|
1
|
Simard JM, Wilhelmy B, Tsymbalyuk N, Shim B, Stokum JA, Evans M, Gaur A, Tosun C, Keledjian K, Ciryam P, Serra R, Gerzanich V. Brain Swelling versus Infarct Size: A Problematizing Review. Brain Sci 2024; 14:229. [PMID: 38539619 PMCID: PMC10968884 DOI: 10.3390/brainsci14030229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/21/2024] [Accepted: 02/24/2024] [Indexed: 05/16/2024] Open
Abstract
In human stroke, brain swelling is an important predictor of neurological outcome and mortality, yet treatments to reduce or prevent brain swelling are extremely limited, due in part to an inadequate understanding of mechanisms. In preclinical studies on cerebroprotection in animal models of stroke, historically, the focus has been on reducing infarct size, and in most studies, a reduction in infarct size has been associated with a corresponding reduction in brain swelling. Unfortunately, such findings on brain swelling have little translational value for treating brain swelling in patients with stroke. This is because, in humans, brain swelling usually becomes evident, either symptomatically or radiologically, days after the infarct size has stabilized, requiring that the prevention or treatment of brain swelling target mechanism(s) that are independent of a reduction in infarct size. In this problematizing review, we highlight the often-neglected concept that brain edema and brain swelling are not simply secondary, correlative phenomena of stroke but distinct pathological entities with unique molecular and cellular mechanisms that are worthy of direct targeting. We outline the advances in approaches for the study of brain swelling that are independent of a reduction in infarct size. Although straightforward, the approaches reviewed in this study have important translational relevance for identifying novel treatment targets for post-ischemic brain swelling.
Collapse
Affiliation(s)
- J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Bradley Wilhelmy
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Natalya Tsymbalyuk
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Bosung Shim
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Jesse A. Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Madison Evans
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Anandita Gaur
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Cigdem Tosun
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Kaspar Keledjian
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Prajwal Ciryam
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Riccardo Serra
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| |
Collapse
|
|
2
|
Shim B, Stokum JA, Moyer M, Tsymbalyuk N, Tsymbalyuk O, Keledjian K, Ivanova S, Tosun C, Gerzanich V, Simard JM. Canagliflozin, an Inhibitor of the Na +-Coupled D-Glucose Cotransporter, SGLT2, Inhibits Astrocyte Swelling and Brain Swelling in Cerebral Ischemia. Cells 2023; 12:2221. [PMID: 37759444 PMCID: PMC10527352 DOI: 10.3390/cells12182221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 08/28/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Brain swelling is a major cause of death and disability in ischemic stroke. Drugs of the gliflozin class, which target the Na+-coupled D-glucose cotransporter, SGLT2, are approved for type 2 diabetes mellitus (T2DM) and may be beneficial in other conditions, but data in cerebral ischemia are limited. We studied murine models of cerebral ischemia with middle cerebral artery occlusion/reperfusion (MCAo/R). Slc5a2/SGLT2 mRNA and protein were upregulated de novo in astrocytes. Live cell imaging of brain slices from mice following MCAo/R showed that astrocytes responded to modest increases in D-glucose by increasing intracellular Na+ and cell volume (cytotoxic edema), both of which were inhibited by the SGLT2 inhibitor, canagliflozin. The effect of canagliflozin was studied in three mouse models of stroke: non-diabetic and T2DM mice with a moderate ischemic insult (MCAo/R, 1/24 h) and non-diabetic mice with a severe ischemic insult (MCAo/R, 2/24 h). Canagliflozin reduced infarct volumes in models with moderate but not severe ischemic insults. However, canagliflozin significantly reduced hemispheric swelling and improved neurological function in all models tested. The ability of canagliflozin to reduce brain swelling regardless of an effect on infarct size has important translational implications, especially in large ischemic strokes.
Collapse
Affiliation(s)
- Bosung Shim
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Jesse A. Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Mitchell Moyer
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Natalya Tsymbalyuk
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Orest Tsymbalyuk
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Kaspar Keledjian
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Svetlana Ivanova
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Cigdem Tosun
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| |
Collapse
|
|
3
|
Stokum JA, Shim B, Negoita S, Tsymbalyuk N, Tsymbalyuk O, Ivanova S, Keledjian K, Bryan J, Blaustein MP, Jha RM, Kahle KT, Gerzanich V, Simard JM. Cation flux through SUR1-TRPM4 and NCX1 in astrocyte endfeet induces water influx through AQP4 and brain swelling after ischemic stroke. Sci Signal 2023; 16:eadd6364. [PMID: 37279286 PMCID: PMC10369355 DOI: 10.1126/scisignal.add6364] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 05/10/2023] [Indexed: 06/08/2023]
Abstract
Brain swelling causes morbidity and mortality in various brain injuries and diseases but lacks effective treatments. Brain swelling is linked to the influx of water into perivascular astrocytes through channels called aquaporins. Water accumulation in astrocytes increases their volume, which contributes to brain swelling. Using a mouse model of severe ischemic stroke, we identified a potentially targetable mechanism that promoted the cell surface localization of aquaporin 4 (AQP4) in perivascular astrocytic endfeet, which completely ensheathe the brain's capillaries. Cerebral ischemia increased the abundance of the heteromeric cation channel SUR1-TRPM4 and of the Na+/Ca2+ exchanger NCX1 in the endfeet of perivascular astrocytes. The influx of Na+ through SUR1-TRPM4 induced Ca2+ transport into cells through NCX1 operating in reverse mode, thus raising the intra-endfoot concentration of Ca2+. This increase in Ca2+ stimulated calmodulin-dependent translocation of AQP4 to the plasma membrane and water influx, which led to cellular edema and brain swelling. Pharmacological inhibition or astrocyte-specific deletion of SUR1-TRPM4 or NCX1 reduced brain swelling and improved neurological function in mice to a similar extent as an AQP4 inhibitor and was independent of infarct size. Thus, channels in astrocyte endfeet could be targeted to reduce postischemic brain swelling in stroke patients.
Collapse
Affiliation(s)
- Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Bosung Shim
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Serban Negoita
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Natalya Tsymbalyuk
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Orest Tsymbalyuk
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Svetlana Ivanova
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Kaspar Keledjian
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Joseph Bryan
- Pacific Northwest Diabetes Research Institute, Seattle, WA 98122, USA
| | - Mordecai P Blaustein
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Ruchira M Jha
- Department of Neurology, Barrow Neurological Institute and St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Kristopher T Kahle
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| |
Collapse
|
|
4
|
Young MJ, Regenhardt RW, Sokol LL, Leslie-Mazwi TM. When Should Neuroendovascular Care for Patients With Acute Stroke Be Palliative? AMA J Ethics 2021; 23:E783-793. [PMID: 34859772 PMCID: PMC8684539 DOI: 10.1001/amajethics.2021.783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Noncurative surgeries intended to relieve suffering during serious illness or near end of life have been analyzed across palliative settings. Yet sparse guidance is available to inform clinical management decisions about whether, when, and which interventions should be offered when ischemic stroke and other neurological complications occur in patients whose survival is extended by other novel disease-modifying interventions. This case commentary examines key ethical and clinical considerations in palliative neuroendovascular care of patients with acute stroke.
Collapse
Affiliation(s)
- Michael J Young
- Fellow in neurology at Massachusetts General Hospital and Brigham and Women's Hospital in Boston
| | - Robert W Regenhardt
- Neuroendovascular fellow and stroke scientist at Massachusetts General Hospital in Boston
| | - Leonard L Sokol
- Neurology resident physician at Northwestern University in Evanston, Illinois
| | | |
Collapse
|
|
5
|
Woo SK, Tsymbalyuk N, Tsymbalyuk O, Ivanova S, Gerzanich V, Simard JM. SUR1-TRPM4 channels, not K ATP, mediate brain swelling following cerebral ischemia. Neurosci Lett 2019; 718:134729. [PMID: 31899311 DOI: 10.1016/j.neulet.2019.134729] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 12/30/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Preclinical and emerging clinical data show that glibenclamide reduces space occupying edema and brain swelling following cerebral ischemia. Glibenclamide is a potent inhibitor of numerous sulfonylurea receptor (SUR)-regulated channels, including KATP (SUR1-KIR6.2, SUR2A-KIR6.2, SUR2B-KIR6.2, SUR2B-KIR6.1) and SUR1-TRPM4. Here, we used molecularly specific oligodeoxynucleotides (ODNs) to investigate the role of various SUR-regulated ion channel subunits in post-ischemic brain swelling. METHODS Focal cerebral ischemia was induced in adult male rats by permanent middle cerebral artery occlusion (pMCAo). We used this model to study the effects of antisense-ODNs (AS-ODNs) directed against Abcc8/SUR1, Trpm4/TRPM4, Kcnj8/KIR6.1 and Kcnj11/KIR6.2 on hemispheric swelling, with sense or scrambled ODNs used as controls. We used antibody-based Förster resonance energy transfer (immuno-FRET) and co-immunoprecipitation to study the co-assembly of SUR1-TRPM4 heteromers. RESULTS In the combined control groups administered sense or scrambled ODNs, pMCAo resulted in uniformly large infarct volumes (mean ± SD: 57.4 ± 8.8 %; n = 34) at 24 h after onset of ischemia, with no effect of AS-ODNs on infarct size. In controls, hemispheric swelling was 23.9 ± 4.1 % (n = 34), and swelling was linearly related to infarct volume (P < 0.02). In the groups administered anti-Abcc8/SUR1 or anti-Trpm4/TRPM4 AS-ODN, hemispheric swelling was significantly less, 11.6 ± 3.9 % and 12.8 ± 5.8 % respectively (P < 0.0001), and the relationship between infarct volume and swelling was reduced and not significant. AS-ODNs directed against Kcnj8/KIR6.1 and Kcnj11/KIR6.2 had no significant effect on hemispheric swelling (23.3 ± 5.4 % and 22.9 ± 5.8 % respectively). Post-ischemic tissues showed co-assembly of SUR1-TRPM4 heteromers. CONCLUSIONS Post-ischemic hemispheric swelling can be decoupled from infarct volume. SUR1-TRPM4 channels, not KATP, mediate post-ischemic brain swelling.
Collapse
Affiliation(s)
- Seung Kyoon Woo
- Departments of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Natalia Tsymbalyuk
- Departments of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Orest Tsymbalyuk
- Departments of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Svetlana Ivanova
- Departments of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Volodymyr Gerzanich
- Departments of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - J Marc Simard
- Departments of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, United States; Departments of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, United States; Departments of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, United States.
| |
Collapse
|
|
6
|
Cerebral Edema and Intracranial Pressure in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
|
7
|
Wang X, Shen B, Sun D, Cui X. Aspirin ameliorates cerebral infarction through regulation of TLR4/NF‑κB‑mediated endoplasmic reticulum stress in mouse model. Mol Med Rep 2017; 17:479-487. [PMID: 29115440 DOI: 10.3892/mmr.2017.7879] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 08/14/2017] [Indexed: 11/06/2022] Open
Abstract
Cerebral infarction is a cerebrovascular disease caused by local brain ischemic necrosis or softening, which is associated with diabetes, obesity, hypertension and rheumatic heart arrhythmia. Previous studies have indicated that aspirin is a potential oral anticoagulant in the treatment of cerebral ischemic stroke. However, the potential mechanism mediated by aspirin in cerebral infarction therapy is not well understood. The present study analyzed the therapeutic effects of aspirin on cerebral infarction and investigated the underlying molecular mechanism of aspirin‑ameliorated benefits for thrombolysis. The results demonstrated that aspirin inhibited inflammation and apoptosis of cerebrovascular endothelial cells in a mouse model of cerebral infarction. Aspirin treatment suppressed toll‑like receptor (TLR)4 and nuclear factor (NF)‑κB expression in cerebrovascular endothelial cells. Endoplasmic reticulum (ER) stress was suppressed by aspirin treatment through the downregulation of protein kinase R‑like endoplasmic reticulum kinase, eukaryotic translation initiation factor 2 subunit 1 and C/EBP homologous protein expression levels in cerebrovascular endothelial cells. It was identified that knockdown of TLR4 inhibited aspirin‑mediated downregulation of NF‑κB signaling pathway and ER stress in cerebrovascular endothelial cells. Expression levels of adenosine diphosphate plasminogen activator inhibitors, von Willebrand factor and thromboxane were downregulated in cerebrovascular endothelial cells and in serum in experimental mice. The results demonstrated that aspirin was beneficial forthrombolysis by decreasing thrombin‑activatable fibrinolysis inhibitor and plasminogen activator inhibitor‑1 expression in a mouse model of cerebral infarction. These results suggested that aspirin may improve cerebral infarction by downregulating TLR4/NF‑κB‑mediated ER stress in a mouse model.
Collapse
Affiliation(s)
- Xin Wang
- Department of Neurosurgery, Dezhou People's Hospital, Dezhou, Shandong 420065, P.R. China
| | - Bin Shen
- Department of Neurosurgery, Dezhou People's Hospital, Dezhou, Shandong 420065, P.R. China
| | - Dezhou Sun
- Department of Neurosurgery, Dezhou People's Hospital, Dezhou, Shandong 420065, P.R. China
| | - Xiangyu Cui
- Department of Neurosurgery, Dezhou People's Hospital, Dezhou, Shandong 420065, P.R. China
| |
Collapse
|
|
8
|
Horsch AD, Dankbaar JW, Stemerdink TA, Bennink E, van Seeters T, Kappelle LJ, Hofmeijer J, de Jong HW, van der Graaf Y, Velthuis BK. Imaging Findings Associated with Space-Occupying Edema in Patients with Large Middle Cerebral Artery Infarcts. AJNR Am J Neuroradiol 2016; 37:831-7. [PMID: 26797136 DOI: 10.3174/ajnr.a4637] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 10/30/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Prominent space-occupying cerebral edema is a devastating complication occurring in some but not all patients with large MCA infarcts. It is unclear why differences in the extent of edema exist. Better knowledge of factors related to prominent edema formation could aid treatment strategies. This study aimed to identify variables associated with the development of prominent edema in patients with large MCA infarcts. MATERIALS AND METHODS From the Dutch Acute Stroke Study (DUST), 137 patients were selected with large MCA infarcts on follow-up NCCT (3 ± 2 days after stroke onset), defined as ASPECTS ≤4. Prominent edema was defined as a midline shift of ≥5 mm on follow-up. Admission patient and treatment characteristics were collected. Admission CT parameters used were ASPECTS on NCCT and CBV and MTT maps, and occlusion site, clot burden, and collaterals on CTA. Permeability on admission CTP, and day 3 recanalization and reperfusion statuses were obtained if available. Unadjusted and adjusted (age and NIHSS) odds ratios were calculated for all variables in relation to prominent edema. RESULTS Prominent edema developed in 51 patients (37%). Adjusted odds ratios for prominent edema were higher with lower ASPECTS on NCCT (adjusted odds ratio, 1.32; 95% CI, 1.13-1.55) and CBV (adjusted odds ratio, 1.26; 95% CI, 1.07-1.49), higher permeability (adjusted odds ratio, 2.35; 95% CI, 1.30-4.24), more proximal thrombus location (adjusted odds ratio, 3.40; 95% CI, 1.57-7.37), higher clot burden (adjusted odds ratio, 2.88; 95% CI, 1.11-7.45), and poor collaterals (adjusted odds ratio, 3.93; 95% CI, 1.78-8.69). CONCLUSIONS Extensive proximal occlusion, poor collaterals, and larger ischemic deficits with higher permeability play a role in the development of prominent edema in large MCA infarcts.
Collapse
Affiliation(s)
- A D Horsch
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - J W Dankbaar
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - T A Stemerdink
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - E Bennink
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - T van Seeters
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - L J Kappelle
- Neurology (L.J.K.), Utrecht Stroke Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J Hofmeijer
- Department of Neurology (J.H.), Rijnstate Hospital, Arnhem, the Netherlands
| | - H W de Jong
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - Y van der Graaf
- Julius Center for Health Sciences and Primary Care (Y.v.d.G.), Utrecht, the Netherlands
| | - B K Velthuis
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| |
Collapse
|
|
9
|
Hao Z, Chang X, Zhou H, Lin S, Liu M. A Cohort Study of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction: A Real-World Experience in Clinical Practice. Medicine (Baltimore) 2015; 94:e1039. [PMID: 26107675 PMCID: PMC4504625 DOI: 10.1097/md.0000000000001039] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Decompressive hemicraniectomy with malignant middle cerebral artery (MCA) infarction is effective but remains underutilized. The aim of this study was to observe the utilization of this intervention in mainland China.We included patients with malignant MCA infarction who admitted in West China Hospital between December 2007 to March 2011. The outcomes were death and favorable outcome (mRS < 4) at 1 month and 1 year. The multivariate logistic regression model was used to identify the independent predictors for outcomes.Ten percent (219/2174) of patients with acute ischemic stroke had malignant MCA infarction and 31.1% (68/219) patients meet the criteria that ≤60 years of age and the timing to hospital <48 hours after stroke onset. Of them, 18 patients (26.5%) underwent to decompressive hemicraniectomy. In total, 31 patients (14.2%) underwent the decompressive surgery. The average age was 53 ± 12 years; median NIHSS score was 21. The case fatality rate of patients in surgery group was significantly lower than those of in nonsurgery group at 1 month and 1 year follow-ups (32.3% and 38.7% vs. 51.1% and 61.2%, respectively, P < 0.05). Patients in surgery group had a higher proportion of good outcome at 1 year follow-up (32.2% vs. 13.3%, P = 0.006). After adjusting for confounders including age, sex, NIHSS score, and GCS score on admission, decompressive hemicraniectomy was an independent predictor of good outcome for 1 year (OR = 3.44, 95% CI, 1.27-9.31).This study shows better outcomes in the surgical group, which are consistent with findings in previous prospective randomized trials. However, this beneficial intervention remains underutilized in clinical settings.
Collapse
Affiliation(s)
- Zilong Hao
- From the Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (ZH, XC, HZ, ML); and Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (SL). Zilong Hao and Xueli Chang contributed equally to this study
| | | | | | | | | |
Collapse
|
|
10
|
Maciel CB, Sheth KN. Malignant MCA Stroke: an Update on Surgical Decompression and Future Directions. Curr Atheroscler Rep 2015; 17:40. [DOI: 10.1007/s11883-015-0519-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|