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Zhang L, Ma J, Wang M, Zhang L, Sun W, Ji H, Yue C, Huang J, Zi W, Li F, Guo C, Wang P. The Association Between National Institutes of Health Stroke Scale Score and Clinical Outcome in Patients with Large Core Infarctions Undergoing Endovascular Treatment. Neurol Ther 2024; 13:563-581. [PMID: 38427274 PMCID: PMC11136902 DOI: 10.1007/s40120-024-00588-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/07/2024] [Indexed: 03/02/2024] Open
Abstract
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.
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Affiliation(s)
- Lingyu Zhang
- School of Clinical Medicine, Shandong Second Medical University, Weifang, 261000, Shandong, China
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No. 70, Heping Road, Huancui District, Weihai City, Shandong Province, China
| | - Jinfu Ma
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Mengmeng Wang
- School of Clinical Medicine, Shandong Second Medical University, Weifang, 261000, Shandong, China
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No. 70, Heping Road, Huancui District, Weihai City, Shandong Province, China
| | - Lin Zhang
- Department of Cardiology, Yantai Penglai Hospital of Traditional Chinese Medicine, Yantai, China
| | - Wenzhe Sun
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Honghong Ji
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No. 70, Heping Road, Huancui District, Weihai City, Shandong Province, China
- The Second School of Clinical Medicine of Binzhou Medical University, Yantai, Shandong, China
| | - Chengsong Yue
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Changwei Guo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China.
| | - Pengfei Wang
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No. 70, Heping Road, Huancui District, Weihai City, Shandong Province, China.
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Cao L, Ma X, Huang W, Xu G, Wang Y, Liu M, Sheng S, Mao K. An Explainable Artificial Intelligence Model to Predict Malignant Cerebral Edema after Acute Anterior Circulating Large-Hemisphere Infarction. Eur Neurol 2024; 87:54-66. [PMID: 38565087 DOI: 10.1159/000538424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 03/16/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Malignant cerebral edema (MCE) is a serious complication and the main cause of poor prognosis in patients with large-hemisphere infarction (LHI). Therefore, the rapid and accurate identification of potential patients with MCE is essential for timely therapy. This study utilized an artificial intelligence-based machine learning approach to establish an interpretable model for predicting MCE in patients with LHI. METHODS This study included 314 patients with LHI not undergoing recanalization therapy. The patients were divided into MCE and non-MCE groups, and the eXtreme Gradient Boosting (XGBoost) model was developed. A confusion matrix was used to measure the prediction performance of the XGBoost model. We also utilized the SHapley Additive exPlanations (SHAP) method to explain the XGBoost model. Decision curve and receiver operating characteristic curve analyses were performed to evaluate the net benefits of the model. RESULTS MCE was observed in 121 (38.5%) of the 314 patients with LHI. The model showed excellent predictive performance, with an area under the curve of 0.916. The SHAP method revealed the top 10 predictive variables of the MCE such as ASPECTS score, NIHSS score, CS score, APACHE II score, HbA1c, AF, NLR, PLT, GCS, and age based on their importance ranking. CONCLUSION An interpretable predictive model can increase transparency and help doctors accurately predict the occurrence of MCE in LHI patients not undergoing recanalization therapy within 48 h of onset, providing patients with better treatment strategies and enabling optimal resource allocation.
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Affiliation(s)
- Liping Cao
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xiaoming Ma
- School of Clinical Medicine, North China University of Science and Technology, Tangshan, China,
| | - Wendie Huang
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Geman Xu
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Yumei Wang
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Meng Liu
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Shiying Sheng
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Keshi Mao
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
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Guo W, Xu M, Song X, Cheng Y, Deng Y, Liu M. Association of Serum Macrophage Migration Inhibitory Factor with 3-Month Poor Outcome and Malignant Cerebral Edema in Patients with Large Hemispheric Infarction. Neurocrit Care 2024:10.1007/s12028-024-01958-8. [PMID: 38561586 DOI: 10.1007/s12028-024-01958-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/06/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND We aimed to investigate the associations of macrophage migration inhibitory factor (MIF), toll-like receptors 2 and 4 (TLR2/4), and matrix metalloproteinase 9 (MMP9) with 3-month poor outcome, death, and malignant cerebral edema (MCE) in patients with large hemispheric infarction (LHI). METHODS Patients with LHI within 24 h of onset were enrolled consecutively. Serum MIF, TLR2/4, and MMP9 concentrations on admission were measured. Poor outcome was defined as a modified Rankin Scale score of ≥ 3 at 3 months. MCE was defined as a decreased level of consciousness, anisocoria and midline shift > 5 mm or basal cistern effacement, or indications for decompressive craniectomy during hospitalization. The cutoff values for MIF/MMP9 were obtained from the receiver operating characteristic curve. RESULTS Of the 130 patients with LHI enrolled, 90 patients (69.2%) had 3-month poor outcome, and MCE occurred in 55 patients (42.3%). Patients with serum MIF concentrations ≤ 7.82 ng/mL for predicting 3-month poor outcome [adjusted odds ratio (OR) 2.827, 95% confidence interval (CI) 1.144-6.990, p = 0.024] also distinguished death (adjusted OR 4.329, 95% CI 1.841-10.178, p = 0.001). Similarly, MMP9 concentrations ≤ 46.56 ng/mL for predicting 3-month poor outcome (adjusted OR 2.814, 95% CI 1.236-6.406, p = 0.014) also distinguished 3-month death (adjusted OR 3.845, 95% CI 1.534-9.637, p = 0.004). CONCLUSIONS Lower serum MIF and MMP9 concentrations at an early stage were independently associated with 3-month poor outcomes and death in patients with LHI. These findings need further confirmation in larger sample studies.
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Affiliation(s)
- Wen Guo
- Center of Cerebrovascular Disease, Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
- The Center of Gerontology and Geriatrics, Sichuan University West China Hospital, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Mangmang Xu
- Center of Cerebrovascular Disease, Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Xindi Song
- Center of Cerebrovascular Disease, Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Yajun Cheng
- Center of Cerebrovascular Disease, Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Yilun Deng
- Center of Cerebrovascular Disease, Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Ming Liu
- Center of Cerebrovascular Disease, Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China.
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Zhao Y, Tang Y, Xie Z. Development and validation of a prognostic computed tomography scoring model for functional outcomes in patients with large hemispheric infarction following decompressive craniectomy. Front Neurol 2024; 15:1336121. [PMID: 38327622 PMCID: PMC10848326 DOI: 10.3389/fneur.2024.1336121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/10/2024] [Indexed: 02/09/2024] Open
Abstract
Background There is no established prognostic scoring system developed for patients with large hemispheric infarction (LHI) following decompressive craniectomy (DC) based on imaging characteristics. The present study aimed to develop and validate a new computed tomography scoring model to assess the 6-month risk of poor functional outcomes (modified-Rankin scale [mRS] score of 4-6) in patients with LHI receiving DC. Methods This retrospective cohort study included patients at two tertiary stroke centers. A prediction model was developed based on a multivariable logistic regression. The final risk factors included the ASPECTS (Alberta Stroke Program Early Computed Tomography Score), longitudinal fissure cistern, Sylvian fissure cistern, and additional vascular territory involvement. 1,000 bootstrap resamples and temporal validation were implemented as validations for the scoring system. Results Of the 100 individuals included in the development cohort, 71 had poor functional outcomes. The scoring model presented excellent discrimination and calibration with C-index = 0.87 for the development cohort, and C-index = 0.83 for the temporal validation cohort with non-significant Hosmer-Lemeshow goodness-of-fit test. The scoring model also showed an improved AUC compared to the ASPECTS. For each point in the score model, the adjusted risk of poor functional outcomes increase by 47.8% (OR = 1.48, p < 0.001). The scores were inversely correlated with MAP (mean arterial pressure, paired t-test, p = 0.0015) and CPP (cerebral perfusion pressure, rho = -0.17, p = 0.04). Conclusion In patients with LHI following DC, the score system is an excellent predictor of poor functional outcomes and is associated with CPP and MAP, which might be worth considering in clinical settings after further external validation.
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Affiliation(s)
| | | | - Zongyi Xie
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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Xie W, Ma X, Xu G, Wang Y, Huang W, Liu M, Sheng S, Yuan J, Wang J. Development and validation of a nomogram for the risk prediction of malignant cerebral edema after acute large hemispheric infarction involving the anterior circulation. Front Neurol 2023; 14:1221879. [PMID: 37780698 PMCID: PMC10538642 DOI: 10.3389/fneur.2023.1221879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/18/2023] [Indexed: 10/03/2023] Open
Abstract
Background Malignant cerebral edema (MCE) is a life-threatening complication of large hemisphere infarction (LHI). Therefore, a fast, accurate, and convenient tool for predicting MCE can guide triage services and facilitate shared decision-making. In this study, we aimed to develop and validate a nomogram for the early prediction of MCE risk in acute LHI involving the anterior circulation and to understand the potential mechanism of MCE. Methods This retrospective study included 312 consecutive patients with LHI from 1 January 2019 to 28 February 2023. The patients were divided into MCE and non-MCE groups. MCE was defined as an obvious mass effect with ≥5 mm midline shift or basal cistern effacement. Least absolute shrinkage and selection operator (LASSO) and logistic regression were performed to explore the MCE-associated factors, including medical records, laboratory data, computed tomography (CT) scans, and independent clinic risk factors. The independent factors were further incorporated to construct a nomogram for MCE prediction. Results Among the 312 patients with LHI, 120 developed MCE. The following eight factors were independently associated with MCE: Glasgow Coma Scale score (p = 0.007), baseline National Institutes of Health Stroke Scale score (p = 0.006), Alberta Stroke Program Early CT Score (p < 0.001), admission monocyte count (p = 0.004), white blood cell count (p = 0.002), HbA1c level (p < 0.001), history of hypertension (p = 0.027), and history of atrial fibrillation (p = 0.114). These characteristics were further used to establish a nomogram for predicting prognosis. The nomogram achieved an AUC-ROC of 0.89 (95% CI, 0.82-0.96). Conclusion Our nomogram based on LASSO-logistic regression is accurate and useful for the early prediction of MCE after LHI. This model can serve as a precise and practical tool for clinical decision-making in patients with LHI who may require aggressive therapeutic approaches.
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Affiliation(s)
- Wei Xie
- Department of Neurology, The Third Affiliated Hospital of Soochow University, The First People's Hospital of Changzhou, Changzhou, China
| | - Xiaoming Ma
- North China University of Science and Technology, Tangshan, China
| | - Geman Xu
- Department of Neurology, The Third Affiliated Hospital of Soochow University, The First People's Hospital of Changzhou, Changzhou, China
- Department of Neurology, Affiliated Fuyang People's Hospital of Anhui Medical University, Fuyang, China
| | - Yumei Wang
- Department of Neurology, The Third Affiliated Hospital of Soochow University, The First People's Hospital of Changzhou, Changzhou, China
| | - Wendie Huang
- Department of Neurology, The Third Affiliated Hospital of Soochow University, The First People's Hospital of Changzhou, Changzhou, China
| | - Meng Liu
- Department of Neurology, The Third Affiliated Hospital of Soochow University, The First People's Hospital of Changzhou, Changzhou, China
| | - Shiying Sheng
- Department of Neurology, The Third Affiliated Hospital of Soochow University, The First People's Hospital of Changzhou, Changzhou, China
| | - Jie Yuan
- Institution of Mental Health, North China University of Science and Technology, Tangshan, China
- Jitang College, North China University of Science and Technology, Tangshan, China
| | - Jing Wang
- Clinical Department, Tangshan Vocational and Technical College, Tangshan, China
- Tangshan Union Medical College Hospital, Tangshan, China
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Spreading Depolarization as a Therapeutic Target in Severe Ischemic Stroke: Physiological and Pharmacological Strategies. J Pers Med 2022; 12:jpm12091447. [PMID: 36143232 PMCID: PMC9502975 DOI: 10.3390/jpm12091447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/26/2022] [Accepted: 08/31/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Spreading depolarization (SD) occurs nearly ubiquitously in malignant hemispheric stroke (MHS) and is strongly implicated in edema progression and lesion expansion. Due to this high burden of SD after infarct, it is of great interest whether SD in MHS patients can be mitigated by physiologic or pharmacologic means and whether this intervention improves clinical outcomes. Here we describe the association between physiological variables and risk of SD in MHS patients who had undergone decompressive craniectomy and present an initial case of using ketamine to target SD in MHS. Methods: We recorded SD using subdural electrodes and time-linked with continuous physiological recordings in five subjects. We assessed physiologic variables in time bins preceding SD compared to those with no SD. Results: Using multivariable logistic regression, we found that increased ETCO2 (OR 0.772, 95% CI 0.655–0.910) and DBP (OR 0.958, 95% CI 0.941–0.991) were protective against SD, while elevated temperature (OR 2.048, 95% CI 1.442–2.909) and WBC (OR 1.113, 95% CI 1.081–1.922) were associated with increased risk of SD. In a subject with recurrent SD, ketamine at a dose of 2 mg/kg/h was found to completely inhibit SD. Conclusion: Fluctuations in physiological variables can be associated with risk of SD after MHS. Ketamine was also found to completely inhibit SD in one subject. These data suggest that use of physiological optimization strategies and/or pharmacologic therapy could inhibit SD in MHS patients, and thereby limit edema and infarct progression. Clinical trials using individualized approaches to target this novel mechanism are warranted.
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Association between Deep Medullary Veins in the Unaffected Hemisphere and Functional Outcome in Acute Cardioembolic Stroke: An Observational Retrospective Study. Brain Sci 2022; 12:brainsci12080978. [PMID: 35892419 PMCID: PMC9330894 DOI: 10.3390/brainsci12080978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/16/2022] [Accepted: 07/20/2022] [Indexed: 02/05/2023] Open
Abstract
Objective: To explore whether deep medullary veins (DMVs) in the unaffected hemisphere were associated with functional outcome in acute cardioembolic stroke patients. Methods: Acute cardioembolic stroke patients at a single center were retrospectively included. DMVs visibility in the unaffected hemisphere was assessed using a well-established four-grade scoring method based on susceptibility-weighted imaging (SWI): grades 0−3 (grade 0 for no visible DMVs; grade 1 for the numbers of conspicuous DMVs < 5; grade 2 for numbers raging from 5 to 10; grade 3 for more than 10). Patients were further divided into mild-to-moderate (grade 0−2) and severe DMVs (grade 3) groups. Functional outcomes were evaluated using the modified Rankin scale (mRS) score at three months. Poor outcome was defined as mRS ≥ 3. Binary logistic regression analysis was used to explore the association between DMVs grade and functional outcome. Results: A total of 170 patients were finally included. Compared with the mild-to-moderate DMVs group (149 patients), the severe DMVs group (21 patients) had higher baseline National Institutes of Health Stroke Scale (NIHSS) scores (p = 0.002), lower levels of admission systolic blood pressure (BP) (p = 0.031), and elevated rates of large infarction (p = 0.003). At three months, the severe DMVs group had higher mRS (p = 0.002). Patients in the poor outcome group (82/170, 48.2%) had older age, higher baseline NIHSS score, lower admission diastolic BP, higher rates of hemorrhagic transformation and large infarction, and an increased proportion of severe DMVs (all p < 0.05). After adjusting for confounders, multivariable regression analysis showed that the severe DMVs grade (adjusted odds ratio [OR] = 5.830, 95% confidence interval [CI] = 1.266−26.856, p = 0.024) was significantly associated with three-month functional outcomes without interaction with other potential risk factors (p for interaction > 0.05). Conclusions: DMVs grade in the unaffected hemisphere was independently associated with three-month functional outcome in acute cardioembolic stroke patients. Patients with severe DMVs were more likely to have a poor functional outcome at three months.
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Picard JM, Schmidt C, Sheth KN, Bösel J. Critical Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00056-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Qi Y, Xing Y, Wang L, Zhang J, Cao Y, Liu L, Chen Y. Multimodal Monitoring in Large Hemispheric Infarction: Quantitative Electroencephalography Combined With Transcranial Doppler for Prognosis Prediction. Front Neurol 2021; 12:724571. [PMID: 34956039 PMCID: PMC8693413 DOI: 10.3389/fneur.2021.724571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 11/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background: We aimed to explore whether transcranial Doppler (TCD) combined with quantitative electroencephalography (QEEG) can improve prognosis evaluation in patients with a large hemispheric infarction (LHI) and to establish an accurate prognosis prediction model. Methods: We prospectively assessed 90-day mortality in patients with LHI. Brain function was monitored using TCD-QEEG at the bedside of the patient. Results: Of the 59 (55.3 ± 10.6 years; 17 men) enrolled patients, 37 (67.3%) patients died within 90 days. The Cox regression analyses revealed that the Glasgow Coma Scale (GCS) score ≤ 8 [hazard ratio (HR), 3.228; 95% CI, 1.335–7.801; p = 0.009], TCD-terminal internal carotid artery as the offending vessel (HR, 3.830; 95% CI, 1.301–11.271; p = 0.015), and QEEG-a (delta + theta)/(alpha + beta) ratio ≥ 3 (HR, 3.647; 95% CI, 1.170–11.373; p = 0.026) independently predicted survival duration. Combining these three factors yielded an area under the receiver operating characteristic curve of 0.905 and had better predictive accuracy than those of individual variables (p < 0.05). Conclusion: TCD and QEEG complement the GCS score to create a reliable multimodal method for monitoring prognosis in patients with LHI.
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Affiliation(s)
- Yajie Qi
- Department of Neurology, The First Hospital of Jilin University, Changchun, China.,Department of Neurosurgery, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Yingqi Xing
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China
| | - Lijuan Wang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Jie Zhang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Yanting Cao
- Department of Neurology, The First Hospital of Jilin University, Changchun, China.,Department of Neurology, Linyi People's Hospital, Linyi, China
| | - Li Liu
- Department of Neurology, The First Hospital of Jilin University, Changchun, China.,Department of Neurology, Changchun People's Hospital, Changchun, China
| | - Ying Chen
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
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Abburi N, Sterenstein A, Breit H, Song S, John S, Da Silva I, Koffman L. Description of an Association Between Leukocytosis and Clinical Outcomes in Large Hemispheric Infarctions. J Stroke Cerebrovasc Dis 2021; 30:105614. [PMID: 33484981 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/15/2020] [Accepted: 01/08/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Large hemispheric infarctions (LHI) are associated with significant morbidity and mortality. Leukocytosis has been observed to directly correlate with stroke severity but has not been specifically described in the LHI population. We hypothesized that patients with LHI and leukocytosis on admission have worse clinical outcomes. METHODS Retrospective study of patients admitted to the neurosciences intensive care unit at a tertiary care center with the diagnosis of acute ischemic stroke from Jan 2012 to Dec 2018. Inclusion criteria included admission imaging with stroke size greater than two-thirds of the middle cerebral artery territory, with or without other vascular territory involvement. Patients were excluded if antibiotics were started on admission for presumed infection. White blood cell count was recorded at admission, along with Modified Rankin Scale on admission and discharge, need for mechanical ventilation, tracheostomy, and discharge disposition. Logistic regression was used for association measures. RESULTS Of the 2,318 patients that were screened, 360 met inclusion criteria. Mean age was 64, median was 63; 51.7% were female. Mean and median NIHSS were 21. Leukocytosis on admission was seen in 139 patients (38.6%), and it was associated with need for mechanical ventilation (p<0.0001, OR 2.54, [1.64-3.95]) and mortality during hospitalization (p<0.0003, OR 2.66, [1.56-4.55]). Results persisted after correction for age and sex in a logistic regression model. CONCLUSIONS Leukocytosis on admission in patients with LHI significantly correlated with mortality and need for mechanical ventilation. There was a trend towards association with poor outcome at discharge, although not statistically significant. Further research may identify how leukocytosis and other SIRS markers may be used to prognosticate outcomes in this challenging patient population.
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Affiliation(s)
- Nandini Abburi
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison St, Suite 1106, Chicago, IL 60612, United States.
| | - Andrea Sterenstein
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison St, Suite 1106, Chicago, IL 60612, United States
| | - Hannah Breit
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison St, Suite 1106, Chicago, IL 60612, United States
| | - Sarah Song
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison St, Suite 1106, Chicago, IL 60612, United States
| | - Sayona John
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison St, Suite 1106, Chicago, IL 60612, United States
| | - Ivan Da Silva
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison St, Suite 1106, Chicago, IL 60612, United States
| | - Lauren Koffman
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison St, Suite 1106, Chicago, IL 60612, United States
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Abstract
Neurological diseases frequently demanding admittance to a dedicated neurological intensive care unit (neurocritical care) comprise space-occupying ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, traumatic brain injury, status epilepticus, bacterial meningitis, myasthenic crisis and Guillain-Barré syndrome. Due to often necessary analgesia, sedation and mechanical ventilation, neuromonitoring should ideally be employed. This consists of bedside invasive and non-invasive methods for monitoring cerebral perfusion, oxygenation, metabolism and neurophysiology. Modern treatment principles in neurocritical care mainly aim at avoiding or attenuating secondary neurological brain damage, in particular directed at sufficient perfusion and oxygenation. These include measures such as neuroprotective ventilation, stabilization of the circulation, decreasing intracranial pressure in brain edema and space-occupying processes, anticonvulsive treatment, temperature management and targeted disease-specific treatment.
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Affiliation(s)
- Julian Bösel
- Klinik für Neurologie, Klinikum Kassel, Mönchebergstr. 41-43, 34125, Kassel, Deutschland.
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Algethamy HM, Samman A, Baeesa SS, Almekhlafi MA, Al Said YA, Hassan A. Decompressive hemicraniectomy for malignant middle cerebral artery infarction. Experience from the Western Province of Saudi Arabia. ACTA ACUST UNITED AC 2019; 22:192-197. [PMID: 28678213 PMCID: PMC5946363 DOI: 10.17712/nsj.2017.3.20170051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective: To describe our experience implementing decompressive hemicraniectomy (DH) for eligible patients with malignant middle cerebral artery (MCA) infarcts. Methods: We retrospectively collected data of malignant MCA infarction patients requiring DH at King Abdulaziz University Hospital & King Faisal Specialist Hospital & Research Center, Jeddah, Kingdom of Saudi Arabia between October 2010 and July 2015. Clinical outcome was assessed immediately postoperatively using Glasgow Coma Score (GCS), and at 12 months using the modified Rankin scale (mRS) and Barthel index. Survival was evaluated at thirty-days and one year after surgery. Results: Six out of 10 patients diagnosed with malignant MCA infarction underwent DH. Among the surgically treated patients (n=6), 4 were males (66%), and the median age was 22.5 years. The median time from admission to surgery was 35.5 hours. The median post-operative GCS was 6.5. Three patients (50%) died within 30 days of DH. In those who survived, the median mRS was 4.5 and BI was 7.5. Conclusion: Decompressive hemicraniectomy saves life and has the potential of improving survival functional outcome when done fast and in carefully selected patients. We call for national awareness of the management of such cases and early intervention.
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Affiliation(s)
- Haifa M Algethamy
- Department of Critical Care Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
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He D, Li Q, Xu G, Hu Z, Li X, Guo Y, Xu S, Wang W, Luo X. Clinical and imaging characteristics of PFO-related stroke with different amounts of right-to-left shunt. Brain Behav 2018; 8:e01122. [PMID: 30311435 PMCID: PMC6236234 DOI: 10.1002/brb3.1122] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 08/23/2018] [Accepted: 08/24/2018] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Right-to-left shunt (RLS) induced by a patent foramen ovale (PFO) is associated with an increased risk of cryptogenic stroke (CS). However, little is known about the relationship between the amount of RLS and the stroke pattern. In this study, we aimed to evaluate the distinct clinical features of PFO-related CS in different RLS degrees resulting from PFO. METHODS This is a cohort study of 222 CS patients admitted to the Tongji Hospital from 1st May 2014 to 31st April 2017. All patients underwent contrast transcranial Doppler examination. And then, 121 (54.5%) were classified as non-RLS group, while 76 (34.2%) were classified as mild RLS group and 25 (11.3%) were large RLS group according to the number of micro-emboli signals. The groups were compared with respect to their clinical and neuroimaging characteristics. RESULTS In terms of risk factors of stroke, the prevalence of hypertension was lower in mild group (p = 0.002). Regarding the infarct patterns in different CS patients, we found that the multiple cortical lesions were more frequently observed (p<0.001) with increasing RLS in DWI. Moreover, there was a rising trend in the proportion of small lesions (≤1 cm) with an increasing RLS (p < 0.01). And as RLS increased, the posterior circulation was more likely to be influenced (p < 0.05). In addition, the serum cholesterol concentration was lower in the large RLS group, compared to the non-RLS group (p = 0.003) and mild RLS group (p = 0.008). While the mean platelet volume (MPV) in mild group was significantly higher than that of non-RLS group (p = 0.013). CONCLUSION Patients with larger RLS show more infarction in posterior circulation, higher frequency of small lesions or multiple cortical lesions. The results of our study indicate that the infarct patterns might be a clue of PFO-related stroke.
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Affiliation(s)
- Dan He
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Qian Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,Department of Neurology, Shenzhen Shekou People's Hospital, Shenzhen, China
| | - Guangjin Xu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zheng Hu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xuefei Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yinping Guo
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shabei Xu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wei Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiang Luo
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Bösel J, Schönenberger S, Dohmen C, Jüttler E, Staykov D, Zweckberger K, Hacke W, Schwab S, Torbey MT, Huttner HB. [Intensive care therapy of space-occupying large hemispheric infarction. Summary of the NCS/DGNI guidelines]. DER NERVENARZT 2016; 86:1018-29. [PMID: 26108877 DOI: 10.1007/s00115-015-4361-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Large hemispheric infarction (LHI), synonymously called malignant middle cerebral artery (MCA) infarction, is a severe neurological disease with a high mortality and morbidity. Treating physicians as well as relatives are often faced with few and low quality data when attempting to apply optimal treatment to these patients and make decisions. While current stroke treatment guidelines focus on risk factors, prevention and acute management, they include only limited recommendations concerning intensive care management of LHI. The Neurocritical Care Society (NCS) and the German Society for Neurocritical and Emergency Medicine (DGNI) organized an interdisciplinary consensus conference on intensive care management of LHI to meet this demand. European and American experts in neurology, neurocritical care, neurosurgery, neuroradiology and neuroanesthesiology were selected based on their expertise and research focus. Subgroups for several main topics elaborated a number of central clinical questions concerning this topic and evaluated the quality of the currently available data according to the grading of recommendation assessment, development and evaluation (GRADE) guideline system. Subsequently, evidence-based recommendations were compiled after weighing the advantages against the disadvantages of certain management options. This is a commented abridged version of the results of the consensus conference.
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Affiliation(s)
- J Bösel
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland,
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