Timing of neurologic deterioration in massive middle cerebral artery infarction: a multicenter review

Predictors of malignant swelling in space-occupying cerebellar infarction

BACKGROUND

Malignant swelling is a fatal complication that can occur abruptly in space-occupying cerebellar infarction. We aimed to establish markers that predict malignant swelling in cerebellar infarction.

METHODS

We retrospectively analysed data of stroke patients who were treated in our hospital between 2014 and 2020. Malignant swelling was defined as a mass effect in the posterior cranial fossa, accompanied by a decrease in consciousness due to compression of the brainstem and/or the development of obstructive hydrocephalus. Statistical analyses were performed on multiple variables to identify predictors of malignant swelling.

RESULTS

Among 7284 stroke patients, we identified 487 patients with an infarct in the cerebellum. 93 patients were suitable for analysis having space-occupying cerebellar infarction. 33 of 93 (35.5%) patients developed malignant swelling. Multivariable analysis revealed infarct volume as the main predictor being independently associated with the development of malignant swelling with a cut-off infarct volume of 38 cm3 being associated with a swelling rate of >50% (OR 32.0, p<0.001). Higher NIHSS (National Institutes of Health Stroke Scale) score on admission (median NIHSS 12 vs 4, OR 1.078; p=0.008) and the presence of additional brainstem infarction (51.5% vs 16.7%, OR 5.312; p=0.013) were associated with the development of malignant swelling in univariate analyses. 13 of 33 (39.4%) cases of malignant swellings occurred after more than 3 days.

CONCLUSIONS

Infarct volume was the key significant predictor of malignant swelling in space-occupying cerebellar infarction. With many cases of malignant swelling occurring after more than 72 hours, we advocate prolonged neurological monitoring.

The Association Between National Institutes of Health Stroke Scale Score and Clinical Outcome in Patients with Large Core Infarctions Undergoing Endovascular Treatment

INTRODUCTION

This study aimed to analyze the association between baseline National Institutes of Health Stroke Scale (NIHSS) scores and clinical outcomes in patients with large core infarctions undergoing endovascular treatment (EVT), a relationship that remains unclear.

METHODS

Data were obtained from the MAGIC study, a prospective multicenter cohort study focusing on patients with acute large core ischemic stroke. This analysis evaluated the impact of NIHSS scores on EVT outcomes in patients with large core infarctions. Primary outcome metrics included favorable outcomes (modified Rankin Scale [mRS] of 0-3 at 90 days), while secondary outcomes encompassed shifts in mRS scores, functional independence (mRS score of 0-2), mRS score of 0-4, and successful recanalization rates. Adverse events considered were symptomatic intracranial hemorrhage (sICH) and mortality.

RESULTS

A total of 490 patients were enrolled in this study. Higher baseline NIHSS scores were inversely correlated with favorable outcomes (adjusted odds ratio [OR] in model 3, 0.848 [0.797-0.903], P < 0.001), particularly in patients with NIHSS scores above 20 (adjusted OR in model 3, 0.518 [0.306-0.878] vs. 0.290 [0.161-0.523]). Regarding adverse events, higher baseline NIHSS scores significantly correlated with increased 90-day mortality rates (adjusted OR in model 3, 1.129 [1.072-1.189], P < 0.001). This correlation became insignificant when baseline NIHSS scores exceeded 22. Additionally, baseline NIHSS scores partially mediated the association between age (indirect effect = - 0.0005, 19.39% mediated) and sex (indirect effect = 0.0457, 25.08% mediated) with the primary outcome.

CONCLUSIONS

The findings indicate that higher baseline NIHSS scores correlate with poorer outcomes and increased mortality, particularly when scores exceed 20. Moreover, age and sex indirectly influence favorable outcomes through their association with baseline NIHSS scores.

Automatic segmentation of hemispheric CSF on MRI using deep learning: Quantifying cerebral edema following large hemispheric infarction

Background and objective

Cerebral edema (CED) is a serious complication of acute ischemic stroke (AIS), especially in patients with large hemispheric infarction (LHI). Herein, a deep learning-based approach is implemented to extract CSF from T2-Weighted Imaging (T2WI) and evaluate the relationship between quantified cerebrospinal fluid and outcomes.

Methods

Patients with acute LHI who underwent magnetic resonance imaging (MRI) were included. We used a deep learning algorithm to segment the CSF from T2WI. The hemispheric CSF ratio was calculated to evaluate its relationship with the degree of brain edema and prognosis in patients with LHI.

Results

For the 93 included patients, the left and right cerebrospinal fluid regions were automatically extracted with a mean Dice similarity coefficient of 0.830. Receiver operating characteristic analysis indicated that hemispheric CSF ratio was an accurate marker for qualitative severe cerebral edema (area under receiver-operating-characteristic curve 0.867 [95% CI, 0.781-0.929]). Multivariate logistic regression analysis of functional prognosis showed that previous stroke (OR = 5.229, 95% CI 1.013-26.984), ASPECT≤6 (OR = 13.208, 95% CI 1.136-153.540) and low hemispheric CSF ratio (OR = 0.966, 95% CI 0.937-0.997) were significantly associated with higher chances for unfavorable functional outcome in patients with LHI.

Conclusions

Automated assessment of CSF volume provides an objective biomarker of cerebral edema that can be leveraged to quantify the degree of cerebral edema and confirm its predictive effect on outcomes after LHI.

Functional Outcome and Mortality Predictors in Patients with Cerebral Ischemic Infarction After Decompressive Craniectomy: Cross-Sectional Study

OBJECTIVE

Surgeons commonly perform Decompressive craniectomy (DC) to manage patients with cerebral ischemic infarction. However, there are conflicting data on the long-term functional outcomes following DC. Therefore, this study aims to determine the functional outcome of patients with cerebral ischemic infarction after DC.

METHODS

This prospective and retrospective cross-sectional study included 148 patients with cerebral ischemic infarction who underwent DC at Ghaem Hospital, Mashhad, Iran, from March 2011 to March 2021. The Modified Rankin Scale (mRS) assesses disability in these patients and determines the recovery and degree of long-term functional outcomes. Demographic and clinical data were extracted and recorded in a researcher-made questionnaire.

RESULTS

In summary, the follow-up revealed a survival rate of 39.2% among patients with ischemic stroke. The comparison of the mean infarct volume in patients with various mRS scores showed that the mean infarct volume was significantly higher in patients with unfavorable functional outcomes, based on mRS scores at discharge (P = 0.05), 3 months mRS (P < 0.01), and mRS score at final follow-up (P = 0.01). Final mortality was higher in patients with higher mRS scores at discharge, after 3 months, and final follow-up (P < 0.01). Older age and infarction volume can predict mRS and mortality in patients with ischemic stroke (P < 0.01).

CONCLUSIONS

The present study showed that mortality and mRS scores at various times are associated with infarction volume and older age in patients with ischemic stroke.

Reperfusion by endovascular thrombectomy and early cerebral edema in anterior circulation stroke: Results from the SITS-International Stroke Thrombectomy Registry

BACKGROUND

A large infarct and expanding cerebral edema (CED) due to a middle cerebral artery occlusion confers a 70% mortality unless treated surgically. There is still conflicting evidence whether reperfusion is associated with a lower risk for CED in acute ischemic stroke.

AIM

To investigate the association of reperfusion with development of early CED after stroke thrombectomy.

METHODS

From the SITS-International Stroke Thrombectomy Registry, we selected patients with occlusion of the intracranial internal carotid or middle cerebral artery (M1 or M2). Successful reperfusion was defined as mTICI ⩾ 2b. Primary outcome was moderate or severe CED, defined as focal brain swelling ⩾1/3 of the hemisphere on imaging scans at 24 h. We used regression methods while adjusting for baseline variables. Effect modification by severe early neurological deficits, as indicators of large infarct at baseline and at 24 h, were explored.

RESULTS

In total, 4640 patients, median age 70 years and median National Institutes of Health Stroke Score (NIHSS) 16, were included. Of these, 86% had successful reperfusion. Moderate or severe CED was less frequent among patients who had reperfusion compared to patients without reperfusion: 12.5% versus 29.6%, p < 0.05, crude risk ratio (RR) 0.42 (95% confidence interval (CI): 0.37-0.49), and adjusted RR 0.50 (95% CI: 0.44-0.57). Analysis of effect modification indicated that severe neurological deficits weakened the association between reperfusion and lower risk of CED. The RR reduction was less favorable in patients with severe neurological deficits, defined as NIHSS score 15 or more at baseline and at 24 h, used as an indicator for larger infarction.

CONCLUSION

In patients with large artery anterior circulation occlusion stroke who underwent thrombectomy, successful reperfusion was associated with approximately 50% lower risk for early CED. Severe neurological deficit at baseline seems to be a predictor for moderate or severe CED also in patients with successful reperfusion by thrombectomy.

The predictive value of EEG reactivity by electrical stimulation and quantitative analysis in critically ill patients with large hemispheric infarction

PURPOSE

The intensive care of critically ill patients with large hemispheric infarction improves the survival rate. However, established prognostic markers for neurological outcome show variable accuracy. We aimed to assess the value of electrical stimulation and quantitative analysis of EEG reactivity for early prognostication in this critically ill population.

MATERIALS AND METHODS

We prospectively enrolled consecutive patients between January 2018 and December 2021. EEG reactivity was randomly performed by pain or electrical stimulation via visual and quantitative analysis. Neurological outcome within 6-month was dichotomized as good (modified Rankin Scale, mRS 0-3) or poor (mRS 4-6).

RESULTS

Ninety-four patients were admitted, and 56 were included in the final analysis. EEG reactivity using electrical stimulation was superior to pain stimulation for good outcome prediction (visual analysis: AUC 0.825 vs. 0.763, P = 0.143; quantitative analysis: AUC 0.931 vs. 0.844, P = 0.058). The AUC of EEG reactivity by pain stimulation with visual analysis was 0.763, which increased to 0.931 by electrical stimulation with quantitative analysis (P = 0.006). When using quantitative analysis, the AUC of EEG reactivity increased (pain stimulation 0.763 vs. 0.844, P = 0.118; electrical stimulation 0.825 vs. 0.931, P = 0.041).

CONCLUSION

EEG reactivity by electrical stimulation and quantitative analysis seems a promising prognostic factor in these critical patients.

Iodine-based dual-energy CT predicts early neurological decline from cerebral edema after large hemispheric infarction

Background & Purpose

Ischemia affecting two thirds of the MCA territory predicts development of malignant cerebral edema. However, early infarcts are hard to diagnose on conventional head CT. We hypothesize that high-energy (190keV) virtual monochromatic images (VMI) from dual-energy CT (DECT) imaging enables earlier detection of secondary injury from malignant cerebral edema (MCE).

Methods

Consecutive LHI patients with NIHSS ≥ 15 and DECT within 10 hours of reperfusion from May 2020 to March 2022 were included. We excluded patients with parenchymal hematoma-type 2 transformation. Retrospective analysis of clinical and novel variables included VMI Alberta Stroke Program Early CT Score (ASPECTS), total iodine content, and VMI infarct volume. Primary outcome was early neurological decline (END). Secondary outcomes included hemorrhagic transformation, decompressive craniectomy (DC), and medical treatment of MCE. Fisher's exact test and Wilcoxon test were used for univariate analysis. Logistic regression was used to develop prediction models for categorical outcomes.

Results

Eighty-four LHI patients with a median age of 67.5 [IQR 57,78] years and NIHSS 22 [IQR 18,25] were included. Twenty-nine patients had END. VMI ASPECTS, total iodine content, and VMI infarct volume were associated with END. VMI ASPECTS, VMI infarct volume, and total iodine content were predictors of END after adjusting for age, sex, initial NIHSS, and tPA administration, with a AUROC of 0.691 [0.572,0.810], 0.877 [0.800, 0.954], and 0.845 [0.750, 0.940]. By including all three predictors, the model achieved AUROC of 0.903 [0.84,0.97] and was cross validated by leave one out method with AUROC of 0.827.

Conclusion

DECT with high-energy VMI and iodine quantification is superior to conventional CT ASPECTS and is a novel predictor for early neurological decline due to malignant cerebral edema after large hemispheric infarction.

Surgery for Malignant Acute Ischemic Stroke: A Narrative Review of the Knowns and Unknowns

Malignant acute ischemic stroke (AIS) is characterized by acute neurological deterioration caused by progressive space-occupying brain edema, often occurring in the first hours to days after symptom onset. Without any treatment, the result is often fatal. Despite advances in treatment for AIS, up to 80% of patients with a large hemispheric stroke or cerebellar stroke are at risk of poor outcome. Decompressive surgery can be life-saving in a subgroup of patients with malignant AIS, but uncertainties exist on patient selection, predictors of malignant infarction, perioperative management, and timing of intervention. Although survivors are left disabled, most agree with the original decision to undergo surgery and would make the same decision again. In this narrative review, we focus on the clinical and radiological predictors of malignant infarction in AIS and outline the technical aspects of decompressive surgery as well as duraplasty and cranioplasty. We discuss the current evidence and recommendations for surgery in AIS, highlighting gaps in knowledge, and suggest directions for future studies. KEY POINTS: · Acute ischemic stroke from occlusion of a proximal intracranial artery can progress quickly to malignant edema, which can be fatal in 80% of patients despite medical management.. · Decompression surgery is life-saving within 48 hours of stroke onset, but the benefits beyond this time and in the elderly are unknown.. · Decompressive surgery is associated with high morbidity, particularly in the elderly. The decision to operate must be made after considering the individual's preference and expectations of quality of life in the context of the clinical condition.. · Further studies are needed to refine surgical technique including value of duraplasty and understand the role monitoring intracranial pressure during and after decompressive surgery.. · More studies are needed on the pathophysiology of malignant cerebral edema, prediction models including imaging and biomarkers to identify which subgroup of patients will benefit from decompressive surgery.. · More research is needed on factors associated with morbidity and mortality after cranioplasty, safety and efficacy of implants, and comparisons between them.. · Further studies are needed to assess the long-term effects of physical disability and quality of life of survivors after surgery, particularly those with severe neurological deficits..

Cerebral Edema in Patients with severe Hemispheric Syndrome: Incidence, Risk Factors, and Outcomes-Data from SITS-ISTR

BACKGROUND AND PURPOSE

Cerebral edema (CED) in ischemic stroke can worsen prognosis and about 70% of patients who develop severe CED die if treated conservatively. We aimed to describe incidence, risk factors and outcomes of CED in patients with extensive ischemia.

METHODS

Oservational study based on Safe Implementation of Treatments in Stroke-International Stroke Treatment Registry (2003-2019). Severe hemispheric syndrome (SHS) at baseline and persistent SHS (pSHS) at 24 hours were defined as National Institutes of Health Stroke Score (NIHSS) >15. Outcomes were moderate/severe CED detected by neuroimaging, functional independence (modified Rankin Scale 0-2) and death at 90 days.

RESULTS

Patients (n=8,560) presented with SHS and developed pSHS at 24 hours; 82.2% received intravenous thrombolysis (IVT), 10.5% IVT+thrombectomy, and 7.3% thrombectomy alone. Median age was 77 and NIHSS 21. Of 7,949 patients with CED data, 3,780 (47.6%) had any CED and 2,297 (28.9%) moderate/severe CED. In the multivariable analysis, age <50 years (relative risk [RR], 1.56), signs of acute infarct (RR, 1.29), hyperdense artery sign (RR, 1.39), blood glucose >128.5 mg/dL (RR, 1.21), and decreased level of consciousness (RR, 1.14) were associated with moderate/severe CED (for all P<0.05). Patients with moderate/severe CED had lower odds to achieve functional Independence (adjusted odds ratio [aOR], 0.35; 95% confidence interval [CI], 0.23 to 0.55) and higher odds of death at 90 days (aOR, 2.54; 95% CI, 2.14 to 3.02).

CONCLUSIONS

In patients with extensive ischemia, the most important predictors for moderate/ severe CED were age <50, high blood glucose, signs of acute infarct, hyperdense artery on baseline scans, and decreased level of consciousness. CED was associated with worse functional outcome and a higher risk of death at 3 months.

Medical management of cerebral edema in large hemispheric infarcts

Acute ischemic stroke confers a high burden of morbidity and mortality globally. Occlusion of large vessels of the anterior circulation, namely the intracranial carotid artery and middle cerebral artery, can result in large hemispheric stroke in ~8% of these patients. Edema from stroke can result in a cascade effect leading to local compression of capillary perfusion, increased stroke burden, elevated intracranial pressure, herniation and death. Mortality from large hemispheric stroke is generally high and surgical intervention may reduce mortality and improve good outcomes in select patients. For those patients who are not eligible candidates for surgical decompression either due timing, medical co-morbidities, or patient and family preferences, the mainstay of medical management for cerebral edema is hyperosmolar therapy. Other neuroprotectants for cerebral edema such as glibenclamide are under investigation. This review will discuss current guidelines and evidence for medical management of cerebral edema in large hemispheric stroke as well as discuss important neuromonitoring and critical care management targeted at reducing morbidity and mortality for these patients.

Implementation of neurocritical care in Thailand

Dedicated neurointensive care units and neurointensivists are rarely available in Thailand, a developing country, despite the high burden of life-threatening neurologic illness, including strokes, post-cardiac arrest brain injury, status epilepticus, and cerebral edema from various etiologies. Therefore, the implementation of neurocritical care is essential to improve patient outcomes. With the resource-limited circumstances, the integration of neurocritical care service by collaboration between intensivists, neurologists, neurosurgeons, and other multidisciplinary care teams into the current institutional practice to take care of critically-ill neurologic patients is more suitable than building a new neurointensive care unit since this approach can promptly be made without reorganization of the hospital system. Providing neurocritical care knowledge to internal medicine and neurology residents and critical care fellows and developing a research system will lead to sustainable quality improvement in patient care. This review article will describe our current situation and strategies to implement neurocritical care in Thailand.

Decompressive Hemicraniectomy and Favorable Outcome in a Pediatric Patient with Malignant Middle Cerebral Artery Infarction

We report a rare case of middle cerebral artery (MCA) stroke in a teenage girl with initial improvement, followed by progression to malignant MCA infarction, requiring an urgent decompressive hemicraniectomy (DHC). Additionally, we report improvement in all areas, including language, comprehension, and motor skills at discharge and the 4-month follow-up. This rare presentation highlights the importance of monitoring the neurological status of a patient with an MCA infarct for progression to a life-threatening malignant MCA infarct. This case report also highlights the importance of consideration of DHC for a favorable outcome of the MMCA infarction.

Hypoxanthine is a pharmacodynamic marker of ischemic brain edema modified by glibenclamide

Brain edema after a large stroke causes significant morbidity and mortality. Here, we seek to identify pharmacodynamic markers of edema that are modified by intravenous (i.v.) glibenclamide (glyburide; BIIB093) treatment. Using metabolomic profiling of 399 plasma samples from patients enrolled in the phase 2 Glyburide Advantage in Malignant Edema and Stroke (GAMES)-RP trial, 152 analytes are measured using liquid chromatography-tandem mass spectrometry. Associations with midline shift (MLS) and the matrix metalloproteinase-9 (MMP-9) level that are further modified by glibenclamide treatment are compared with placebo. Hypoxanthine is the only measured metabolite that associates with MLS and MMP-9. In sensitivity analyses, greater hypoxanthine levels also associate with increased net water uptake (NWU), as measured on serial head computed tomography (CT) scans. Finally, we find that treatment with i.v. glibenclamide reduces plasma hypoxanthine levels across all post-treatment time points. Hypoxanthine, which has been previously linked to inflammation, is a biomarker of brain edema and a treatment response marker of i.v. glibenclamide treatment.

Understanding of the Lower Extremity Motor Recovery After First-Ever Ischemic Stroke

BACKGROUND

We aimed to verify the validity of the proportional recovery model for the lower extremity.

METHODS

We reviewed clinical data of patients enrolled in the Korean Stroke Cohort for Functioning and Rehabilitation between August 2012 and May 2015. Recovery proportion was calculated as the amount of motor recovery over initial motor impairment, measured as the Fugl-Meyer Assessment of Lower Extremity score. We used the logistic regression method to model the probability of achieving the full Fugl-Meyer Assessment of Lower Extremity score, whereby we considered the ceiling effect of the score. To show the difference in the prevalence of achieving the full Fugl-Meyer Assessment of Lower Extremity score between 3 and 6 months poststroke, we constructed a marginal model through the generalized estimating equation method. We also performed the propensity score matching analysis to show the dependency of recovery proportion on the initial motor deficit at 3 and 6 months poststroke.

RESULTS

We evaluated 1085 patients. The recovery proportions at 3 and 6 months poststroke were 0.67±0.42 and 0.75±0.39, respectively. A 1-unit decrease in the initial neurological impairment and the age at stroke onset increased the probability of achieving the full Fugl-Meyer Assessment of Lower Extremity score, which occurred at both 3 and 6 months poststroke. The prevalence of those who reach full lower limb motor recovery differs significantly between 3 and 6 months poststroke. We also found out that the recovery proportion at both 3 and 6 months poststroke is determined by the initial motor deficits of the lower limb. These results are not consistent with the proportional recovery model.

CONCLUSIONS

Our results demonstrated that the proportional recovery model for the lower limb is invalid.

Predicting Functional Outcome After Decompressive Craniectomy for Malignant Hemispheric Infarction: Clinical and Novel Imaging Factors

OBJECTIVE

Decompressive craniectomy (DC) is an established optional treatment for malignant hemispheric infarction (MHI). We analyzed relevant clinical factors and computed tomography (CT) measurements in patients with DC for MHI to identify predictors of functional outcome 3-6 months after stroke.

METHODS

This study was performed at 2 comprehensive stroke centers. The inclusion criteria required DC for MHI, no additional intraoperative procedures (strokectomy or cerebral ventricular drain placement), and documented functional status 3-6 months after the stroke. We classified functional outcome as acceptable if the modified Rankin Scale score was <5, or as unacceptable if it was 5 or 6 (bedbound and totally dependent on others or death). Multiple logistic regression analyzed relevant clinical factors and multiple perioperative CT measurements to identify predictors of acceptable functional outcome.

RESULTS

Of 87 identified consecutive patients, 66 met the inclusion criteria. Acceptable functional outcome occurred in 35 of 66 (53%) patients. Likelihood of acceptable functional outcome decreased significantly with increasing age (OR 0.92, 95% CI 0.82-0.97, P = 0.004) and with increasing post-DC midline brain shift (OR 0.78, 95% CI 0.64-0.96, P = 0.016), and decreased non-significantly with left-sided stroke (OR 0.30, 95% CI 0.08-1.10, P = 0.069) and with increasing craniectomy barrier thickness (OR 0.92, 95% CI 0.85-1.01, P = 0.076).

CONCLUSIONS

Patient age and the post-DC midline shift may be useful in prognosticating functional outcome after DC for MHI. Stroke side and craniectomy barrier thickness merit further ideally prospective outcome prediction testing.

20-hydroxyeiscosatetraenoic acid may be as a predictor of malignant middle cerebral artery infarction in patients with massive middle cerebral artery infarction

Background

Early identification of massive middle cerebral artery infarction (MCAI) at risk for malignant MCAI (m-MCAI) may be useful in selecting patients for aggressive therapies. The aim of this study was to determine whether CYP metabolites may help to predict impending m-MCAI.

Methods

This is a prospective, two-center observational study in 256 patients with acute massive MCAI. Plasma levels of 20-hydroxyeicosatetraenoic acid (20-HETE), epoxyeicosatrienoic acids, and dihydroxyeicosatrienoic acids were measured at admission. Brain computed tomography (CT) was performed at admission and repeated between day 3 and 7, or earlier if there was neurological deterioration. The primary outcome was m-MCAI. The m-MCAI was diagnosed when follow-up brain CT detected a more than two-thirds space-occupying MCAI with midline shift, compression of the basal cisterns, and neurological worsening.

Results

In total of 256 enrolled patients, 77 (30.1%) patients developed m-MCAI. Among the 77 patients with m-MCAI, 60 (77.9%) patients died during 3 months of stroke onset. 20-HETE level on admission was significantly higher in patients with m-MCAI than those without m-MCAI. There was an increase in the risk of m-MCAI with increase of 20-HETE levels. The third and fourth quartiles of 20-HETE levels were independent predictors of m-MCAI (OR: 2.86; 95% CI: 1.16 – 6.68; P = 0.025, and OR: 4.23; 95% CI: 1.35 – 8.26; P = 0.002, respectively).

Conclusions

Incidence of m-MCAI was high in patients with massive MCAI and the prognosis of m-MCAI is very poor. Elevated plasma 20-HETE may be as a predictor for m-MCAI in acute massive MCAI, and it might useful in clinical practice in therapeutic decision making.

Decompressive Craniectomy for Hemispheric Infarction in a Low-Income Population

BACKGROUND

Stroke is a worldwide leading cause of mortality and disability, and there are substantial economic costs for poststroke care. Disadvantaged populations show increased incidence, severity, and unfavorable outcomes. This study aimed to report the survival, functional outcome, and caregiver satisfaction of low-income patients diagnosed with a large hemispheric infarction (LHI) who underwent decompressive craniectomy (DC).

METHODS

A retrospective analysis was conducted in consecutive adult patients with an LHI who underwent DC at a single center between October 2015 and September 2019. Demographic, clinical, and radiologic data were reviewed. The primary outcomes were 1-year survival and favorable functional outcome.

RESULTS

Forty-nine patients were included; those <60 years of age showed a higher proportion of favorable functional outcomes (76% vs. 33%; P = 0.031) but similar survival (52% vs. 56%; P = 0.645) than older patients, respectively. Performing the craniectomy in <48 hours from stroke onset compared with ≥48 hours showed no statistically significant differences in survival (59% vs. 46%; P = 0.352) and favorable functional outcomes (56% vs. 70%; P = 0.683), respectively. In retrospective thinking, 79% of caregivers would decide to perform the surgery again.

CONCLUSIONS

Age group and time from stroke onset to craniectomy were not associated with survival; notwithstanding, a higher proportion of patients <60 years of age were associated with a favorable functional outcome compared with older patients. Additionally, if given the option, most caregivers would decide to perform the surgery again, independently of the grade of disability of the patient.

Contemporary Review on Craniectomy and Cranioplasty; Part 1: Decompressive Craniectomy

ABSTRACT

This paper aims to review clinical benefits of decompressive craniectomy (DC) in both adult and paediatric populations; its indications and factors contributing to its postoperative success. The Glasgow Outcome Scale and the Modified Rankin Scale are the most commonly used scales to assess the long-term outcome in patients post DC. In adult traumatic brain injury patients, 2 randomized clinical trials were carried out; DECRA (Decompressive Craniectomy in Diffuse Traumatic Brain Injury) and RESCUEicp (Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of inter cranial pressure) employing collectively 555 patients. Despite the differences in these trials, their initial results affirm DC can lead to reduced mortality and more favorable outcomes. In ischemic stroke adult patients, different clinical trials of HAMLET (Dutch trial of Hemicraniectomy after middle cerebral artery infarction with life-threatening Edema), DESTINY (German trial of Decompressive Surgery for the treatment of Malignant Infarct of the Middle Cerebral Artery), and DECIMAL (French trial of Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarcts) suggested that DC improves survival compared with best medical management, but with an increased proportion of treated individuals surviving with moderate or severe disability. With regard to the size of bone to be removed, the larger the defect the better the results with a minimum diameter of 11 to 12 cm of bone flap. Cranioplasty timing varies and ranges from 6 weeks to more than 12 months post DC, depending on completion of medical treatment, clinical recovery, resolution of any infection, and an evaluation of soft tissues at the defect site.

Computed Tomography Based Score of Early Ischemic Changes Predicts Malignant Infarction

Background and Purpose: Identification of ischemic stroke patients at high risk of developing life-threatening malignant infarction at an early stage is critical to consider more rigorous monitoring and further therapeutic measures. We hypothesized that a score consisting of simple measurements of visually evident ischemic changes in non-enhanced CT (NEMMI score) predicts malignant middle cerebral artery (MCA) infarctions (MMI) with similar diagnostic power compared to other baseline clinical and imaging parameters. Methods: One hundred and nine patients with acute proximal MCA occlusion were included. Fifteen (13.8%) patients developed MMI. NEMMI score was defined using the sum of the maximum diameter (anterior-posterior plus medio-lateral) of the hypoattenuated lesion in baseline-CT multiplied by a hypoattenuation factor (3-point visual grading in non-enhanced CT, no/subtle/clear hypoattenuation = 1/2/3). Receiver operating characteristic (ROC) curve analysis and multivariable logistic regression analysis were used to calculate the predictive values of the NEMMI score, baseline clinical and other imaging parameters. Results: The median NEMMI score at baseline was 13.6 (IQR: 11.6-31.1) for MMI patients, and 7.7 (IQR: 3.9-11.2) for patients with non-malignant infarctions (p < 0.0001). Based on ROC curve analysis, a NEMMI score >10.5 identified MMI with good discriminative power (AUC: 0.84, sensitivity/specificity: 93.3/70.7%), which was higher compared to age (AUC: 0.76), NIHSS (AUC: 0.61), or ischemic core volume (AUC: 0.80). In multivariable logistic regression analysis, NEMMI score was significantly and independently associated with MMI (OR: 1.33, 95%CI: 1.13-1.56, p < 0.001), adjusted for recanalization status. Conclusion: The NEMMI score is a quick and simple rating tool of early ischemic changes on CT and could serve as an important surrogate marker for developing malignant edema. Its diagnostic accuracy was similar to CTP and clinical parameters.

Absent Cortical Venous Filling Is Associated with Aggravated Brain Edema in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Predicting malignant cerebral edema can help identify patients who may benefit from appropriate evidence-based interventions. We investigated whether absent cortical venous filling is associated with more pronounced early brain edema, which leads to malignant cerebral edema.

MATERIALS AND METHODS

Patients with acute ischemic stroke caused by large-vessel occlusion in the MCA territory who presented between July 2017 and September 2019 to our hospital were included. Collateral filling was rated using the modified Tan scale on CTA, and good collaterals were defined as a score of 2-3. The Cortical Vein Opacification Score (COVES) was calculated, and absent cortical venous filling was defined as a score of 0. Early brain edema was determined using net water uptake on baseline CT images. Malignant cerebral edema was defined as a midline shift of ≥5 mm on follow-up imaging or a massive cerebral swelling leading to decompressive hemicraniectomy or death. Multivariate linear and logistic regression models were performed to analyze data.

RESULTS

A total of 163 patients were included. Net water uptake was significantly higher in patients with absent than in those with favorable cortical venous filling (8.1% versus 4.2%; P < .001). In the multivariable regression analysis, absent cortical venous filling (β = 2.04; 95% CI, 0.75-3.32; P = .002) was significantly and independently associated with higher net water uptake. Absent cortical venous filling (OR, 14.68; 95% CI, 4.03-53.45; P < .001) and higher net water uptake (OR, 1.29; 95% CI, 1.05-1.58; P = .016) were significantly associated with increased likelihood of malignant cerebral edema.

CONCLUSIONS

Patients with absent cortical venous filling were associated with an increased early brain edema and a higher risk of malignant cerebral edema. These patients may be targeted for optimized adjuvant antiedematous treatment.

Improvement in Midline Shift Is a Positive Prognostic Predictor for Malignant Middle Cerebral Artery Infarction Patients Undergoing Decompressive Craniectomy

Objective: The aim of this retrospective study is to evaluate the risk factors of malignant middle cerebral artery infarction (MMCAI) patients and explore an applicable prognostic predictor for MMCAI patients undergoing decompressive craniectomy (DC). Methods: Clinical data from the period 2012-2017 were retrospectively evaluated. Forty-three consecutive MMCAI patients undergoing DC were enrolled in this study. The 30-day mortality was assessed, and age, location, hypertension, pupil dilation, onset to operation duration, midline shift, and Glasgow Coma Scale (GCS) score were identified by univariate analysis and binary logistic regression. Results: In this retrospective study for DC patients, the 30-day mortality was 44.2%. In the univariate analysis, advanced age (≥60 years), right hemispheric location, hypertension, pupil dilation, shorter onset to operation duration (<48 h), improved midline shift (t = 4.214, p < 0.01), and lower pre-operation GCS score were significant predictors of death within 30 days. In binary logistic regression analysis, age [odds ratio (OR) = 1.141, 95% CI 1.011-1.287], the improvement of the midline shift (OR = 0.764, 95% CI 0.59-0.988), and pupillary dilation (OR = 15.10, 95% CI 1.374-165.954) were independent influencing factors. For the receiver operating characteristic (ROC) analysis of the relationship between post-operation outcomes and midline shift improvement, the area under the curve (AUC) was 0.844, and the cutoff point of midline shift improvement was 0.83 cm. Conclusion: Improved midline shift was a significant predictor of 30-day mortality. The improved midline shift of >0.83 cm indicated survival at 30 days.

External Validation and Modification of the EDEMA Score for Predicting Malignant Brain Edema After Acute Ischemic Stroke

BACKGROUND

Accurate prediction of malignant brain edema (MBE) after stroke is paramount to facilitate close monitoring and timely surgical intervention. The Enhanced Detection of Edema in Malignant Anterior Circulation Stroke (EDEMA) score was useful to predict potentially lethal malignant edema in Western populations. We aimed to validate and modify it to achieve a better predictive value for MBE in Chinese patients.

METHODS

Of ischemic stroke patients consecutively admitted in the Department of Neurology, West China Hospital between January 2010 and December 2017, we included patients with anterior circulation stroke, early signs of brain edema on computed tomography within 24 h of onset, and admission National Institutes of Health Stroke Scale (NIHSS) score ≥ 8. MBE was defined as the development of signs of herniation (including decrease in consciousness and/or anisocoria), accompanied by midline shift ≥ 5 mm on follow-up imaging. The EDEMA score consisted of five parameters: glucose, stroke history, reperfusion therapy, midline shift, and cistern effacement. We created a modified score by adding admission NIHSS score to the original EDEMA score. The discrimination of the score was assessed by the area under the receiver operating characteristics curve (AUC). Calibration was assessed by Hosmer-Lemeshow test and calibration plot. We compared the discrimination of the original and modified score by AUC, net reclassification improvement (NRI), and integrated discrimination improvement (IDI). Clinical usefulness of the two scores was compared by plotting net benefits at different threshold probabilities in the decision curve analysis.

RESULTS

Of the 478 eligible patients (mean age 67.3 years; median NIHSS score 16), 93 (19%) developed MBE. The EDEMA score showed moderate discrimination (AUC 0.72, 95% confidence interval [CI] 0.67-0.76) and good calibration (Hosmer-Lemeshow test, P = 0.77). The modified score showed an improved discriminative ability (AUC 0.80, 95% CI 0.76-0.84, P < 0.001; NRI 0.67, 95% CI 0.55-0.78, P < 0.001; IDI 0.07, 95% CI 0.06-0.09, P < 0.001). Decision curves showed that the modified score had a higher net benefit than the original score in a range of threshold probabilities lower than 60%.

CONCLUSIONS

The original EDEMA score showed an acceptable predictive value for MBE in Chinese patients. By adding the admission NIHSS score, the modified score allowed for a more accurate prediction and clinical usefulness. Further validation in large cohorts of different ethnicities is needed to confirm our findings.

Surgical Decompression for Space-Occupying Hemispheric Infarction: A Systematic Review and Individual Patient Meta-analysis of Randomized Clinical Trials

Importance

In patients with space-occupying hemispheric infarction, surgical decompression reduces the risk of death and increases the chance of a favorable outcome. Uncertainties, however, still remain about the benefit of this treatment for specific patient groups.

Objective

To assess whether surgical decompression for space-occupying hemispheric infarction is associated with a reduced risk of death and an increased chance of favorable outcomes, as well as whether this association is modified by patient characteristics.

Data Sources

MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Stroke Trials Registry were searched from database inception to October 9, 2019, for English-language articles that reported on the results of randomized clinical trials of surgical decompression vs conservative treatment in patients with space-occupying hemispheric infarction.

Study Selection

Published and unpublished randomized clinical trials comparing surgical decompression with medical treatment alone were selected.

Data Extraction and Synthesis

Patient-level data were extracted from the trial databases according to a predefined protocol and statistical analysis plan. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and the Cochrane Collaboration's tool for assessing risk of bias were used. One-stage, mixed-effect logistic regression modeling was used for all analyses.

Main Outcomes and Measures

The primary outcome was a favorable outcome (modified Rankin Scale [mRS] score ≤3) at 1 year after stroke. Secondary outcomes included death, reasonable (mRS score ≤4) and excellent (mRS score ≤2) outcomes at 6 months and 1 year, and an ordinal shift analysis across all levels of the mRS. Variables for subgroup analyses were age, sex, presence of aphasia, stroke severity, time to randomization, and involved vascular territories.

Results

Data from 488 patients from 7 trials from 6 countries were available for analysis. The risk of bias was considered low to moderate for 6 studies. Surgical decompression was associated with a decreased chance of death (adjusted odds ratio, 0.16; 95% CI, 0.10-0.24) and increased chance of a favorable outcome (adjusted odds ratio, 2.95; 95% CI, 1.55-5.60), without evidence of heterogeneity of treatment effect across any of the prespecified subgroups. Too few patients were treated later than 48 hours after stroke onset to allow reliable conclusions in this subgroup, and the reported proportions of elderly patients reaching a favorable outcome differed considerably among studies.

Conclusions and Relevance

The results suggest that the benefit of surgical decompression for space-occupying hemispheric infarction is consistent across a wide range of patients. The benefit of surgery after day 2 and in elderly patients remains uncertain.

Dynamic Neural Network Changes Revealed by Voxel-Based Functional Connectivity Strength in Left Basal Ganglia Ischemic Stroke

Objective

This study intends to track whole-brain functional connectivity strength (FCS) changes and the lateralization index (LI) in left basal ganglia (BG) ischemic stroke patients.

Methods

Twenty-five patients (N = 25; aged 52.73 ± 10.51 years) with five visits at <7, 14, 30, 90, and 180 days and 26 healthy controls (HCs; N = 26; 51.84 ± 8.06 years) were examined with resting-state functional magnetic resonance imaging (rs-fMRI) and motor function testing. FCS and LI were calculated through constructing the voxel-based brain functional network. One-way analysis of covariance (ANOVA) was first performed to obtain longitudinal FCS and LI changes in patients among the five visits (Bonferroni corrected, P < 0.05). Then, pairwise comparisons of FCS and LI were obtained during the five visits, and the two-sample t test was used to examine between-group differences in FCS [family-wise error (FWE) corrected, P < 0.05] and LI. Correlations between connectivity metrics (FCS and LI) and motor function were further assessed.

Results

Compared to HCs, decreased FCS in the patients localized in the calcarine and inferior occipital gyrus (IOG), while increased FCS gathered in the middle prefrontal cortex (MPFC), middle frontal gyrus, and insula (P < 0.05). The LI and FCS of patients first decreased and then increased, which showed significant differences compared with HCs (P < 0.05) and demonstrated a transition at the 30-day visit. Additionally, LI at the third visit was significantly different from those at the other visits (P < 0.05). No significant longitudinal correlations were observed between motor function and FCS or LI (P > 0.05).

Conclusion

Focal ischemic stroke in the left BG leads to extensive alterations in the FCS. Strong plasticity in the functional networks could be reorganized in different temporal dynamics to facilitate motor recovery after BG stroke, contribute to diagnosing the disease course, and estimate the intervention treatment.

Effect of Recanalization on Cerebral Edema, Long-Term Outcome, and Quality of Life in Patients with Large Hemispheric Infarctions

OBJECTIVES

Space-occupying cerebral edema is the main cause of mortality and poor functional outcome in patients with large cerebral artery occlusion (LVO). We aimed to determine whether recanalization of LVO would augment cerebral edema volume and the impact on functional outcome and quality of life (QoL).

MATERIALS AND METHODS

Prospectively, 43 patients with large middle cerebral artery territory infarction or NIHSS ≥ 12 on admission were enrolled. The degree of recanalization (partial and complete versus no recanalization) was assessed by computed tomography (CT)-angiography or Duplex ultrasound more than 24 h after symptom onset. Cerebral edema volume was measured on follow up CTs by computer-based planimetry. Mortality, functional outcome (by modified Ranking Scale (mRS) and Barthel Index (BI)) were assessed at discharge and 12 months, and QoL (by SF-36 and EQ-5D-3L) at 12 months.

RESULTS

Mean cerebral edema volume was 333±141 ml without recanalization (n=13, group 1) and 276±140 ml with partial or complete recanalization (n=30, group 2, p= 0.23). There were no significant differences in mortality at discharge (38% versus 23%), at 12 months (58% versus 48%), in functional outcome at discharge (mRS 0-3: 0% both; mRS 4-5: 62% versus 77%) and at 12 months (mRS 0-3: 0% versus 11%; mRS 4-5: 42% versus 41%). The BI improved significantly from discharge to 12 months only in group 2 (p=0.001). Mean physical component score in SF-36 was 25.6±6.4, psychological component score was 41.9±14.1. In the EQ-5D-3L, most patients reported problems with activities of daily living, reduced mobility, and selfcare.

CONCLUSIONS

Recanalization of a large cerebral artery occlusion in the anterior circulation territories is not associated with amplification of post-ischemic cerebral edema but may be correlated with better long-term functional outcome. QoL was low and mainly dependent on physical disability. The association between recanalization, collateral status and development of cerebral edema after LVO and the effect on functional outcome and quality of life should be explored in a larger patient population.

Outcome After Decompressive Craniectomy for Middle Cerebral Artery Infarction: Timing of the Intervention

BACKGROUND

Based on randomized controlled trials (RCTs), clinical guidelines for the treatment of space-occupying hemispheric infarct employ age (≤60 yr) and time elapsed since stroke onset (≤48 h) as decisive criteria whether to perform decompressive craniectomy (DC). However, only few patients in these RCTs underwent DC after 48 h.

OBJECTIVE

To study the association between the timing of DC and (un)favorable outcome in patients with space-occupying middle cerebral artery (MCA) infarct undergoing DC.

METHODS

We performed a single-center cohort study from 2007 to 2017. Unfavorable outcome at 1 yr was defined as a Glasgow outcome scale 1 to 3. Additionally, we systematically reviewed the literature up to November 2018, including studies reporting on the timing of DC and other predictors of outcome. We performed Firth penalized likelihood and random-effects meta-analysis with odds ratio (OR) on unfavorable outcome.

RESULTS

A total of 66 patients were enrolled. A total of 26 (39%) patients achieved favorable and 40 (61%) unfavorable outcomes (13 [20%] died). DC after 48 h since stroke diagnosis did not significantly increase the risk of unfavorable outcome (OR 0.8, 95% CI 0.3-2.3). Also, in the meta-analysis, DC after 48 h of stroke onset was not associated with a higher risk of unfavorable outcome (OR 1.11; 95% CI 0.89-1.38).

CONCLUSION

The outcome of DC performed after 48 h in patients with malignant MCA infarct was not worse than the outcome of DC performed within 48 h. Contrary to current guidelines, we, therefore, advocate not to set a restriction of ≤48 h on the time elapsed since stroke onset in the decision whether to perform DC.

Outgrowth endothelial cells form a functional cerebral barrier and restore its integrity after damage

Breakdown of blood-brain barrier, formed mainly by brain microvascular endothelial cells (BMECs), represents the major cause of mortality during early phases of ischemic strokes. Hence, discovery of novel agents that can effectively replace dead or dying endothelial cells to restore blood-brain barrier integrity is of paramount importance in stroke medicine. Although endothelial progenitor cells (EPCs) represent one such agents, their rarity in peripheral blood severely limits their adequate isolation and therapeutic use for acute ischemic stroke which necessitate their ex vivo expansion and generate early EPCs and outgrowth endothelial cells (OECs) as a result. Functional analyses of these cells, in the present study, demonstrated that only OECs endocytosed DiI-labelled acetylated low-density lipoprotein and formed tubules on matrigel, prominent endothelial cell and angiogenesis markers, respectively. Further analyses by flow cytometry demonstrated that OECs expressed specific markers for stemness (CD34), immaturity (CD133) and endothelial cells (CD31) but not for hematopoietic cells (CD45). Like BMECs, OECs established an equally tight in vitro model of human BBB with astrocytes and pericytes, suggesting their capacity to form tight junctions. Ischemic injury mimicked by concurrent deprivation of oxygen and glucose (4 hours) or deprivation of oxygen and glucose followed by reperfusion (20 hours) affected both barrier integrity and function in a similar fashion as evidenced by decreases in transendothelial electrical resistance and increases in paracellular flux, respectively. Wound scratch assays comparing the vasculoreparative capacity of cells revealed that, compared to BMECs, OECs possessed a greater proliferative and directional migratory capacity. In a triple culture model of BBB established with astrocytes, pericytes and BMEC, exogenous addition of OECs effectively repaired the damage induced on endothelial layer in serum-free conditions. Taken together, these data demonstrate that OECs may effectively home to the site of vascular injury and repair the damage to maintain (neuro)vascular homeostasis during or after a cerebral ischemic injury.

An Association Between Hyperchloremia and Acute Kidney Injury in Patients With Acute Ischemic Stroke

Background and Purpose

While an association between hyperchloremia and worse outcomes, such as acute kidney injury and increased mortality, has been demonstrated in hemorrhagic stroke, it is unclear whether the same relationship exists after acute ischemic stroke. This study aims to determine the relationship between moderate hyperchloremia (serum chloride ≥115 mmol/L) and acute kidney injury in patients with ischemic stroke.

Methods

This is a multicenter, retrospective, propensity-matched cohort study of adults admitted for acute ischemic stroke. The primary objective was to determine the relationship between moderate hyperchloremia and acute kidney injury, as defined by the Acute Kidney Injury Network criteria. Secondary objectives included mortality and hospital length of stay.

Results

A total of 407 patients were included in the unmatched cohort (332 nonhyperchloremia and 75 hyperchloremia) and 114 patients (57 in each group) were matched based upon propensity scores. In the matched cohort, hyperchloremia was associated with an increased risk of acute kidney injury (relative risk 1.91 [95% confidence interval 1.01-3.59]) and a longer hospital length of stay (16 vs 12 days; P = .03). Mortality was higher in the hyperchloremia group (19.3% vs 10.5%, P = .19), but this did not reach statistical significance.

Conclusions

In this study, hyperchloremia after ischemic stroke was associated with increased rates of acute kidney injury and longer hospital length of stay. Further research is needed to determine which interventions may increase chloride levels in patients with acute ischemic stroke and the association between hyperchloremia and clinical outcomes.

Automated quantitative assessment of cerebral edema after ischemic stroke using CSF volumetrics

Reduction in CSF volume from baseline to follow-up CT at or beyond 24 -hs can serve as a quantitative biomarker of cerebral edema after stroke. We have demonstrated that assessment of CSF displacement reflects edema metrics such as lesion volume, midline shift, and neurologic deterioration. We have also developed a neural network-based image segmentation algorithm that can automatically measure CSF volume on serial CT scans from stroke patients. We have integrated this algorithm into an image processing pipeline that can extract this edema biomarker from large cohorts of stroke patients. Finally, we have created a stroke repository that can archive and process images from thousands of stroke patients in order to measure CSF volumetrics. We plan on applying this metric as a quantitative endophenotype of cerebral edema to facilitate early prediction of clinical deterioration as well as large-scale genetic studies.

[Prognostic factors for mortality due to acute arterial stroke in a North African population]

Introduction

cerebrovascular accident (stroke) constitutes a major public health problem due to the number of people affected and to its medical social and economic consequences. This study aims to identify poor vital prognostic factors for survival in patients with acute arterial stroke.

Methods

we conducted a prospective study of patients with symptoms suggestive of stroke at the two University Hospitals of Sfax, Tunisia over a period of 4 months. Patients were followed-up for a period of 1 month.

Results

we collected data from 200 patients. After one month of follow-up, mortality was 19.9%. Poor prognostic factors were: male sex, consumption of tobacco, a history of stroke, low Glasgow score, high NIHSS, headaches, acute symptomatic epileptic seizures, Babinski's sign, mydriasis, aphasia, combined deviation of the head and the eyes, high PAS, PAD and PAM, hyperthermia, hyperglycaemia, leukocytosis, high concentration of CRP, creatinine, urea and troponin T, haemorrhagic stroke, perilesional oedema, a mass effect, commitment, total middle cerebral artery topography of ischemia, early signs of ischemia, meningeal hemorrhage, ventricular flood, hydrocephalus, the recourse to respiratory support, to anti-edematous treatment and to antihypertensive therapy, hemorrhagic transformation, vascular epilepsy, infectious, metabolic complications, complications of bed sores.

Conclusion

the identification of the predictive factors for survival allows for optimisation of therapeutic procedures and better implementation of patient' management. A comparative study will be considered to measure the impact of the corrective measures.

Management of the Patient with Malignant Hemispheric Stroke

Malignant hemispheric stroke occurs in 10% of ischemic strokes and has one of the highest mortality and morbidity rates. This stroke, also known as malignant middle cerebral artery stroke, may cause ischemia to an entire hemisphere causing edema, herniation, and death. A collaborative interdisciplinary team approach is needed to manage these complex stroke patients. The nurse plays a vital role in bedside management and support of the patient and family through this complex course of care. This article discusses malignant middle cerebral artery stroke pathophysiology, techniques to predict patients at risk for herniation, collaborative care strategies, and nursing care.

Decompressive hemicraniectomy versus medical treatment of malignant middle cerebral artery infarction: a systematic review and meta-analysis

OBJECTIVES

To estimate evidence for decompressive hemicraniectomy (DHC) versus medical treatment effects on survival rate and favorable functional recovery among patients of malignant middle cerebral artery infarction (MMCAI) in randomized controlled trials (RCTs).

DESIGN

The present study is a systematic review and meta-analysis of RCTs.

SETTING

The MEDLINE/PubMed, EMBASE, Springer, Cochrane Collaboration database, China National Knowledge Infrastructure (CNKI) database, and Wanfang database were comprehensively searched for RCTs regarding the effects of DHC versus medical treatment among patients of MMCAI in these English and Chinese electronic databases from inception to 1 June 2019. Two reviewers independently retrieved RCTs and extracted relevant information. The methodological quality of the included trials was estimated using the Cochrane risk of bias tool. Review Manager5.3.5 software was used for statistical analyses. The statistical power of meta-analysis was estimated by Power and Precision, version 4 software.

PARTICIPANTS

Nine RCTs with a total of 425 patients with MMCAI, containing 210 cases in the DHC group and 215 cases in the medical treatment group, met the inclusion criteria were included. Primary outcomes were measured by survival rate, defined as modified Rankin scale (mRS) score 0-5 and favorable functional recovery as mRS score 0-3. The follow-up time of all studies was at 6-12months.

RESULTS

First, compared with the medical treatment group, DHC was associated with a statistically significant increase survival rate (RR: 1.96, 95%CI 1.61-2.38, P < 0.00001) and favorable functional recovery (RR: 1.62, 95%CI 1.11-2.37, P = 0.01). Second, subgroup analysis: (1) Compared with the medical treatment group among patients age ≤60 years, DHC was associated with a statistically significant increase survival rate (RR = 2.20, 95%CI 1.60-3.04, P < 0.00001); (2) Compared with the medical treatment group among patients of age >60 years, DHC was also associated with a statistically significant increase survival rate (RR: 1.93, 95%CI 1.45-2.59, P < 0.00001); (3) Compared with the medical treatment group, the time of DHC was preformed within 48 h from the onset of stroke that could statistically significant increase survival rate (RR: 2.16, 95%CI 1.69-2.75, P < 0.00001). Third, sensitivity analyses that measured the results were consistent, indicating that the results were stable. Fourth, the results of statistical power analysis were ≥80%. Finally, the funnel plot of the survival rate included nine RCTs showed no remarkable publication bias.

CONCLUSIONS

Our study results indicated that DHC could increase survival rate and favorable functional recovery among patients age ≤60 or >60 years. The optimal time for DHC might be no more than 48 h from the onset of symptoms. However, due to the limitations of this research, it is necessary to design high quality, large-scale RCTs to further evaluate these findings.

Paramedic Global Impression of Change During Prehospital Evaluation and Transport for Acute Stroke

Background and Purpose- The prehospital setting is a promising site for therapeutic intervention in stroke, but current stroke screening tools do not account for the evolution of neurological symptoms in this early period. We developed and validated the Paramedic Global Impression of Change (PGIC) Scale in a large, prospective, randomized trial. Methods- In the prehospital FAST-MAG (Field Administration of Stroke Therapy-Magnesium) randomized trial conducted from 2005 to 2013, EMS providers were asked to complete the PGIC Scale (5-point Likert scale values: 1-much improved, 2-mildly improved, 3-unchanged, 4-mildly worsened, 5-much worsened) for neurological symptom change during transport for consecutive patients transported by ambulance within 2 hours of onset. We analyzed PGIC concurrent validity (compared with change in Glasgow Coma Scale, Los Angeles Motor Scale), convergent validity (compared with National Institutes of Health Stroke Scale severity measure performed in the emergency department), and predictive validity (of neurological deterioration after hospital arrival and of final 90-day functional outcome). We used PGIC to characterize differential prehospital course among stroke subtypes. Results- Paramedics completed the PGIC in 1691 of 1700 subjects (99.5%), among whom 635 (37.5%) had neurological deficit evolution (32% improvement, 5.5% worsening) during a median prehospital care period of 33 (IQR, 27-39) minutes. Improvement was associated with diagnosis of cerebral ischemia rather than intracranial hemorrhage, milder stroke deficits on emergency department arrival, and more frequent nondisabled and independent 3-month outcomes. Conversely, worsening on the PGIC was associated with intracranial hemorrhage, more severe neurological deficits on emergency department arrival, more frequent treatment with thrombolytic therapy, and poor disability outcome at 3 months. Conclusions- The PGIC scale is a simple, validated measure of prehospital patient course that has the potential to provide information useful to emergency department decision-making. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00059332.

Second-look strokectomy of cerebral infarction areas in patients with severe herniation

OBJECTIVE

Decompressive craniectomies (DCs) are performed on patients suffering large cerebral infarctions. The efficacy of this procedure has been demonstrated in several trials. In some cases, however, this procedure alone is not sufficient and patients still suffer refractory elevations of intracranial pressure (ICP). The goal of this study was to determine whether resection of infarcted tissue, termed strokectomy, performed as a second-look procedure after DC, improves outcome in selected cases.

METHODS

The authors retrospectively evaluated data of patients who underwent a DC due to a cerebral infarction at their institution from 2009 to 2016, including patients who underwent a strokectomy procedure after DC. Clinical records, imaging data, outcome scores, and neurological symptoms were analyzed, and clinical outcomes and mortality rates in the strokectomy group were compared to those for similar patients in recently published randomized controlled trials.

RESULTS

Of 198 patients who underwent DC due to cerebral infarction, 12 patients underwent strokectomy as a second surgical procedure, with a median National Institutes of Health Stroke Scale (NIHSS) score of 19 for patients with versus 16 for those without secondary strokectomy (p = 0.029). Either refractory increases of ICP > 20 mm Hg or dilated pupils in addition to herniation visible on CT images were triggers for strokectomy surgery. Ten of 12 (83%) patients had infarctions in more than one territory (p < 0.001). After 12 months, 43% of patients had a good outcome according to the modified Rankin Scale (mRS) score (≤ 3). In the subgroup of patients suffering infarctions in more than one vascular territory, functional outcome after 12 months was better (mRS ≤ 3 in 40% of patients in comparison to 9%; p = 0.027). A 1:3 case-control analysis matched to age, side of infarction, sex, and vascular territory confirmed these results (mRS ≤ 3, 42% in comparison to 11%; p = 0.032). Age, NIHSS score on admission, and number of vascular territories involved were identified as risk factors in multivariate analysis (p < 0.05). Patients in the strokectomy group had more infections (p < 0.001). According to these results, the authors developed a scale (Münster Stroke Score, 0-6 points) to predict whether patients might benefit from additional strokectomy. Receiver-operating characteristic (ROC) curve analysis revealed an area under the curve (AUC) of 0.86 (p < 0.001). The authors recommend a Münster Stroke Score of ≥ 3 as a cutoff, with a sensitivity of 92% and specificity of 66%, for predicting benefit from strokectomy.

CONCLUSIONS

In this study in comparison to former studies, mortality rates were lower and clinical outcome was comparable to that of previously published trials regarding large cerebral infarctions. Second surgery including strokectomy may help achieve better outcomes, especially in cases of infarction of more than one vascular territory.

Reduction in Cerebrospinal Fluid Volume as an Early Quantitative Biomarker of Cerebral Edema After Ischemic Stroke

Background and Purpose- Cerebral edema (CED) develops in the hours to days after stroke; the resulting increase in brain volume may lead to midline shift (MLS) and neurological deterioration. The time course and implications of edema formation are not well characterized across the spectrum of stroke. We analyzed displacement of cerebrospinal fluid (ΔCSF) as a dynamic quantitative imaging biomarker of edema formation. Methods- We selected subjects enrolled in a stroke cohort study who presented within 6 hours of onset and had baseline and ≥1 follow-up brain computed tomography scans available. We applied a neural network-based algorithm to quantify hemispheric CSF volume at each imaging time point and modeled CSF trajectory over time (using a piecewise linear mixed-effects model). We evaluated ΔCSF within the first 24 hours as an early biomarker of CED (defined as developing MLS on computed tomography beyond 24 hours) and poor outcome (modified Rankin Scale score, 3-6). Results- We had serial imaging in 738 subjects with stroke, of whom 91 (13%) developed CED with MLS. Age did not differ (69 versus 70 years), but baseline National Institutes of Health Stroke Scale was higher (16 versus 7) and baseline CSF volume lower (132 versus 161 mL, both P<0.001) in those with CED. ΔCSF was faster in those developing MLS, with the majority seen by 24 hours (36% versus 11% or 2.4 versus 0.8 mL/h; P<0.0001). Risk of CED almost doubled for every 10% ΔCSF within 24 hours (odds ratio, 1.76 [95% CI, 1.46-2.14]), adjusting for age, glucose, and National Institutes of Health Stroke Scale. Risk of neurological deterioration (1.6-point increase in National Institutes of Health Stroke Scale at 24 hours) and poor outcome (adjusted odds ratio, 1.34 [95% CI, 1.15-1.56]) was also greater for every 10% increase in ΔCSF. Conclusions- CSF volumetrics provides quantitative evaluation of early edema formation. ΔCSF from baseline to 24-hour computed tomography is a promising early biomarker for the development of MLS and worse neurological outcome.

Effect of Recanalization on Cerebral Edema in Ischemic Stroke Treated With Thrombolysis and/or Endovascular Therapy

Background and Purpose- A large infarct and expanding cerebral edema (CED) due to a middle cerebral artery occlusion confers a 70% mortality unless treated surgically. Reperfusion may cause blood-brain barrier disruption and a risk for cerebral edema and secondary parenchymal hemorrhage (PH). We aimed to investigate the effect of recanalization on development of early CED and PH after recanalization therapy. Methods- From the SITS-International Stroke Treatment Registry, we selected patients with signs of artery occlusion at baseline (either Hyperdense Artery Sign or computed tomography/magnetic resonance imaging angiographic occlusion). We defined recanalization as the disappearance of radiological signs of occlusion at 22 to 36 hours. Primary outcome was moderate to severe CED and secondary outcome was PH on 22- to 36-hour imaging scans. We used logistic regression with adjustment for baseline variables and PH. Results- Twenty two thousand one hundred eighty-four patients fulfilled the inclusion criteria (n=18 318 received intravenous thrombolysis, n=3071 received intravenous thrombolysis+thrombectomy, n=795 received thrombectomy). Recanalization occurred in 64.1%. Median age was 71 versus 71 years and National Institutes of Health Stroke Scale score 15 versus 16 in the recanalized versus nonrecanalized patients respectively. Recanalized patients had a lower risk for CED (13.0% versus 23.6%), adjusted odds ratio (aOR), 0.52 (95% CI, 0.46-0.59), and a higher risk for PH (8.9% versus 6.5%), adjusted odds ratio, 1.37 (95% CI, 1.22-1.55), than nonrecanalized patients. Conclusions- In patients with acute ischemic stroke, recanalization was associated with a lower risk for early CED even after adjustment for higher rate for PH in recanalized patients.

Surgical Decompression versus Conservative Treatment in Patients with Malignant Infarction of the Middle Cerebral Artery: Direct Comparison of Death-Related Complications

BACKGROUND

Surgical decompression and conservative treatment are routinely used in the treatment of patients with malignant infarction of the middle cerebral artery (MIMCA). However, efficacy and safety are controversial. The purpose of this study is to systematically compare the clinical outcomes between surgical decompression and conservative treatment in patients with MIMCA.

METHODS

This study retrieved available academic randomized controlled trials (RCTs) comparing the clinical outcomes between surgical decompression and conservative treatment in patients with MIMCA from the databases of ScienceDirect, Cochrane Library, Embase, and PubMed. The references of previous reviews and related clinical studies were manually checked to retrieve potential literature that was not involved in our electronic search results.

RESULTS

A total of 7 RCTs were included in the study. The overall number of participants in the surgical decompression group was 165, whereas it was 173 in the conservative treatment group. The results revealed that the surgical decompression group was related to a lower incidence of 1-year death (odds ratio [OR], 0.192; 95% confidence interval [CI], 0.119-0.309; P < 0.001), 1-year death in patients >60 years of age (OR, 0.202; 95% CI, 0.097-0.421; P < 0.001), 1-year death in patients <60 years of age (OR, 0.145; 95% CI, 0.069-0.301; P < 0.001), 1-year death in patients treated within 48 hours of stroke onset (OR, 0.159; 95% CI, 0.090-0.282; P < 0.001), and modified Rankin Scale (mRS) score ≤3 (OR, 2.082; 95% CI, 1.185-3.658; P < 0.001).

CONCLUSIONS

Based on current evidence for patients with MIMCA, decompressive surgery not only is a life-saving therapy but also reduces the incidence of mortality without increasing the risk of severe disability.

Intravenous Glibenclamide Reduces Lesional Water Uptake in Large Hemispheric Infarction

Background and Purpose- Prior studies have shown a linear relationship between computed tomography (CT)-derived radiodensity and water uptake, or brain edema, within stroke lesions. To test the hypothesis that intravenous glibenclamide (glyburide; BIIB093) reduces ischemic brain water uptake, we quantified the lesional net water uptake (NWU) on serial CT scans from patients enrolled in the phase 2 GAMES-RP Trial (Glyburide Advantage in Malignant Edema and Stroke). Methods- This was a post hoc exploratory analysis of the GAMES-RP study. Noncontrast CT scans performed between admission and day 7 (n=264) were analyzed in the GAMES-RP modified intention-to-treat sample. Quantitative change in CT radiodensity (ie, NWU) and midline shift (MLS) was measured. The gray and white matter NWU were also examined separately. Repeated-measures mixed-effects models were used to assess the effect of intravenous glibenclamide on MLS or NWU. Results- A median of 3 CT scans (interquartile range, 2-4) were performed per patient during the first 7 days after stroke. In a repeated-measures regression model, greater NWU was associated with increased MLS (β=0.23; 95% CI, 0.20-0.26; P<0.001). Treatment with intravenous glibenclamide was associated with reduced NWU (β=-2.80; 95% CI, -5.07 to -0.53; P=0.016) and reduced MLS (β=-1.50; 95% CI, -2.71 to -0.28; P=0.016). Treatment with intravenous glibenclamide reduced both gray and white matter water uptake. In mediation analysis, gray matter NWU (β=0.15; 95% CI, 0.11-0.20; P<0.001) contributed to a greater proportion of MLS mass effect, as compared with white matter NWU (β=0.08; 95% CI, 0.03-0.13; P=0.001). Conclusions- In this phase 2 post hoc analysis, intravenous glibenclamide reduced both water accumulation and mass effect after large hemispheric infarction. This study demonstrates NWU is a quantitative and modifiable biomarker of ischemic brain edema accumulation. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT01794182.

Maximum Decompressive Hemicraniectomy for Patients with Malignant Hemispheric Infarction

Objective

The authors applied maximum external decompression for malignant hemispheric infarction and investigated the functional outcome according to the patient age.

Methods

Twenty-five patients with malignant hemispheric infarction were treated using a hemicraniectomy with maximum external decompression, comprising a larger (>14cm) hemicraniectomy, resection of the temporalis muscle and its fascia, spaciously expansive duraplasty, and approximation of the skin flap. The medical and diagnostic imaging records for the patients were reviewed, and 1-year functional outcome data obtained for the younger group (aged ≤ 60 years) and elderly group (aged > 60 years).

Results

The patients (n=25) who underwent maximum surgical decompression revealed a minimal mortality rate (n=2, 8.0%). The patients (n=14) in the younger group all survived with mRS scores of 2 (n=1, 7.1%), 3 (n=7, 50.0%), 4 (n=3, 21.4%), or 5 (n=3, 21.4%). A majority of the younger patients (57.1% with mRS ≤3) lived with functional independence. When the 1-year mRS scores were dichotomized between favorable (mRS ≤3) and unfavorable (mRS ≥4) outcomes, the younger group had significantly more patients with a favorable outcome than the elderly group (57.1% versus 9.1%, p=0.033). In contrast, in the elderly group, most patients showed unfavorable outcomes with the mRS scores of 4 (n=5, 45.5%), 5 (n=3, 27.3%), or 6 (n=2, 18.2%), whereas only one patient showed favorable outcome (mRS 3). A majority of the elderly patients (45.5% with mRS 4) survived with moderately severe disability.

Conclusion

For malignant hemispheric infarction, a hemicraniectomy with maximum external decompression was found to considerably increase survival with a favorable outcome in functional independence (mRS ≤3) for younger patients aged ≤60 years. It can be optimal surgical treatment for younger patients.