyond that then individual patients need to considered for surgery on an individual basis.