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Wang J, Xiong X, Ma Y, Yin Y, Ye J, Fu J. Higher baseline subcortical net water uptake in computed tomography predicts malignant middle cerebral artery infarction in patients with acute ischemic stroke. Clin Radiol 2024; 79:e1339-e1346. [PMID: 39198107 DOI: 10.1016/j.crad.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 07/07/2024] [Accepted: 08/01/2024] [Indexed: 09/01/2024]
Abstract
AIM The objective of this study was to assess the predictive performance of net water uptake (NWU) based on the Alberta stroke program early CT score (ASPECTS) from different ASPECT regions in relation to the development of malignant middle cerebral artery (MCA) infarction. MATERIAL AND METHODS Patients with acute ischemic stroke (AIS) of the MCA territory were retrospectively enrolled between January 2019 and July 2022. Patients were divided into two groups according to the follow-up CT after 24-48 hours: malignant and nonmalignant infarction. NWUs were measured on diverse ASPECT regions on admission non-contrast CT, namely affected ASPECTS-NWU (af-ASPECTS-NWU), subcortical ASPECTS-NWU (sc-ASPECTS-NWU), and cortical ASPECTS-NWU (c-ASPECTS-NWU). Baseline characteristics were collected for univariate analyses and multivariate regression analyses to explore the independent risk factors for malignant infarction. Receiver operating characteristic (ROC) curves were plotted and compared. RESULTS patients were included in the final analysis. Malignant MCA infarction was achieved in 42 (27.45%) patients and nonmalignant was 111 (72.55%). Compared with the nonmalignant infarction group, higher baseline National Institute of Health stroke scale (NIHSS) score, af-ASPECTS-NWU, c-ASPECTS-NWU, sc-ASPECTS-NWU, and lower ASPECTS were noted in the malignant infarction group (all P < 0.001). Multivariate logistic regression showed that only baseline sc-ASPECTS-NWU (>3.6%) was a positive factor for malignant MCA infarction. The ROC analysis indicated the highest predictive value of sc-ASPECTS-NWU for indicating malignant infarction with the area under ROC curve (AUC) 0.91. CONCLUSION Higher baseline sc-ASPECTS-NWU was a quantitative predictor for malignant MCA infarction in patients with AIS, which could be helpful for treatment decisions.
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Affiliation(s)
- J Wang
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu, China
| | - X Xiong
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu, China
| | - Y Ma
- Department of Interventional Radiology, Northern Jiangsu People's Hospital, Yangzhou 225001, Jiangsu, China
| | - Y Yin
- Department of Radiology, Northern Jiangsu People's Hospital, Yangzhou 225001, Jiangsu, China
| | - J Ye
- Department of Radiology, Northern Jiangsu People's Hospital, Yangzhou 225001, Jiangsu, China
| | - J Fu
- Department of Radiology, Northern Jiangsu People's Hospital, Yangzhou 225001, Jiangsu, China.
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Feghali J, Jackson CM. Therapeutic implications for the PD-1 axis in cerebrovascular injury. Neurotherapeutics 2024:e00459. [PMID: 39368872 DOI: 10.1016/j.neurot.2024.e00459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 09/22/2024] [Indexed: 10/07/2024] Open
Abstract
Since the discovery and characterization of the PD-1/PD-L pathway, mounting evidence has emerged regarding its role in regulating neuroinflammation following cerebrovascular injury. Classically, PD-L1 on antigen-presenting cells or tissues binds PD-1 on T cell surfaces resulting in T cell inhibition. In myeloid cells, PD-1 stimulation induces polarization of microglia and macrophages into an anti-inflammatory, restorative phenotype. The therapeutic potential of PD-1 agonism in ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage-related vasospasm, and traumatic brain injury rests on the notion of harnessing the immunomodulatory function of immune checkpoint pathways to temper the harmful effects of immune overactivation and secondary injury while promoting repair and recovery. Immune checkpoint agonism has greater specificity than the wider and non-specific anti-inflammatory effects of other agents, such as steroids. PD-1 agonism has already demonstrated success in clinical trials for rheumatoid arthritis and is being tested in other chronic inflammatory diseases. Further investigation of PD-1 agonism as a therapeutic strategy in cerebrovascular injury can help clarify the mechanisms underlying clinical benefit, develop drugs with optimal pharmacodynamic and pharmacokinetic properties, and mitigate unwanted side effects.
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Affiliation(s)
- James Feghali
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher M Jackson
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Mohamed SA, Adlung A, Ludwig NK, Samartzi M, Schad LR, Fatar M, Neumaier-Probst E. Temporal and Spatial Dynamics of Ischemic Stroke Lesions after Acute Therapy: A Comprehensive Edema Assessment Using Combined 1H- and 23Na-MRI. Cerebrovasc Dis 2024:1-11. [PMID: 39053442 DOI: 10.1159/000540162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 06/14/2024] [Indexed: 07/27/2024] Open
Abstract
INTRODUCTION Ischemic cerebral stroke initiates a complex cascade of pathophysiological events, involving various forms of molecular shifts and edema. Early intervention is pivotal in minimizing tissue loss and improving clinical outcomes. This study explores the temporal and spatial evolution of tissue sodium concentration (TSC) in acute ischemic lesions after acute therapy using 23Na-MRI in addition to conventional 1H-MRI. METHODS Prospectively, from examined 58 patients with acute ischemic stroke with a combined 1H/23Na-MRI within 72 h of symptom onset after receiving acute therapy, 31 patients were included in the evaluation of this study. After co-registration of the 23Na-MRI images to the morphological 1H-MRI images, manual segmentation of the ischemic lesions was performed, and the ADC and TSC measurements were quantified and correlated with the time of onset and lesion volume. RESULTS The mean TSC in ischemic lesions correlated positively with lesion volume (r = 0.52, p = 0.002) and showed a significant association with the time of stroke onset (r = 0.8, p < 0.001). Patients who were treated only with intravenous rtPA showed homogenous sodium signal intensity in the ischemic lesions, whereas the patients who received mechanical recanalization exhibited distinctive sodium signal intensity patterns with focal significant TSC differences. CONCLUSION The integration of 1H- and 23Na-MRI provides a nuanced understanding of temporal and spatial changes due to different types of edema in ischemic stroke lesions following acute treatment. Further exploration of these findings may enhance our understanding of stroke pathophysiology and guide personalized therapeutic interventions.
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Affiliation(s)
- Sherif A Mohamed
- Department of Neuroradiology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Anne Adlung
- Department of Computer Assisted Clinical Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, New York, USA
| | - Nadia K Ludwig
- Department of Computer Assisted Clinical Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Löwenstein Medical Technology, Karlsruhe, Germany
| | - Melina Samartzi
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany
| | - Lothar R Schad
- Department of Computer Assisted Clinical Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Marc Fatar
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Eva Neumaier-Probst
- Department of Neuroradiology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Ong CJ, Huang Q, Kim ISY, Pohlmann J, Chatzidakis S, Brush B, Zhang Y, Du Y, Malinger LA, Benjamin EJ, Dupuis J, Greer DM, Smirnakis SM, Trinquart L. Association of Dynamic Trajectories of Time-Series Data and Life-Threatening Mass Effect in Large Middle Cerebral Artery Stroke. Neurocrit Care 2024:10.1007/s12028-024-02036-9. [PMID: 38955931 DOI: 10.1007/s12028-024-02036-9] [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: 11/14/2023] [Accepted: 06/05/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Life-threatening, space-occupying mass effect due to cerebral edema and/or hemorrhagic transformation is an early complication of patients with middle cerebral artery stroke. Little is known about longitudinal trajectories of laboratory and vital signs leading up to radiographic and clinical deterioration related to this mass effect. METHODS We curated a retrospective data set of 635 patients with large middle cerebral artery stroke totaling 95,463 data points for 10 longitudinal covariates and 40 time-independent covariates. We assessed trajectories of the 10 longitudinal variables during the 72 h preceding three outcomes representative of life-threatening mass effect: midline shift ≥ 5 mm, pineal gland shift (PGS) > 4 mm, and decompressive hemicraniectomy (DHC). We used a "backward-looking" trajectory approach. Patients were aligned based on outcome occurrence time and the trajectory of each variable was assessed before that outcome by accounting for cases and noncases, adjusting for confounders. We evaluated longitudinal trajectories with Cox proportional time-dependent regression. RESULTS Of 635 patients, 49.0% were female, and the mean age was 69 years. Thirty five percent of patients had midline shift ≥ 5 mm, 24.3% of patients had PGS > 4 mm, and 10.7% of patients underwent DHC. Backward-looking trajectories showed mild increases in white blood cell count (10-11 K/UL within 72 h), temperature (up to half a degree within 24 h), and sodium levels (1-3 mEq/L within 24 h) before the three outcomes of interest. We also observed a decrease in heart rate (75-65 beats per minute) 24 h before DHC. We found a significant association between increased white blood cell count with PGS > 4 mm (hazard ratio 1.05, p value 0.007). CONCLUSIONS Longitudinal profiling adjusted for confounders demonstrated that white blood cell count, temperature, and sodium levels appear to increase before radiographic and clinical indicators of space-occupying mass effect. These findings will inform the development of multivariable dynamic risk models to aid prediction of life-threatening, space-occupying mass effect.
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Affiliation(s)
- Charlene J Ong
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, MA, 02118, USA.
- Chobanian and Avedisian School of Medicine, Boston University School of Medicine, 85 E Concord St, Boston, MA, 02118, USA.
- Department of Neurology, Brigham & Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA.
| | - Qiuxi Huang
- Department of Epidemiology, Boston University School of Public Health, 715 Albany St, Boston, MA, 02118, USA
| | - Ivy So Yeon Kim
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, MA, 02118, USA
| | - Jack Pohlmann
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, MA, 02118, USA
| | - Stefanos Chatzidakis
- Department of Neurology, Brigham & Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Benjamin Brush
- New York University Langone Hospital and NYU Grossman School of Medicine, 550 1St Ave, New York, NY, 10016, USA
| | - Yihan Zhang
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, MA, 02118, USA
| | - Yili Du
- Chobanian and Avedisian School of Medicine, Boston University School of Medicine, 85 E Concord St, Boston, MA, 02118, USA
| | - Leigh Ann Malinger
- Chobanian and Avedisian School of Medicine, Boston University School of Medicine, 85 E Concord St, Boston, MA, 02118, USA
| | - Emelia J Benjamin
- Department of Epidemiology, Boston University School of Public Health, 715 Albany St, Boston, MA, 02118, USA
- Department of Cardiology, Boston Medical Center and Boston University Chobanian and Avedisian School of Medicine, 85 E Concord St, Boston, MA, 02118, USA
| | - Josée Dupuis
- Department of Epidemiology, Boston University School of Public Health, 715 Albany St, Boston, MA, 02118, USA
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 2001 McGill College, Montreal, QC, Canada
| | - David M Greer
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, MA, 02118, USA
- Chobanian and Avedisian School of Medicine, Boston University School of Medicine, 85 E Concord St, Boston, MA, 02118, USA
| | - Stelios M Smirnakis
- Department of Neurology, Brigham & Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
- Department of Neurology, Jamaica Plain Veterans Administration Medical Center, 150 S Huntington Ave, Boston, MA, 02130, USA
| | - Ludovic Trinquart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Boston, MA, 02111, USA
- Tufts Clinical and Translational Science Institute, Tufts University, 419 Boston Ave, Medford, MA, 02155, USA
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Tang A, Ma X, Ren Y, Zhang H, Xie W, Liu M, Sheng S, Mao K. External validation and comparison of MBE, EDEMA, and modified EDEMA scores for predicting malignant cerebral EDEMA in Chinese patients with large hemispheric infarction patients without revascularization. J Clin Neurosci 2024; 122:66-72. [PMID: 38489953 DOI: 10.1016/j.jocn.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 03/02/2024] [Accepted: 03/06/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Malignant cerebral edema (MCE) is a severe condition characterized by rapid neurological deterioration and a potentially poor prognosis. Scoring systems including the malignant brain edema (MBE) score, Enhanced Detection of Edema in Malignant Anterior Circulation Stroke score (EDEMA), and modified EDEMA score, have been developed to predict MCE in patients with large hemispheric infarction (LHI). We aimed to externally validate and comparethe predictive efficacy of these scores in LHI patients within 48 h of onset and not undergoing reperfusion therapy. METHODS Demographic, clinical and radiological data were retrospectively collected from LHI patients within 48 h of onset and not receiving reperfusion therapy. Patients were divided into MCE and non-MCE group. The calibration, discrimination, and clinical practicability of the three scores were verified using Hosmer-Lemeshow goodness-of-fit test, receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA), respectively. Finally, continuous net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were applied to determine the discrimination performance of the three scores. RESULTS A total of 314 patients were included in the study, with 122 cases being MCE patients. The Hosmer-Lemeshow goodness-of-fit test showed excellent fitting ability across the MBE (p = 0.36), EDEMA (p = 0.61), and modified EDEMA scores (p = 0.62) in our patients. The MBE, EDEMA, and modified EDEMA scores had the AUCs of 0.855 (95 % CI 0.818-0.898), 0.782 (95 % CI 0.727-0.837) and 0.878 (95 % CI 0.844-0.919) respectively. The MBE (NRI, 0.33; 95 % CI, 0.11-0.56, p = 0.003 and IDI, 0.11; 95 % CI, 0.03-0.18; p = 0.004) and modified EDEMA scores (NRI, 1.10; 95 % CI, 0.94-1.26; p < 0.001 and IDI, 0.17; 95 % CI, 0.13-0.20, p < 0.001) showed better performance than the EDEMA score. DCA demonstrated that the modified EDEMA score outperformed the other two scores, possessing heightened clinical usefulness. CONCLUSIONS The MBE, EDEMA, and modified EDEMA scores for predicting MCE are also applicable in non-revascularization LHI patients within 48 h of onset. Both the MBE and modified EDEMA scores demonstrated higher predictive validity as predictive tools for MCE in LHI patients than the EDEMA score. Furthermore, the modified EDEMA score could be a suitable prediction tool in Chinese patients for its excellent clinical utility.
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Affiliation(s)
- Anqi Tang
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xiaoming Ma
- North China University of Science and Technology, Tangshan, China
| | - Yi Ren
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Hao Zhang
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Wei Xie
- 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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Kim JE, Lee RP, Yazigi E, Atta L, Feghali J, Pant A, Jain A, Levitan I, Kim E, Patel K, Kannapadi N, Shah P, Bibic A, Hou Z, Caplan JM, Gonzalez LF, Huang J, Xu R, Fan J, Tyler B, Brem H, Boussiotis VA, Jantzie L, Robinson S, Koehler RC, Lim M, Tamargo RJ, Jackson CM. Soluble PD-L1 reprograms blood monocytes to prevent cerebral edema and facilitate recovery after ischemic stroke. Brain Behav Immun 2024; 116:160-174. [PMID: 38070624 PMCID: PMC11220828 DOI: 10.1016/j.bbi.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/20/2023] [Accepted: 12/04/2023] [Indexed: 01/21/2024] Open
Abstract
Acute cerebral ischemia triggers a profound inflammatory response. While macrophages polarized to an M2-like phenotype clear debris and facilitate tissue repair, aberrant or prolonged macrophage activation is counterproductive to recovery. The inhibitory immune checkpoint Programmed Cell Death Protein 1 (PD-1) is upregulated on macrophage precursors (monocytes) in the blood after acute cerebrovascular injury. To investigate the therapeutic potential of PD-1 activation, we immunophenotyped circulating monocytes from patients and found that PD-1 expression was upregulated in the acute period after stroke. Murine studies using a temporary middle cerebral artery (MCA) occlusion (MCAO) model showed that intraperitoneal administration of soluble Programmed Death Ligand-1 (sPD-L1) significantly decreased brain edema and improved overall survival. Mice receiving sPD-L1 also had higher performance scores short-term, and more closely resembled sham animals on assessments of long-term functional recovery. These clinical and radiographic benefits were abrogated in global and myeloid-specific PD-1 knockout animals, confirming PD-1+ monocytes as the therapeutic target of sPD-L1. Single-cell RNA sequencing revealed that treatment skewed monocyte maturation to a non-classical Ly6Clo, CD43hi, PD-L1+ phenotype. These data support peripheral activation of PD-1 on inflammatory monocytes as a therapeutic strategy to treat neuroinflammation after acute ischemic stroke.
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Affiliation(s)
- Jennifer E Kim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Ryan P Lee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Eli Yazigi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Lyla Atta
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, the United States of America; Center for Computational Biology, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, the United States of America; Medical Scientist Training Program, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Ayush Pant
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America; Medical Scientist Training Program, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Aanchal Jain
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Idan Levitan
- Department of Neurosurgery, Rabin Medical Center, Sackler Medical School, Petah Tikva, Israel
| | - Eileen Kim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Kisha Patel
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Nivedha Kannapadi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Pavan Shah
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Adnan Bibic
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, the United States of America; The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Zhipeng Hou
- Department of Radiology, School of Medicine, Johns Hopkins University, Baltimore, MD, the United States of America
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - L Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Jean Fan
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, the United States of America
| | - Betty Tyler
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Henry Brem
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Vassiliki A Boussiotis
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, the United States of America
| | - Lauren Jantzie
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America; Departments of Pediatrics, Johns Hopkins University School of Medicine, Maryland, the United States of America; Kennedy Krieger Institute, Maryland, the United States of America; Department of Neurology, Johns Hopkins University School of Medicine, Maryland, the United States of America
| | - Shenandoah Robinson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America; Departments of Pediatrics, Johns Hopkins University School of Medicine, Maryland, the United States of America; Kennedy Krieger Institute, Maryland, the United States of America; Department of Neurology, Johns Hopkins University School of Medicine, Maryland, the United States of America
| | - Raymond C Koehler
- Departments of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, the United States of America
| | - Michael Lim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, the United States of America
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America.
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Cappellari M, Pracucci G, Saia V, Sallustio F, Casetta I, Fainardi E, Capasso F, Nencini P, Vallone S, Bigliardi G, Saletti A, De Vito A, Ruggiero M, Longoni M, Semeraro V, Boero G, Silvagni U, Stancati F, Lafe E, Mazzacane F, Bracco S, Tassi R, Comelli S, Melis M, Romano D, Napoletano R, Menozzi R, Scoditti U, Chiumarulo L, Petruzzellis M, Vinci SL, Ferraù L, Taglialatela F, Zini A, Sanna A, Tassinari T, Iacobucci M, Nicolini E, Bergui M, Cerrato P, Giorgianni A, Princiotta Cariddi L, Amistà P, Russo M, Gallesio I, Sepe F, Comai A, Franchini E, Filauri P, Orlandi B, Besana M, Giossi A, Lazzarotti GA, Orlandi G, Castellano D, Naldi A, Plebani M, Zivelonghi C, Invernizzi P, Mangiafico S, Toni D. Predictors for hemorrhagic transformation and cerebral edema in stroke patients with first-pass complete recanalization. Int J Stroke 2023; 18:1238-1246. [PMID: 37337362 DOI: 10.1177/17474930231185690] [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] [Indexed: 06/21/2023]
Abstract
BACKGROUND Predictors of radiological complications attributable to reperfusion injury remain unknown when baseline setting is optimal for endovascular treatment and procedural setting is the best in stroke patients with large vessel occlusion (LVO). AIMS To identify clinical and radiological/procedural predictors for hemorrhagic transformation (HT) and cerebral edema (CED) at 24 hr in patients obtaining complete recanalization in one pass of thrombectomy for ischemic stroke ⩽ 6 h from symptom onset with intra-cranial anterior circulation LVO and ASPECTS ⩾ 6. METHODS We conducted a cohort study on prospectively collected data from 1400 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. RESULTS HT was reported in 248 (18%) patients and early CED was reported in 260 (19.2%) patients. In the logistic regression model including predictors from a first model with clinical variables and from a second model with radiological/procedural variables, diabetes mellitus (odds ratio (OR) = 1.832, 95% confidence interval (CI) = 1.201-2.795), higher National Institutes of Health Stroke Scale (NIHSS) (OR = 1.076, 95% CI = 1.044-1.110), lower Alberta Stroke Program Early CT (ASPECTS) (OR = 0.815, 95% CI = 0.694-0.957), and longer onset-to-groin time (OR = 1.005, 95% CI = 1.002-1.007) were predictors of HT, whereas general anesthesia was inversely associated with HT (OR = 0.540, 95% CI = 0.355-0.820). Higher NIHSS (OR = 1.049, 95% CI = 1.021-1.077), lower ASPECTS (OR = 0.700, 95% CI = 0.613-0.801), intravenous thrombolysis (OR = 1.464, 95% CI = 1.061-2.020), longer onset-to-groin time (OR = 1.002, 95% CI = 1.001-1.005), and longer procedure time (OR = 1.009, 95% CI = 1.004-1.015) were predictors of early CED. After repeating a fourth logistic regression model including also good collaterals, the same variables remained predictors for HT and/or early CED, except diabetes mellitus and thrombolysis, while good collaterals were inversely associated with early CED (OR = 0.385, 95% CI = 0.248-0.599). CONCLUSIONS Higher NIHSS, lower ASPECTS, and longer onset-to-groin time were predictors for both HT and early CED. General anesthesia and good collaterals were inversely associated with HT and early CED, respectively. Longer procedure time was predictor of early CED.
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Affiliation(s)
- Manuel Cappellari
- Stroke Unit, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Elvis Lafe
- Policlinico IRCCS San Matteo, Pavia, Italy
| | | | - Sandra Bracco
- Ospedale S. Maria delle Scotte-University Hospital, Siena, Italy
| | - Rossana Tassi
- Ospedale S. Maria delle Scotte-University Hospital, Siena, Italy
| | | | | | - Daniele Romano
- AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | | | | | | | | | | | | | | | | | - Andrea Zini
- IRCCS Istituto di Scienze Neurologiche di Bologna, Bologna, Italy
| | | | | | | | | | - Mauro Bergui
- Città della Salute e della Scienza-Molinette, Torino, Italy
| | - Paolo Cerrato
- Città della Salute e della Scienza-Molinette, Torino, Italy
| | - Andrea Giorgianni
- ASST Sette Laghi Varese-Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | | | | | - Monia Russo
- Ospedale S. Maria Misericordia, Rovigo, Italy
| | - Ivan Gallesio
- AO SS Antonio e Biagio e C. Arrigo, Alessandria, Italy
| | - Federica Sepe
- AO SS Antonio e Biagio e C. Arrigo, Alessandria, Italy
| | | | | | | | | | | | | | | | | | | | | | - Mauro Plebani
- Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | | | | | - Salvatore Mangiafico
- Sapienza University of Rome, Rome, Italy
- IRCCS Neuromed, Pozzilli, Italy
- Tor Vergata University, Rome, Italy
- S. Andrea Hospital, Rome, Italy
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Ong C, Huang Q, Kim I, Pohlmann J, Chatzidakis S, Brush B, Zhang Y, Du Y, Mallinger LA, Benjamin EJ, Dupuis J, Greer D, Smirnakis S, Trinquart L. Dynamic trajectories of life-threatening mass effect in patients with large middle cerebral artery stroke. RESEARCH SQUARE 2023:rs.3.rs-3594179. [PMID: 38045289 PMCID: PMC10690305 DOI: 10.21203/rs.3.rs-3594179/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Background Life-threatening, space-occupying mass effect due to cerebral edema and/or hemorrhagic transformation is an early complication of patients with middle cerebral artery (MCA) stroke. Little is known about longitudinal trajectories of laboratory and vital signs leading up to radiographic and clinical deterioration related to this mass effect. Methods We curated a granular retrospective dataset of 635 patients with large middle cerebral artery (MCA) stroke totaling 108,547 data points for repeated measurements of 10 covariates, and 40 time-independent covariates. We assessed longitudinal trajectories of the 10 longitudinal variables during the 72 hours preceding three outcomes representative of life-threatening mass effect: midline shift (MLS) ≥5mm, pineal gland shift (PGS) >4mm, and decompressive hemicraniectomy (DHC). We used a "backward looking" trajectory approach. Patients were aligned according to the time of outcome occurrence and the trajectory of each variable was assessed prior to that outcome by accounting for both cases and non-cases. Results Of 635 patients, 49% were female, and mean age was 69 years. Thirty five percent of patients had MLS ≥ 5mm, 24.1% had PGS >4mm, and DHC occurred in 10.7%. For the three outcomes of interest, backward-looking trajectories showed mild increases in white blood cell count (10 up to 11 K/UL within 72 hours), temperature (up to half a degree within 24 hours), and sodium (1-3 mEq/L within 24 hours) leading up to outcomes. We also observed a decrease in heart rate (75 - 65 beats per minute) 24 hours prior to DHC. Conclusions Univariable longitudinal profiling showed that temperature, white blood cell count, and sodium increase prior to radiographic and clinical indicators of space-occupying mass effect. These findings will inform development of multivariable dynamic risk models to aid prediction of life-threatening space-occupying mass effect.
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Affiliation(s)
| | | | | | | | | | | | | | - Yili Du
- Boston University School of Medicine: Boston University Chobanian & Avedisian School of Medicine
| | - Leigh Ann Mallinger
- Boston University School of Medicine: Boston University Chobanian & Avedisian School of Medicine
| | - Emelia J Benjamin
- Boston University School of Medicine: Boston University Chobanian & Avedisian School of Medicine
| | | | - David Greer
- Boston University School of Medicine: Boston University Chobanian & Avedisian School of Medicine
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9
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Migdady I, Johnson-Black PH, Leslie-Mazwi T, Malhotra R. Current and Emerging Endovascular and Neurocritical Care Management Strategies in Large-Core Ischemic Stroke. J Clin Med 2023; 12:6641. [PMID: 37892779 PMCID: PMC10607145 DOI: 10.3390/jcm12206641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
The volume of infarcted tissue in patients with ischemic stroke is consistently associated with increased morbidity and mortality. Initial studies of endovascular thrombectomy for large-vessel occlusion excluded patients with established large-core infarcts, even when large volumes of salvageable brain tissue were present, due to the high risk of hemorrhagic transformation and reperfusion injury. However, recent retrospective and prospective studies have shown improved outcomes with endovascular thrombectomy, and several clinical trials were recently published to evaluate the efficacy of endovascular management of patients presenting with large-core infarcts. With or without thrombectomy, patients with large-core infarcts remain at high risk of in-hospital complications such as hemorrhagic transformation, malignant cerebral edema, seizures, and others. Expert neurocritical care management is necessary to optimize blood pressure control, mitigate secondary brain injury, manage cerebral edema and elevated intracranial pressure, and implement various neuroprotective measures. Herein, we present an overview of the current and emerging evidence pertaining to endovascular treatment for large-core infarcts, recent advances in neurocritical care strategies, and their impact on optimizing patient outcomes.
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Affiliation(s)
- Ibrahim Migdady
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Phoebe H. Johnson-Black
- Department of Neurosurgery, Division of Neurocritical Care, UCLA David Geffen School of Medicine, Ronald Reagan Medical Center, Los Angeles, CA 90095, USA;
| | | | - Rishi Malhotra
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
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10
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Guimarães de Almeida Barros A, Roquim E Silva L, Pessoa A, Eiras Falcão A, Viana Magno LA, Valadão Freitas Rosa D, Aurelio Romano Silva M, Marques de Miranda D, Nicolato R. Use of biomarkers for predicting a malignant course in acute ischemic stroke: an observational case-control study. Sci Rep 2023; 13:16097. [PMID: 37752283 PMCID: PMC10522689 DOI: 10.1038/s41598-023-43408-z] [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: 05/18/2023] [Accepted: 09/23/2023] [Indexed: 09/28/2023] Open
Abstract
Acute ischemic stroke is a sudden neurological event caused by brain ischemia. Patients with large vessel occlusion are at high risk of developing significant cerebral edema, which can lead to rapid neurological decline. The optimal timing for decompressive hemicraniectomy to prevent further brain damage is still uncertain. This study aimed to identify potential predictors of severe brain edema. The data indicate that specific cytokines may help identify patients with a higher risk of developing life-threatening brain swelling in the early phase post-stroke. The association between a positive biomarker and the outcome was calculated, and three biomarkers-S100B protein, MMP-9, and IL-10-were found to be significantly associated with malignant edema. A model was derived for early predicting malignant cerebral edema, including S100B protein and IL-1 beta. These findings suggest that molecular biomarkers related to the ischemic cascade may be a helpful way of predicting the development of malignant cerebral edema in ischemic stroke patients, potentially widening the time window for intervention and assisting in decision-making. In conclusion, this study provides insights into the molecular mechanisms of severe brain edema and highlights the potential use of biomarkers in predicting the course of ischemic stroke.
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Affiliation(s)
| | - Lucas Roquim E Silva
- Medical School of Universidade Federal de Minas Gerais, Prof. Alfredo Balena Avenue, 190, Belo Horizonte, 30130-100, Brazil
| | - Alberlúcio Pessoa
- Medical School of Universidade Federal de Minas Gerais, Prof. Alfredo Balena Avenue, 190, Belo Horizonte, 30130-100, Brazil
| | - Antonio Eiras Falcão
- Medical School of Universidade Estadual de Campinas, R. Vital Brasil, 251, Cidade Universitária, Campinas, 13083-888, Brazil
| | - Luiz Alexandre Viana Magno
- Medical School of Universidade Federal de Minas Gerais, Prof. Alfredo Balena Avenue, 190, Belo Horizonte, 30130-100, Brazil
| | - Daniela Valadão Freitas Rosa
- Medical School of Universidade Federal de Minas Gerais, Prof. Alfredo Balena Avenue, 190, Belo Horizonte, 30130-100, Brazil
| | - Marco Aurelio Romano Silva
- Medical School of Universidade Federal de Minas Gerais, Prof. Alfredo Balena Avenue, 190, Belo Horizonte, 30130-100, Brazil
| | - Debora Marques de Miranda
- Medical School of Universidade Federal de Minas Gerais, Prof. Alfredo Balena Avenue, 190, Belo Horizonte, 30130-100, Brazil
| | - Rodrigo Nicolato
- Medical School of Universidade Federal de Minas Gerais, Prof. Alfredo Balena Avenue, 190, Belo Horizonte, 30130-100, Brazil
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11
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He Y, Zuo M, Huang J, Jiang Y, Zhou L, Li G, Chen L, Liu Q, Liang D, Wang Y, Wang L, Zhou Z. A Novel Nomogram for Predicting Malignant Cerebral Edema After Endovascular Thrombectomy in Acute Ischemic Stroke: A Retrospective Cohort Study. World Neurosurg 2023; 173:e548-e558. [PMID: 36842531 DOI: 10.1016/j.wneu.2023.02.091] [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: 02/13/2023] [Accepted: 02/20/2023] [Indexed: 02/28/2023]
Abstract
BACKGROUND Malignant cerebral edema (MCE) is a common and feared complication after endovascular thrombectomy (EVT) in acute ischemic stroke (AIS). This study aimed to establish a nomogram to predict MCE in anterior circulation large vessel occlusion stroke (LVOS) patients receiving EVT in order to guide the postoperative medical care in the acute phase. METHODS In this retrospective cohort study, 381 patients with anterior circulation LVOS receiving EVT were screened from 636 hospitalized patients with LVOS at 2 stroke medical centers. Clinical baseline data and imaging data were collected within 2-5 days of admission to the hospital. The patients were divided into 2 groups based on whether MCE occurred after EVT. Multivariate logistic regression analysis was used to evaluate the independent risk factors for MCE and to establish a nomogram. RESULTS Sixty-six patients out of 381 (17.32%) developed MCE. The independent risk factors for MCE included admission National Institutes of Health Stroke Scale (NIHSS) ≥16 (odds ratio [OR] 1.851; 95% CI 1.029-3.329; P = 0.038), ASPECT score (OR 0.621; 95% CI 0.519-0.744; P < 0.001), right hemisphere (OR 1.636; 95% CI 0.941-2.843; P = 0.079), collateral circulation (OR 0.155; 95% CI 0.074-0.324; P < 0.001), recanalization (OR 0.223; 95% CI 0.109-0.457; P < 0.001), hematocrit (OR, 0.937; 95% CI: 0.892-0.985; P =0.010), and glucose (OR 1.118; 95% CI 1.023-1.223; P = 0.036), which were adopted as parameters of the nomogram. The receiver operating characteristic curve analysis showed that the area under the curve of the nomogram in predicting MCE was 0.901(95% CI 0.848-0.940; P < 0.001). The Hosmer-Lemeshow test results were not significant (P = 0.685), demonstrating a good calibration of the nomogram. CONCLUSIONS The novel nomogram composed of admission NIHSS, ASPECT scores, right hemisphere, collateral circulation, recanalization, hematocrit, and serum glucose provide a potential predictor for MCE in patients with AIS after EVT.
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Affiliation(s)
- Yuxuan He
- Department of Neurology, School of Medicine, Chongqing University, Chongqing, China; Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Meng Zuo
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jialu Huang
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Ying Jiang
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Linke Zhou
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Guangjian Li
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Lin Chen
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Qu Liu
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Dingwen Liang
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yu Wang
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Li Wang
- Department of Neurology, Zigong Third People's Hospital, Zigong, Sichuang, China
| | - Zhenhua Zhou
- Department of Neurology, School of Medicine, Chongqing University, Chongqing, China; Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.
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12
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Shao Y, Chen X, Wang H, Shang Y, Xu J, Zhang J, Wang P, Geng Y. Large mismatch profile predicts rapidly progressing brain edema in acute anterior circulation large vessel occlusion patients undergoing endovascular thrombectomy. Front Neurol 2023; 13:982911. [PMID: 36686510 PMCID: PMC9846046 DOI: 10.3389/fneur.2022.982911] [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: 06/30/2022] [Accepted: 12/05/2022] [Indexed: 01/05/2023] Open
Abstract
Background Brain edema is a severe complication in patients with large vessel occlusion (LVO) that can reduce the effectiveness of endovascular therapy (EVT). This study aimed to investigate the association of the perfusion profile at baseline computed tomography (CT) perfusion with rapidly progressing brain edema (RPBE) after EVT in patients with acute anterior LVO. Methods We retrospectively reviewed consecutive data collected from 149 patients with anterior LVO who underwent EVT at our center. Brain edema was measured by the swelling score (0-6 score), and RPBE was defined as the swelling score increased by more than 2 scores within 24 h after EVT. We investigated the effect of RPBE on poor outcomes [National Institute of Health Stroke Scale (NIHSS) score and modified Rankin scale (mRS) score at discharge, the occurrence of hemorrhagic transformation, and mortality rate in the hospital] using the Mann-Whitney U-test and chi-square test. A multivariate logistic regression model was used to assess the relationship between perfusion imaging parameters and RPBE occurrence. Results Overall, 39 patients (26.2%) experienced RPBE after EVT. At discharge, RPBE was associated with higher NIHSS scores (Z = 3.52, 95% CI 2.0-12.0, P < 0.001) and higher mRS scores (Z = 3.67, 95% CI 0.0-1.0, P < 0.001) including the more frequent occurrence of hemorrhagic transformation (χ2 = 22.17, 95% CI 0.29-0.59, P < 0.001) and higher mortality rates in hospital (χ2 = 9.54, 95% CI 0.06-0.36, P = 0.002). Univariate analysis showed that intravenous thrombolysis, baseline ischemic core volume, and baseline mismatch ratio correlated with RPBE (all P < 0.05). After dividing the mismatch ratio into quartiles and performing a chi-square test between quartiles, we found that the occurrence of RPBE in Q4 (mismatch ratio > 11.3) was significantly lower than that in Q1 (mismatch ratio ≤ 3.0) (P < 0.05). The result of multivariate logistic regression analysis showed that compared with baseline mismatch ratio <5.1, baseline mismatch ratio between 5.1 and 11.3 (OR:3.85, 95% CI 1.06-14.29, P = 0.040), and mismatch ratio >11.3 (OR:5.26, 95% CI 1.28-20.00, P = 0.021) were independent protective factors for RPBE. Conclusion In patients with anterior circulation LVO stroke undergoing successful EVT, a large mismatch ratio at baseline is a protective factor for RPBE, which is associated with poor outcomes.
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Affiliation(s)
- Yanqi Shao
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xinyi Chen
- Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Huiyuan Wang
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,Department of Clinical Medicine, Bengbu Medical College, Bengbu, China
| | - Yafei Shang
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,Department of Clinical Medicine, Bengbu Medical College, Bengbu, China
| | - Jie Xu
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jinshi Zhang
- Department of Nephrology, Urology and Nephrology Center, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Peng Wang
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yu Geng
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,*Correspondence: Yu Geng ✉
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13
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Escudero-Martínez I, Thorén M, Ringleb P, Nunes AP, Cappellari M, Rand VM, Sobolewski P, Egido J, Toni D, Chen SY, Tsao N, Ahmed N. Cerebral Edema in Patients with severe Hemispheric Syndrome: Incidence, Risk Factors, and Outcomes-Data from SITS-ISTR. J Stroke 2023; 25:101-110. [PMID: 36470246 PMCID: PMC9911855 DOI: 10.5853/jos.2022.01956] [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: 06/14/2022] [Accepted: 08/11/2022] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Irene Escudero-Martínez
- Department of Neurology, University Hospital La FE, Valencia, Spain,Neurovascular Research Laboratory, Biomedicine Institute IBiS, Sevilla, Spain,Correspondence: IreneEscudero-Martínez Stroke Unit, Department of Neurology, University Hospital La Fe, Av. Fernando Abril 106, 46026, Valencia, Spain Tel: +34-96-124-4000 Fax: +34-96-124-6241 E-mail:
| | - Magnus Thorén
- Department of Neurology, Danderyd Hospital, Stockholm, Sweden,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Peter Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ana Paiva Nunes
- Department of Neurology, Sao Jose Hospital, University Hospital Lisboa, Lisboa, Portugal
| | - Manuel Cappellari
- Department of Neuroscience, Integrate University Hospital, Verona, Italy
| | - Viiu-Marika Rand
- Department of Neurology, North Estonia Medical Centre Foundation, Tallinn, Estonia
| | - Piotr Sobolewski
- Department of Neurology and Stroke Unit in Sandomierz, Collegium Medicum, Jan Kochanowski University in Kielce, Kielce, Poland
| | - Jose Egido
- Stroke Unit, Department of Neurology, San Carlos Clinic Hospital, Madrid, Spain
| | - Danilo Toni
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | | | | | - Niaz Ahmed
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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14
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Honegger T, Schweizer J, Bicvic A, Westphal LP, Schütz V, Inauen C, Pokorny T, Bracher K, Arnold M, Fischer U, Bonati LH, De Marchis GM, Nedeltchev K, Kahles T, Cereda C, Kägi G, Montaner J, Bustamante A, Palà E, Ntaios G, Foerch C, Luft A, Spanaus K, Saleh L, von Eckardstein A, Arnold M, Katan M. Serum S-100B adds incremental value for the prediction of symptomatic intracranial hemorrhage and brain edema after acute ischemic stroke. Eur Stroke J 2022; 8:309-319. [PMID: 37021149 PMCID: PMC10068408 DOI: 10.1177/23969873221145391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Early identification of patients developing symptomatic intracranial hemorrhage and symptomatic brain edema after acute ischemic stroke is essential for clinical decision-making. Astroglial protein S-100B is a marker of blood-brain barrier disruption, which plays an important role in the formation of intracranial hemorrhage and brain edema. In this study, we assessed the prognostic value of serum S-100B for the development of these complications. Methods: Serum S-100B levels were measured within 24 h from symptom onset in 1749 consecutive acute ischemic stroke patients from the prospective, observational, multicenter BIOSIGNAL cohort study (mean age 72.0 years, 58.3% male). To determine symptomatic intracranial hemorrhage or symptomatic brain edema, follow-up neuroimaging was performed in all patients receiving reperfusion therapy or experiencing clinical worsening with an NIHSS increase of ⩾4. Results: Forty six patients (2.6%) developed symptomatic intracranial hemorrhage and 90 patients (5.2%) developed symptomatic brain edema. After adjustment for established risk factors, log10S-100B levels remained independently associated with both symptomatic intracranial hemorrhage (OR 3.41, 95% CI 1.7–6.9, p = 0.001) and symptomatic brain edema (OR 4.08, 95% CI 2.3–7.1, p < 0.001) in multivariable logistic regression models. Adding S-100B to the clinical prediction model increased the AUC from 0.72 to 0.75 ( p = 0.001) for symptomatic intracranial hemorrhage and from 0.78 to 0.81 ( p < 0.0001) for symptomatic brain edema. Conclusions: Serum S-100B levels measured within 24 h after symptom onset are independently associated with the development of symptomatic intracranial hemorrhage and symptomatic brain edema in acute ischemic stroke patients. Thus, S-100B may be useful for early risk-stratification regarding stroke complications.
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Affiliation(s)
- Tim Honegger
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Juliane Schweizer
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Antonela Bicvic
- Department of Neurology, Inselspital University of Berne, Switzerland
| | - Laura P Westphal
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Valerie Schütz
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Corinne Inauen
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Pokorny
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Katja Bracher
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital University of Berne, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital University of Berne, Switzerland
- Department of Neurology and Stroke Center, University Hospital Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel, Switzerland
| | | | | | - Timo Kahles
- Department of Neurology, Kantonsspital Aarau, Switzerland
| | - Carlo Cereda
- Stroke Center, Neurocenter of Southern Switzerland (NSI), Ospedale Regionale di Lugano, Switzerland
| | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, Switzerland
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d’Hebron Institute of Research (VHIR) Barcelona
- Institute de Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville
- Department of Neurology, Hospital Universitario Virgen Macarena, Seville
| | - Alejandro Bustamante
- Stroke Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Elena Palà
- Neurovascular Research Laboratory, Vall d’Hebron Institute of Research (VHIR)-Universitat Autònoma de Barcelona, Barcelona, Spain
| | - George Ntaios
- Department of Internal Medicine, University of Thessaly, Larissa, Greece
| | | | - Andreas Luft
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Katharina Spanaus
- Institute of Clinical Chemistry, University Hospital Zurich, Switzerland
| | - Lanja Saleh
- Institute of Clinical Chemistry, University Hospital Zurich, Switzerland
| | | | - Markus Arnold
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Mira Katan
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Department of Neurology and Stroke Center, University Hospital Basel, Switzerland
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15
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Wu MN, Fang PT, Yang IH, Hsu CY, Lai CL, Liou LM. Association between proteinuria and the development of malignant middle cerebral artery infarction: A retrospective cohort study. Medicine (Baltimore) 2022; 101:e30389. [PMID: 36123945 PMCID: PMC9478230 DOI: 10.1097/md.0000000000030389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A disrupted blood-brain barrier (BBB) with extravasation of macromolecules plays a critical role in the development of malignant middle cerebral artery infarction (MMI). Proteinuria is considered a marker of generalized endothelial dysfunction, including BBB disruption. This study aimed to clarify whether proteinuria identified in the acute stage of stroke is associated with MMI development. Patients with infarctions involving the middle cerebral artery territory were reviewed. Urine samples collected within 8 hours after stroke were analyzed using urine dipsticks. Patients were divided into proteinuria (urine dipstick reading of 1 + to 4+) and nonproteinuria groups. MMI was present if either signs of uncal herniation or a progressive conscious disturbance were recorded along with a midline shift > 5 mm identified on follow-up computed tomography (CT). Among the 1261 patients identified between January 2010 and June 2019, 138 were eligible for final analyses. Patients in the MMI group had lower Alberta Stroke Program Early CT Scores (ASPECTS), higher National Institutes of Health Stroke Scale scores, and a greater proportion of proteinuria than those in the non-MMI group. Four multivariate logistic regression models were used to clarify the role of proteinuria in MMI development. In model 1, proteinuria was significantly associated with MMI after adjusting for age, sex, dyslipidemia and ASPECTS (OR = 2.987, 95% CI = 1.329-6.716, P = .0081). The risk of developing MMI in patients with proteinuria remained significant in model 2 (OR = 3.066, 95% CI = 1.349-6.968, P = .0075) after adjusting for estimated glomerular filtrate rate (eGFR) < 60ml/min/1.73 m2 in addition to variables in model 1. In model 3, proteinuria was still significantly associated with MMI after adjusting for age, sex, dyslipidemia, ASPECTS, hypertension, diabetes, and atrial fibrillation (OR = 2.521, 95% CI = 1.075-5.912, P = .0335). In model 4, the risk of developing MMI in patients with proteinuria remained significant (OR = 2.579, 95% CI = 1.094-6.079, P = .0304) after adjusting for eGFR < 60ml/min/1.73 m2 in addition to variables in model 3. Proteinuria is independently associated with MMI development. Proteinuria may be a clinically accessible predictor of MMI development.
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Affiliation(s)
- Meng-Ni Wu
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Pen-Tzu Fang
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - I-Hsiao Yang
- Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chung-Yao Hsu
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chiou-Lian Lai
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Li-Min Liou
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- *Correspondence: Li-Min Liou, No.100, Tzyou 1st Road, Kaohsiung city 80754, Taiwan (e-mail: )
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Lim JX, Liu SJ, Cheong TM, Saffari SE, Han JX, Chen MW. Intracranial Pressure as an Objective Biomarker of Decompression Adequacy in Large Territory Infarction: A Multicenter Observational Study. Front Surg 2022; 9:823899. [PMID: 35769152 PMCID: PMC9235838 DOI: 10.3389/fsurg.2022.823899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 04/06/2022] [Indexed: 12/21/2022] Open
Abstract
Background Decompressive craniectomy (DC) improves the survival and functional outcomes in patients with malignant cerebral infarction. Currently, there are no objective intraoperative markers that indicates adequate decompression. We hypothesise that closure intracranial pressure (ICP) correlates with postoperative outcomes. Methods This is a multicentre retrospective review of all 75 DCs performed for malignant cerebral infarction. The patients were divided into inadequate ICP (iICP) and good ICP (gICP) groups based on a suitable ICP threshold determined with tiered receiver operating characteristic and association analysis. Multivariable logistic regression was performed for various postoperative outcomes. Results An ICP threshold of 7 mmHg was determined, with 36 patients (48.0%) and 39 patients (52.0%) in the iICP and gICP group, respectively. After adjustment, postoperative osmotherapy usage was more likely in the iICP group (OR 6.32, p = 0.003), and when given, was given for a longer median duration (iICP, 4 days; gICP, 1 day, p = 0.003). There was no difference in complications amongst both groups. When an ICP threshold of 11 mmHg was applied, there was significant difference in the duration on ventilator (ICP ≥11 mmHg, 3–9 days, ICP <11 mmHg, 3–5 days, p = 0.023). Conclusion Surgical decompression works complementarily with postoperative medical therapy to manage progressive cerebral edema in malignant cerebral infarctions. This is a retrospective study which showed that closure ICP, a novel objective intraoperative biomarker, is able to guide the adequacy of DC in this condition. Various surgical manoeuvres can be performed to ensure that this surgical aim is accomplished.
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Affiliation(s)
- Jia Xu Lim
- National Neuroscience Institute, Department of Neurosurgery, Singhealth, Singapore, Singapore
- Correspondence: Jia Xu Lim
| | - Sherry Jiani Liu
- National Neuroscience Institute, Department of Neurosurgery, Singhealth, Singapore, Singapore
| | - Tien Meng Cheong
- National Neuroscience Institute, Department of Neurosurgery, Singhealth, Singapore, Singapore
| | - Seyed Ehsan Saffari
- Center for Qualitative Medicine, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Julian Xinguang Han
- National Neuroscience Institute, Department of Neurosurgery, Singhealth, Singapore, Singapore
| | - Min Wei Chen
- National Neuroscience Institute, Department of Neurosurgery, Singhealth, Singapore, Singapore
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Jiang QM, Yu S, Dong XF, Wang HS, Hou J, Huang ZC, Guo ZL, You SJ, Xiao GD. Predictors and Dynamic Nomogram to Determine the Individual Risk of Malignant Brain Edema After Endovascular Thrombectomy in Acute Ischemic Stroke. J Clin Neurol 2022; 18:298-307. [PMID: 35196752 PMCID: PMC9163945 DOI: 10.3988/jcn.2022.18.3.298] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/11/2021] [Accepted: 11/11/2021] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose This study aimed to construct an optimal dynamic nomogram for predicting malignant brain edema (MBE) in acute ischemic stroke (AIS) patients after endovascular thrombectomy (ET). Methods We enrolled AIS patients after ET from May 2017 to April 2021. MBE was defined as a midline shift of >5 mm at the septum pellucidum or pineal gland based on follow-up computed tomography within 5 days after ET. Multivariate logistic regression and LASSO (least absolute shrinkage and selection operator) regression were used to construct the nomogram. The area under the receiver operating characteristic curve (AUC) and decision-curve analysis were used to compare our nomogram with two previous risk models for predicting brain edema after ET. Results MBE developed in 72 (21.9%) of the 329 eligible patients. Our dynamic web-based nomogram (https://successful.shinyapps.io/DynNomapp/) consisted of five parameters: basal cistern effacement, postoperative National Institutes of Health Stroke Scale (NIHSS) score, brain atrophy, hypoattenuation area, and stroke etiology. The nomogram showed good discrimination ability, with a C-index (Harrell’s concordance index) of 0.925 (95% confidence interval=0.890–0.961), and good calibration (Hosmer-Lemeshow test, p=0.386). All variables had variance inflation factors of <1.5 and tolerances of >0.7, suggesting no significant collinearity among them. The AUC of our nomogram (0.925) was superior to those of Xiang-liang Chen and colleagues (0.843) and Ming-yang Du and colleagues (0.728). Conclusions Our web-based dynamic nomogram reliably predicted the risk of MBE in AIS patients after ET, and hence is worthy of further evaluation.
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Affiliation(s)
- Qian-Mei Jiang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Shuai Yu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiao-Feng Dong
- Department of Neurology, Suzhou Municipal Hospital, Suzhou, China
| | - Huai-Shun Wang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jie Hou
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhi-Chao Huang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhi-Liang Guo
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Shou-Jiang You
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China.
| | - Guo-Dong Xiao
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China.
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18
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Zhang X, Huang P, Zhang R. Evaluation and Prediction of Post-stroke Cerebral Edema Based on Neuroimaging. Front Neurol 2022; 12:763018. [PMID: 35087464 PMCID: PMC8786707 DOI: 10.3389/fneur.2021.763018] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022] Open
Abstract
Cerebral edema is a common complication of acute ischemic stroke that leads to poorer functional outcomes and substantially increases the mortality rate. Given that its negative effects can be reduced by more intensive monitoring and evidence-based interventions, the early identification of patients with a high risk of severe edema is crucial. Neuroimaging is essential for the assessment and prediction of edema. Simple markers, such as midline shift and hypodensity volume on computed tomography, have been used to evaluate edema in clinical trials; however, advanced techniques can be applied to examine the underlying mechanisms. In this study, we aimed to review current imaging tools in the assessment and prediction of cerebral edema to provide guidance for using these methods in clinical practice.
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Affiliation(s)
| | | | - Ruiting Zhang
- Department of Radiology, School of Medicine, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
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19
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Decompressive Craniectomy for Infarction and Intracranial Hemorrhages. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00078-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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20
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Li J, Zhang P, Liu Y, Chen W, Yi X, Wang C. Stroke Lateralization in Large Hemisphere Infarctions: Characteristics, Stroke-Related Complications, and Outcomes. Front Neurol 2021; 12:774247. [PMID: 34956055 PMCID: PMC8702425 DOI: 10.3389/fneur.2021.774247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 11/05/2021] [Indexed: 12/28/2022] Open
Abstract
Objectives: To assess the hemispheric differences in characteristics, stroke-related complications, and outcomes of patients with large hemisphere infarctions (LHI). Methods: We enrolled consecutive patients admitted within 24 h after the diagnosis of LHI (defined as an ischemic stroke involving more than 50% of the territory of the middle cerebral artery in computed tomography and/or magnetic resonance imaging). Univariate and multivariate analysis were performed to explore the association between lateralization and stroke-related complications and clinical outcomes. Results: A total of 314 patients with LHI were enrolled, with 171 (54.5%) having right hemispheric involvement. Right-sided patients with LHI had lower baseline National Institutes of Health Stroke Scale (NIHSS) score (18 vs. 22, p < 0.001), higher frequency of atrial fibrillation (69.0 vs. 52.4%, p = 0.003), and higher proportion of cardio-embolism (73.1 vs. 56.6%, p = 0.013) than the left. Right-sided LHI had higher incidence rates of malignant brain edema (MBE) (48.5 vs. 30.8%, p = 0.001) and a composite of cardiovascular events (29.8 vs. 17.5%, p = 0.011) during hospitalization. The incidence rate of 1-month mortality (34.5 vs. 23.8%, p = 0.036) was higher in right-sided patients with LHI, but there were no hemispheric differences in the incidence rates of 3-month mortality and unfavorable outcome (both p > 0.05). Multivariate analyses suggested right hemisphere involvement was independently associated with increased risk of MBE (adjusted OR 2.37, 95% CI 1.26–4.43, p = 0.007) and composite of cardiovascular events (adjusted OR 2.04, 95% CI 1.12–3.72, p = 0.020). However, it was not independently associated with 1-month death, 3-month mortality, and 3-month unfavorable outcome (all p > 0.05). Conclusions: Right-sided patients with LHI had higher frequency of atrial fibrillation and cardio-embolism than the left-sided patients. Right hemisphere involvement was independently associated with increased risk of MBE and composite of cardiovascular events during hospitalization, whereas stroke lateralization was not an independent predictor of mortality and unfavorable outcome in patients with LHI.
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Affiliation(s)
- Jie Li
- Department of Neurology, People's Hospital of Deyang, Deyang, China
| | - Ping Zhang
- Department of Neurology, People's Hospital of Deyang, Deyang, China
| | - Yingying Liu
- Department of Neurology, People's Hospital of Deyang, Deyang, China
| | - Wanli Chen
- Department of Neurology, People's Hospital of Deyang, Deyang, China
| | - Xingyang Yi
- Department of Neurology, People's Hospital of Deyang, Deyang, China
| | - Chun Wang
- Department of Neurology, People's Hospital of Deyang, Deyang, China
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21
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Krishnan R, Mays W, Elijovich L. Complications of Mechanical Thrombectomy in Acute Ischemic Stroke. Neurology 2021; 97:S115-S125. [PMID: 34785610 DOI: 10.1212/wnl.0000000000012803] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 06/23/2021] [Indexed: 01/01/2023] Open
Abstract
Multiple randomized clinical trials have supported the use of mechanical thrombectomy (MT) as standard of care in the treatment of large vessel occlusion acute ischemic stroke. Optimal outcomes depend not only on early reperfusion therapy but also on post thrombectomy care. Early recognition of post MT complications including reperfusion hemorrhage, cerebral edema and large space occupying infarcts, and access site complications can guide early initiation of lifesaving therapies that can improve neurologic outcomes. Knowledge of common complications and their management is essential for stroke neurologists and critical care providers to ensure optimal outcomes. We present a review of the available literature evaluating the common complications in patients undergoing MT with emphasis on early recognition and management.
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Affiliation(s)
- Rashi Krishnan
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - William Mays
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - Lucas Elijovich
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis.
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22
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Decompressive Hemicraniectomy in the Modern Era of Mechanical Thrombectomy. World Neurosurg 2021; 156:e77-e84. [PMID: 34500100 DOI: 10.1016/j.wneu.2021.08.138] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES We aim to determine the incidence of decompressive hemicraniectomy (DHC) in the modern era of mechanical thrombectomy techniques and improved revascularization outcomes. METHODS We performed a retrospective analysis of 512 patients admitted with acute ischemic strokes with anterior circulation large-vessel occlusion that were treated by mechanical thrombectomy from 2010-2019. The primary endpoint was the need for surgical decompression. Secondary endpoints were infarct size, hemorrhagic conversion, and functional outcome at hospital discharge. RESULTS Of the 512 patients, 18 (3.5%) underwent DHC at a median 2.0 days from stroke onset. The DHC group was significantly younger than the non-DHC group (P < 0.001), had worse reperfusion rates (P = 0.024) and larger infarct size (P < 0.001). Hemorrhagic conversion was more frequent in the DHC group but did not reach statistical significance (P = 0.08). From 2010-2015, 196 patients underwent a mechanical thrombectomy, 13 of whom (6.6%) required a DHC, while 316 patients underwent mechanical thrombectomy from 2016-2019 and only 5 patients required a DHC (1.6%; P = 0.002). Younger age (P < 0.001), urinary tract infection (P < 0.001) and increasing infarct size were significantly associated with needing a DHC. When controlling for other risk factors, higher thrombolysis in cerebral infarction score significantly reduced the need for decompressive hemicraniectomy (P = 0.004). CONCLUSIONS This is one of the largest single-center experiences demonstrating that improved recanalization decreased the need for DHC without increasing the risk of hemorrhagic conversion.
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Wang Y, Huang H, He W, Zhang S, Liu M, Wu S. Association between serum NLRP3 and malignant brain edema in patients with acute ischemic stroke. BMC Neurol 2021; 21:341. [PMID: 34493232 PMCID: PMC8422708 DOI: 10.1186/s12883-021-02369-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/28/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND We aimed to explore the association of serum level of the nucleotide-binding oligomerization domain-like receptor family pyrin domain-containing 3 (NLRP3) and its related inflammatory biomarkers (hypoxia inducible factor-1α, cathepsin B, caspase-1 and matrix metalloproteinase-9) with malignant brain edema (MBE) in patients with acute ischemic stroke. METHODS We prospectively enrolled patients with acute ischemic stroke admitted < 24 h from onset of symptoms. Brain CT was performed on admission and blood samples were collected. Repeated brain CT/MRI was performed < 7 days of admission to identify the presence of MBE, defined as neurological deterioration with imaging signs of midline shift or compressed basal cisterns. Logistic regression analysis was performed to assess the association between inflammatory biomarkers and MBE, adjusted for age and National Institutes of Health Stroke Scale (NIHSS). RESULTS 200 patients (69.3 ± 14.3 years; male 55 %) were included for analysis, of whom 26 patients developed MBE (median time from stroke onset to MBE 32.5 h). Compared with patients without MBE, those with MBE had higher level of serum concentration of NLRP3 (median time from onset to blood collection 3 h, 1.85 ng/ml vs. 1.11 ng/ml, P = 0.026). NLRP3 level was positively correlated with NIHSS on admission (Spearman ρ = 0.18, P = 0.01) and the association between NLRP3 and MBE was attenuated (OR 1.47, 95 % CI 0.88-2.46, P = 0.138) after adjusting for age and NIHSS. There was no significant difference in other biomarkers between MBE and non-MBE groups. CONCLUSIONS There was a trend of association between a higher level of serum concentration of NLRP3 and an increased risk of MBE after ischemic stroke, possibly confounded by the severity of stroke, which is worth further validation in large cohort studies.
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Affiliation(s)
- Yanan Wang
- Department of Neurology, West China Hospital, Sichuan University, 610041, Chengdu, China
| | - Hexiao Huang
- West China School of Medicine, Sichuan University, 610041, Chengdu, China
| | - Weihong He
- Department of Physiology, West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, 610041, Chengdu, China
| | - Shihong Zhang
- Department of Neurology, West China Hospital, Sichuan University, 610041, Chengdu, China
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, 610041, Chengdu, China
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, 610041, Chengdu, China.
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van der Worp HB, Hofmeijer J, Jüttler E, Lal A, Michel P, Santalucia P, Schönenberger S, Steiner T, Thomalla G. European Stroke Organisation (ESO) guidelines on the management of space-occupying brain infarction. Eur Stroke J 2021; 6:XC-CX. [PMID: 34414308 PMCID: PMC8370072 DOI: 10.1177/23969873211014112] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/13/2021] [Indexed: 01/29/2023] Open
Abstract
Space-occupying brain oedema is a potentially life-threatening complication in the first days after large hemispheric or cerebellar infarction. Several treatment strategies for this complication are available, but the size and quality of the scientific evidence on which these strategies are based vary considerably. The aim of this Guideline document is to assist physicians in their management decisions when treating patients with space-occupying hemispheric or cerebellar infarction. These Guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. A working group identified 13 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence-based recommendations. An expert consensus statement was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high-quality evidence to recommend surgical decompression to reduce the risk of death and to increase the chance of a favourable outcome in adult patients aged up to and including 60 years with space-occupying hemispheric infarction who can be treated within 48 hours of stroke onset, and low-quality evidence to support this treatment in older patients. There is continued uncertainty about the benefit and risks of surgical decompression in patients with space-occupying hemispheric infarction if this is done after the first 48 hours. There is also continued uncertainty about the selection of patients with space-occupying cerebellar infarction for surgical decompression or drainage of cerebrospinal fluid. These Guidelines further provide details on the management of specific subgroups of patients with space-occupying hemispheric infarction, on the value of monitoring of intracranial pressure, and on the benefits and risks of medical treatment options. We encourage new high-quality studies assessing the risks and benefits of different treatment strategies for patients with space-occupying brain infarction.
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Affiliation(s)
- H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
- Department of Clinical Neurophysiology, University of Twente, Enschede, the Netherlands
| | - Eric Jüttler
- Department of Neurology, Kliniken Ostalb, Aalen, Germany
| | - Avtar Lal
- European Stroke Organisation, Basel, Switzerland
| | - Patrik Michel
- Centre Cérébrovasculaire, Service de Neurologie, Département des Neurosciences Cliniques CHUV, Lausanne, Switzerland
| | - Paola Santalucia
- Neurology-Stroke Unit, San Giuseppe Hospital-Multimedica, Milan, Italy
| | | | - Thorsten Steiner
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Götz Thomalla
- Department of Neurology, Center for Clinical Neurosciences, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Abstract
Objectives: Concise “synthetic” review of the state of the art of management of acute ischemic stroke. Data Sources: Available literature on PubMed. Study Selection: We selected landmark studies, recent clinical trials, observational studies, and professional guidelines on the management of stroke including the last 10 years. Data Extraction: Eligible studies were identified and results leading to guideline recommendations were summarized. Data Synthesis: Stroke mortality has been declining over the past 6 decades, and as a result, stroke has fallen from the second to the fifth leading cause of death in the United States. This trend may follow recent advances in the management of stroke, which highlight the importance of early recognition and early revascularization. Recent studies have shown that early recognition, emergency interventional treatment of acute ischemic stroke, and treatment in dedicated stroke centers can significantly reduce stroke-related morbidity and mortality. However, stroke remains the second leading cause of death worldwide and the number one cause for acquired long-term disability, resulting in a global annual economic burden. Conclusions: Appropriate treatment of ischemic stroke is essential in the reduction of mortality and morbidity. Management of stroke involves a multidisciplinary approach that starts and extends beyond hospital admission.
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26
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Wu MN, Fang PT, Hung CH, Hsu CY, Chou PS, Yang YH. The association between white matter changes and development of malignant middle cerebral artery infarction: A case-control study. Medicine (Baltimore) 2021; 100:e25751. [PMID: 33907171 PMCID: PMC8084049 DOI: 10.1097/md.0000000000025751] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 03/11/2021] [Accepted: 04/08/2021] [Indexed: 02/05/2023] Open
Abstract
ABSTRACT Disrupted blood-brain barrier (BBB) in patients with ischemic stroke plays a critical role in malignant middle cerebral artery infarction (MMI) development.Cerebral white matter changes (WMC), particularly in the deep subcortical area or in severe one, may be also underlain by disrupted BBB. It is unclear whether the presence of WMC with potential premorbid disruption of BBB makes patients susceptible to MMI. Therefore, this study aimed to clarify any putative relationship between the MMI and WMC in terms of their severity and locations.In this case-control study, patients with infarction in the middle cerebral artery territory were retrospectively reviewed. Brain magnetic resonance images were analyzed according to Fazekas scale, and identified WMC were divided into periventricular WMC (PV-WMC) and deep subcortical WMC (deep-WMC). Patients were scored as having WMC, PV-WMC, deep-WMC, severe PV-WMC, and severe deep-WMC according to the severity and locations. Patients were defined as having MMI if either a progressive conscious disturbance or signs of uncal herniation was recorded in combination with a midline shift >5 mm identified on the follow-up computed tomography.Among 297 patients admitted between July 2009 and February 2015, 92 patients were eligible for final analysis. Compared to patients without MMI, patients with MMI had a higher score of National Institutes of Health Stroke Scale, a larger infarct volume, and an increasingly greater proportion of severe PV-WMC, deep-WMC, and severe deep-WMC, respectively. After adjustment for sex, age, infarct volume, and history of hypertension, severe deep-WMC (odds ratio [OR] = 6.362, 95% confidence interval [CI] = 1.444-28.023, P = .0144) and severe PV-WMC (odds ratio = 5.608, 95% confidence interval = 1.107-28.399, P = .0372) were significantly associated with MMI development.MMI and WMC are significantly associated such that MMI development is more likely when PV-WMC or deep-WMC is more severe. We hypothesize that Fazekas scale-defined severe deep-WMC and PV-WMC may be considered as clinically approachable predictors of MMI development. These findings support that the WMC with potential premorbid disrupted BBB may make patients susceptible to MMI, and further prospective study should be conducted to clarify this hypothesis.
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Affiliation(s)
| | - Pen-Tzu Fang
- Department of Radiation Oncology, Kaohsiung Medical University Hospital
| | | | | | | | - Yuan-Han Yang
- Department of Neurology
- Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan)
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27
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Lehrieder D, Layer K, Müller HP, Rücker V, Kassubek J, Juettler E, Neugebauer H. Association of Infarct Volume Before Hemicraniectomy and Outcome After Malignant Infarction. Neurology 2021; 96:e2704-e2713. [PMID: 33875557 DOI: 10.1212/wnl.0000000000011987] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/26/2021] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo determine the impact of infarct volume before hemicraniectomy in malignant middle cerebral artery infarction (MMI) as an independent predictor for patient selection and outcome prediction, we retrospectively analyzed data of 140 patients from a prospective multi-center study.MethodsPatients from the DESTINY-Registry that underwent hemicraniectomy after ischemic infarction of >50% of the middle cerebral artery territory were included. Functional outcome according to the modified Rankin Scale (mRS) was assessed at 12 months. Unfavorable outcome was defined as mRS 4-6. Infarct size was quantified semi-automatically from computed tomography or magnetic resonance imaging before hemicraniectomy. Subgroup analyses in patients fulfilling inclusion criteria of randomized trials in younger patients (age≤60y) were predefined.ResultsAmong 140 patients with complete datasets (34% female, mean (SD) age 54 (11) years), 105 (75%) had an unfavorable outcome (mRS > 3). Mean (SD) infarct volume was 238 (63) ml. Multivariable logistic regression identified age (OR 1.08 per 1 year increase; 95%-CI 1.02-1.13; p=0.004), infarct size (OR 1.27 per 10ml increase; 95%-CI 1.12-1.44; p<0.001) and NIHSS (OR 1.10; 95%-CI 1.01-1.20; p=0.030) before hemicraniectomy as independent predictors for unfavorable outcome. Findings were reproduced in patients fulfilling inclusion criteria of randomized trials in younger patients. Infarct volume thresholds for prediction of unfavorable outcome with high specificity (94% in overall cohort and 92% in younger patients) were more than 258 ml before hemicraniectomy.ConclusionOutcome in MMI strongly depends on age and infarct size before hemicraniectomy. Standardized volumetry may be helpful in the process of decision making concerning hemicraniectomy.
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Affiliation(s)
| | | | | | - Viktoria Rücker
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg
| | - Jan Kassubek
- Department of Neurology, University Hospital of Ulm, Ulm
| | - Eric Juettler
- Department of Neurology, Ostalb-Klinikum Aalen, Aalen
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Bernsen MLE, Kauw F, Martens JM, van der Lugt A, Yo LS, van Walderveen MA, Roos YB, van der Worp HB, Dankbaar JW, Hofmeijer J. Malignant infarction after endovascular treatment: Incidence and prediction. Int J Stroke 2021; 17:198-206. [PMID: 33724092 DOI: 10.1177/17474930211006290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Early prediction of malignant infarction may guide treatment decisions. For patients who received endovascular treatment, the risk of malignant infarction is unknown and risk factors are unrevealed. AIMS The objective of this study is to estimate the incidence of malignant infarction after endovascular treatment in patients with an occlusion of the anterior circulation, to identify independent risk factors, and to establish a model for prediction. METHODS We analyzed patients who received endovascular treatment for a large vessel occlusion in the anterior circulation within 6.5 h after symptom onset, included in the Dutch MR CLEAN Registry between March 2014 and June 2016. We compared patients with and without malignant infarction. Candidate predictors were incorporated in a multivariable binary logistic regression model. The final prediction model was established using backward elimination. Discrimination and calibration were evaluated with the area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow test. RESULTS Of 1445 patients, 82 (6%) developed malignant infarction. Independent predictors were lower age, higher National Institutes of Health Stroke Scale (NIHSS), lower alberta stroke program early CT score (ASPECTS), internal carotid artery occlusion, lower collateral score, longer times from onset to groin puncture, and unsuccessful reperfusion. The AUROC of a prediction model combining these features was 0.83 (95% confidence interval (CI): 0.79-0.88) and the Hosmer-Lemeshow test indicated appropriate calibration (P = 0.937). CONCLUSION The risk of malignant infarction after endovascular treatment started within 6.5 h of stroke onset is approximately 6%. Successful reperfusion decreases the risk. A prediction model combining easily retrievable measures of age, ASPECTS, collateral status, and reperfusion shows good discrimination between patients who will develop malignant infarction and those who will not.
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Affiliation(s)
| | - Frans Kauw
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jasper M Martens
- Department of Radiology & Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Lonneke Sf Yo
- Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Yvo Bwem Roos
- Department of Neurology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - H Bart van der Worp
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan W Dankbaar
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands.,Faculty of Science and Technology, Technical Medical Center, University of Twente, Enschede, The Netherlands
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Pires Monteiro S, Voogd E, Muzzi L, De Vecchis G, Mossink B, Levers M, Hassink G, Van Putten M, Le Feber J, Hofmeijer J, Frega M. Neuroprotective effect of hypoxic preconditioning and neuronal activation in a in vitro human model of the ischemic penumbra. J Neural Eng 2021; 18:036016. [PMID: 33724235 DOI: 10.1088/1741-2552/abe68a] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE In ischemic stroke, treatments to protect neurons from irreversible damage are urgently needed. Studies in animal models have shown that neuroprotective treatments targeting neuronal silencing improve brain recovery, but in clinical trials none of these were effective in patients. This failure of translation poses doubts on the real efficacy of treatments tested and on the validity of animal models for human stroke. Here, we established a human neuronal model of the ischemic penumbra by using human induced pluripotent stem cells and we provided an in-depth characterization of neuronal responses to hypoxia and treatment strategies at the network level. APPROACH We generated neurons from induced pluripotent stem cells derived from healthy donor and we cultured them on micro-electrode arrays. We measured the electrophysiological activity of human neuronal networks under controlled hypoxic conditions. We tested the effect of different treatment strategies on neuronal network functionality. MAIN RESULTS Human neuronal networks are vulnerable to hypoxia reflected by a decrease in activity and synchronicity under low oxygen conditions. We observe that full, partial or absent recovery depend on the timing of re-oxygenation and we provide a critical time threshold that, if crossed, is associated with irreversible impairments. We found that hypoxic preconditioning improves resistance to a second hypoxic insult. Finally, in contrast to previously tested, ineffective treatments, we show that stimulatory treatments counteracting neuronal silencing during hypoxia, such as optogenetic stimulation, are neuroprotective. SIGNIFICANCE We presented a human neuronal model of the ischemic penumbra and we provided insights that may offer the basis for novel therapeutic approaches for patients after stroke. The use of human neurons might improve drug discovery and translation of findings to patients and might open new perspectives for personalized investigations.
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Affiliation(s)
- Sara Pires Monteiro
- Department of Clinical Neurophysiology, University of Twente, 7522 NB Enschede, The Netherlands
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Sun W, Li G, Song Y, Zhu Z, Yang Z, Chen Y, Miao J, Song X, Lan Y, Qiu X, Zhu S, Fan Y. A web based dynamic MANA Nomogram for predicting the malignant cerebral edema in patients with large hemispheric infarction. BMC Neurol 2020; 20:360. [PMID: 32993551 PMCID: PMC7523347 DOI: 10.1186/s12883-020-01935-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 09/17/2020] [Indexed: 12/04/2022] Open
Abstract
Background For large hemispheric infarction (LHI), malignant cerebral edema (MCE) is a life-threatening complication with a mortality rate approaching 80%. Establishing a convenient prediction model of MCE after LHI is vital for the rapid identification of high-risk patients as well as for a better understanding of the potential mechanism underlying MCE. Methods One hundred forty-two consecutive patients with LHI within 24 h of onset between January 1, 2016 and August 31, 2019 were retrospectively reviewed. MCE was defined as patient death or received decompressive hemicraniectomy (DHC) with obvious mass effect (≥ 5 mm midline shift or Basal cistern effacement). Binary logistic regression was performed to identify independent predictors of MCE. Independent prognostic factors were incorporated to build a dynamic nomogram for MCE prediction. Results After adjusting for confounders, four independent factors were identified, including previously known atrial fibrillation (KAF), midline shift (MLS), National Institutes of Health Stroke Scale (NIHSS) and anterior cerebral artery (ACA) territory involvement. To facilitate the nomogram use for clinicians, we used the “Dynnom” package to build a dynamic MANA (acronym for MLS, ACA territory involvement, NIHSS and KAF) nomogram on web (http://www.MANA-nom.com) to calculate the exact probability of developing MCE. The MANA nomogram’s C-statistic was up to 0.887 ± 0.041 and the AUC-ROC value in this cohort was 0.887 (95%CI, 0.828 ~ 0.934). Conclusions Independent MCE predictors included KAF, MLS, NIHSS, and ACA territory involvement. The dynamic MANA nomogram is a convenient, practical and effective clinical decision-making tool for predicting MCE after LHI in Chinese patients.
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Affiliation(s)
- Wenzhe Sun
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Guo Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Yang Song
- School of Medicine and Health Management; Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Zhou Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Zhaoxia Yang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Yuxi Chen
- The Solomon H. Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - Jinfeng Miao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Xiaoyan Song
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Yan Lan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Xiuli Qiu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Suiqiang Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China.
| | - Yebin Fan
- School of Computer Science and Technology, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China.
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Murata Y, Sugimoto K, Yang C, Harada K, Gono R, Harada T, Miyashita Y, Higashisaka K, Katada R, Tanaka J, Matsumoto H. Activated microglia-derived macrophage-like cells exacerbate brain edema after ischemic stroke correlate with astrocytic expression of aquaporin-4 and interleukin-1 alpha release. Neurochem Int 2020; 140:104848. [PMID: 32920036 DOI: 10.1016/j.neuint.2020.104848] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 09/04/2020] [Accepted: 09/07/2020] [Indexed: 01/22/2023]
Abstract
Brain edema following brain infarction affects mobility and mortality. The mechanisms underlying this process remain to be elucidated. Animal studies have shown that aquaporin-4 (AQP4) expression in astrocytes increases after stroke, and its deletion significantly reduces brain swelling. Recently, two kinds of cells, resident microglia-derived macrophage-like cells (MG-MΦ) and bone marrow-derived macrophages (BM-MΦ), have been reported to accumulate in the ischemic core and stimulate adjacent astrocytes. Therefore, we hypothesized that these cells play crucial roles in the expression of AQP4 and ultimately lead to exacerbated brain edema. To verify this hypothesis, we investigated the role of MG- or BM-MΦ in brain edema using a rat model of transient middle cerebral artery occlusion and rat astrocyte primary cultures. AQP4 expression significantly increased in the peri-infarct tissue at 3-7 days post-reperfusion (dpr) and in the core tissue at 5 and 7 dpr, which synchronized with the expression of Iba1, Il1a, Tnf, and C1qa mRNA. Interleukin (IL)-1α treatment or coculture with MG- and BM-MΦ increased AQP4 expression in astrocytes, while an IL-1 receptor type I antagonist reduced these effects. Furthermore, aggravated animals exhibited high expression of Aqp4 and Il1a mRNA in the ischemic core at 7 dpr, which led to the exacerbation of brain edema. MG-MΦ signature genes were highly expressed in the ischemic core in aggravated rats, while BM-MΦ signature genes were weakly expressed. These findings suggest that IL-1α produced by MG-MΦ induces astrocytic AQP4 expression in the peri-infarct and ischemic core tissues, thereby exacerbating brain edema. Therefore, the regulation of MG-MΦ may prevent the exacerbation of brain edema.
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Affiliation(s)
- Yukie Murata
- Department of Legal Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan.
| | - Kana Sugimoto
- Department of Legal Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan.
| | - Chihpin Yang
- Department of Legal Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan.
| | - Kazuo Harada
- Department of Legal Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan.
| | - Rina Gono
- Department of Legal Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan.
| | - Teiji Harada
- Department of Legal Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan.
| | - Yohei Miyashita
- Department of Legal Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan.
| | - Kazuma Higashisaka
- Department of Legal Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan.
| | - Ryuichi Katada
- Department of Legal Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan.
| | - Junya Tanaka
- Department of Molecular and Cellular Physiology, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan.
| | - Hiroshi Matsumoto
- Department of Legal Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan.
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Li J, Zhang P, Wu S, Yuan R, Liu J, Tao W, Wang D, Liu M. Impaired consciousness at stroke onset in large hemisphere infarction: incidence, risk factors and outcome. Sci Rep 2020; 10:13170. [PMID: 32759986 PMCID: PMC7406648 DOI: 10.1038/s41598-020-70172-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 07/23/2020] [Indexed: 02/05/2023] Open
Abstract
Impaired consciousness (IC) at stroke onset in large hemispheric infarctions (LHI) patients is common in clinical practice. However, little is known about the incidence and risk factors of IC at stroke onset in LHI. Besides, stroke-related complications and clinical outcomes in relation to the development of IC has not been systematically examined. Data of 256 consecutive patients with LHI were collected. IC at stroke onset was retrospectively collected from the initial emergency department and/or admission records. Of the 256 LHI patients enrolled, 93 (36.3%) had IC at stroke onset. LHI patients with IC at stroke onset were older (median age 66 vs. 61, p = 0.041), had shorter prehospital delay (24 vs. 26 h, p < 0.001and higher baseline National Institutes of Health Stroke Scale (NIHSS) score (19 vs. 12, p < 0.001). Independent risk factors of IC at stroke onset were high NIHSS score (odds ratio, OR 1.17, 95% confidence interval [CI] 1.12 to 1.23) and atrial fibrillation (OR 1.93, 95% CI 1.07 to 3.47). Dyslipidemia appeared to protect against IC at stroke onset (adjusted OR 0.416, 95% CI 0.175 to 0.988). IC at stroke onset was associated with higher frequency of stroke-related complications (90.32% vs. 67.48%, p < 0.001), especially brain edema (45.16% vs. 23.31%, p < 0.001) and pneumonia (63.44% vs. 47.82%, p = 0.019). The IC group had higher rates of in-hospital death (23.66% vs. 11.66%, p = 0.012), 3-month mortality (49.46% vs. 24.87%, p = 0.002), and 3-month unfavorable outcome (64.51% vs. 49.07%, p = 0.017). However, after adjusting for age, baseline NIHSS score and other confounders, IC at stroke onset was not an independent predictor of in-hospital death (adjusted OR 0.56, 95% CI 0.22 to 1.47), 3-month mortality (adjusted OR 0.54, 95% CI 0.25 to 1.14) and 3-month unfavorable outcome (adjusted OR 0.64, 95% CI 0.31 to 1.33) in LHI patients (all p > 0.05). Our results suggested that IC occur in 1 out of every 3 LHI patients at stroke onset and was associated with initial stroke severity and atrial fibrillation. LHI patients with IC at stroke onset more frequently had stroke-related complications, 3-month mortality and unfavorable outcome, whereas IC was not an independent predictor of poor outcomes.
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Affiliation(s)
- Jie Li
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China. .,Department of Neurology, People's Hospital of Deyang City, No. 173, North Taishan Road, Deyang, 618000, Sichuan Province, People's Republic of China.
| | - Ping Zhang
- Department of Neurology, People's Hospital of Deyang City, No. 173, North Taishan Road, Deyang, 618000, Sichuan Province, People's Republic of China
| | - Simiao Wu
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Ruozhen Yuan
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Junfeng Liu
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Wendan Tao
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Deren Wang
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Ming Liu
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China.
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Quantitative Serial CT Imaging-Derived Features Improve Prediction of Malignant Cerebral Edema after Ischemic Stroke. Neurocrit Care 2020; 33:785-792. [PMID: 32729090 DOI: 10.1007/s12028-020-01056-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/16/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Malignant cerebral edema develops in a small subset of patients with hemispheric strokes, precipitating deterioration and death if decompressive hemicraniectomy (DHC) is not performed in a timely manner. Predicting which stroke patients will develop malignant edema is imprecise based on clinical data alone. Head computed tomography (CT) imaging is often performed at baseline and 24-h. We determined the incremental value of incorporating imaging-derived features from serial CTs to enhance prediction of malignant edema. METHODS We identified hemispheric stroke patients at three sites with NIHSS ≥ 7 who had baseline as well as 24-h clinical and CT imaging data. We extracted quantitative imaging features from baseline and follow-up CTs, including CSF volume, intracranial reserve (CSF/cranial volume), as well as midline shift (MLS) and infarct-related hypodensity volume. Potentially lethal malignant edema was defined as requiring DHC or dying with MLS over 5-mm. We built machine-learning models using logistic regression first with baseline data and then adding 24-h data including reduction in CSF volume (ΔCSF). Model performance was evaluated with cross-validation using metrics of recall (sensitivity), precision (predictive value), as well as area under receiver-operating-characteristic and precision-recall curves (AUROC, AUPRC). RESULTS Twenty of 361 patients (6%) died or underwent DHC. Baseline clinical variables alone had recall of 60% with low precision (7%), AUROC 0.59, AUPRC 0.15. Adding baseline intracranial reserve improved recall to 80% and AUROC to 0.82 but precision remained only 16% (AUPRC 0.28). Incorporating ΔCSF improved AUPRC to 0.53 (AUROC 0.91) while all imaging features further improved prediction (recall 90%, precision 38%, AUROC 0.96, AUPRC 0.66). CONCLUSION Incorporating quantitative CT-based imaging features from baseline and 24-h CT enhances identification of patients with malignant edema needing DHC. Further refinements and external validation of such imaging-based machine-learning models are required.
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Wen X, Li Y, He X, Xu Y, Shu Z, Hu X, Chen J, Jiang H, Gong X. Prediction of Malignant Acute Middle Cerebral Artery Infarction via Computed Tomography Radiomics. Front Neurosci 2020; 14:708. [PMID: 32733197 PMCID: PMC7358521 DOI: 10.3389/fnins.2020.00708] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/11/2020] [Indexed: 12/23/2022] Open
Abstract
Malignant middle cerebral artery infarction (mMCAi) is a serious complication of cerebral infarction usually associated with poor patient prognosis. In this retrospective study, we analyzed clinical information as well as non-contrast computed tomography (NCCT) and computed tomography angiography (CTA) data from patients with cerebral infarction in the middle cerebral artery (MCA) territory acquired within 24 h from symptoms onset. Then, we aimed to develop a model based on the radiomics signature to predict the development of mMCAi in cerebral infarction patients. Patients were divided randomly into training (n = 87) and validation (n = 39) sets. A total of 396 texture features were extracted from each NCCT image from the 126 patients. The least absolute shrinkage and selection operator regression analysis was used to reduce the feature dimension and construct an accurate radiomics signature based on the remaining texture features. Subsequently, we developed a model based on the radiomics signature and Alberta Stroke Program Early CT Score (ASPECTS) based on NCCT to predict mMCAi. Our prediction model showed a good predictive performance with an AUC of 0.917 [95% confidence interval (CI), 0.863-0.972] and 0.913 [95% CI, 0.795-1] in the training and validation sets, respectively. Additionally, the decision curve analysis (DCA) validated the clinical efficacy of the combined risk factors of radiomics signature and ASPECTS based on NCCT in the prediction of mMCAi development in patients with acute stroke across a wide range of threshold probabilities. Our research indicates that radiomics signature can be an instrumental tool to predict the risk of mMCAi.
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Affiliation(s)
- Xuehua Wen
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Yumei Li
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xiaodong He
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Yuyun Xu
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Zhenyu Shu
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xingfei Hu
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Junfa Chen
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Hongyang Jiang
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xiangyang Gong
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China.,Institute of Artificial Intelligence and Remote Imaging, Hangzhou Medical College, Hangzhou, China
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Tracol C, Vannier S, Hurel C, Tuffier S, Eugene F, Le Reste PJ. Predictors of malignant middle cerebral artery infarction after mechanical thrombectomy. Rev Neurol (Paris) 2020; 176:619-625. [PMID: 32624178 DOI: 10.1016/j.neurol.2020.01.352] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 01/05/2020] [Accepted: 01/10/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Several predictors have been described to early diagnose malignant middle cerebral artery infarction (MMI) and select patient for hemicraniectomy. Nevertheless, few studies have assessed them among patients with acute ischemic stroke undergoing mechanical endovascular thrombectomy (MET). The overall objective in this study was to evaluate these predictors in patients undergoing MET in the purpose to guide the medical care in the acute phase. METHODS We selected patients from a prospective local database which reference all patients eligible for treatment with Alteplase thrombolysis and/or mechanical endovascular thrombectomy in acute stroke. We investigated demographic, clinical, and radiological data. Multivariate regression analysis was used to identify clinical and imaging predictors of MMI. RESULTS In 32 months, 66 patients were included. Eighteen (27.3%) developed MMI. Malignant evolution was associated with: severity of neurological deficit and level of consciousness at admission, infarct size in DWI sequence and involvement of other vascular territories. Study groups didn't differ in terms of successful reperfusion. Two variables were identified as independent predictors of MMI: DWI infarct volume (p<0.001) and time to thrombectomy (p=0.018). A decision tree based on these two factors was able to predict malignant evolution with high specificity (100%) and sensibility (73%). CONCLUSION Our study proposes a practical decision tree including DWI lesion volume and delay before thrombectomy to early and accurately predict MMI in a subgroup of patients with MCA infarction undergoing MET regardless to the status of reperfusion.
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Affiliation(s)
- C Tracol
- Neurology, university hospital, 37, quai de la Prevalaye, 35000 Rennes, France.
| | - S Vannier
- Neurology, university hospital, Rennes, France
| | - C Hurel
- Department of epidemiology, university hospital, Rennes, France
| | - S Tuffier
- Department of epidemiology, university hospital, Rennes, France
| | - F Eugene
- Radiology, university hospital, Rennes, France
| | - P J Le Reste
- Neurosurgery, university hospital, Rennes, France
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Du X, Liu Q, Li Q, Yang Z, Liao J, Gong H, Wu L, Wei J, Tan Q, Du H, Zhao R, Zhao L. Prognostic value of cerebral infarction coefficient in patients with massive cerebral infarction. Clin Neurol Neurosurg 2020; 196:106009. [PMID: 32554235 DOI: 10.1016/j.clineuro.2020.106009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/03/2020] [Accepted: 06/07/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We proposed the concept of the cerebral infarction coefficient, which is cerebral infarction volume/brain volume. This study aimed to evaluate the prognostic value of the cerebral infarction coefficient in patients with massive cerebral infarction (MCI). METHODS According to the modified Rankin score, 71 patients with acute MCI were divided into good prognosis and poor prognosis groups. Clinical and imaging data of the two groups were collected and univariate analysis was carried out. If there were significant differences in the data between the two groups, binary logistic regression analysis was performed. RESULTS The poor prognosis group had a significantly higher cerebral infarction volume, cerebral infarction coefficient, and D-dimer levels, older age, the highest body temperature, a higher rate of a history of atrial fibrillation, and a lower rate of a history of hypertension compared with the good prognosis group (all P < 0.05). Binary logistic regression analysis showed that the cerebral infarction coefficient was an independent risk factor for a poor prognosis of patients with MCI (P < 0.05, 95 % confidence interval, 2.091, 42.562), and the odds ratio was 8.506. The area under the receiver operating characteristic curve for the cerebral infarction coefficient was 0.753. When the cut-off value was 7.8 %, the sensitivity of predicting a poor prognosis of patients with MCI was 92.5 %. CONCLUSION The cerebral infarction coefficient may have predictive value in determining the prognosis of patients with MCI.
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Affiliation(s)
- Xiaoyan Du
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China; Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Qingjun Liu
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China; Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, China.
| | - Zhao Yang
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China; Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Juan Liao
- Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Hongmin Gong
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China; Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Lin Wu
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China; Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Jing Wei
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Qing Tan
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China; Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Hongheng Du
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China; Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Rui Zhao
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China; Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
| | - Libo Zhao
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, 439 Xuanhua Road, Yongchuan District, Chongqing, China; Chongqing key laboratory of cerebrovascular disease research, 439 Xuanhua Road, Yongchuan District, Chongqing, China.
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Predictors of malignant cerebral edema in cerebral artery infarction: A meta-analysis. J Neurol Sci 2020; 409:116607. [DOI: 10.1016/j.jns.2019.116607] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 11/29/2019] [Accepted: 12/01/2019] [Indexed: 12/29/2022]
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Decompressive Craniectomy: A Preliminary Study of Comparative Radiographic Characteristics Predicting Outcome in Malignant Ischemic Stroke. World Neurosurg 2020; 133:e267-e274. [DOI: 10.1016/j.wneu.2019.08.223] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 08/27/2019] [Accepted: 08/29/2019] [Indexed: 11/21/2022]
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Thorén M, Dixit A, Escudero-Martínez I, Gdovinová Z, Klecka L, Rand VM, Toni D, Vilionskis A, Wahlgren N, Ahmed N. Effect of Recanalization on Cerebral Edema in Ischemic Stroke Treated With Thrombolysis and/or Endovascular Therapy. Stroke 2019; 51:216-223. [PMID: 31818228 DOI: 10.1161/strokeaha.119.026692] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Magnus Thorén
- From the Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden (M.T., N.A.)
| | - Anand Dixit
- Newcastle upon Tyne NHS Foundation Trust, University of Newcastle upon Tyne, United Kingdom (A.D.)
| | - Irene Escudero-Martínez
- Department of Neurology, University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain (I.E.-M.)
| | - Zuzana Gdovinová
- Department of Neurology, Faculty of Medicine, P.J. Safarik University Košice, Slovak republic (Z.G.)
| | - Lukas Klecka
- Departement of Neurology, Municipal hospital of Ostrava, Czech Republic (L.K.)
| | - Viiu-Marika Rand
- Department of Neurology, North Estonia Medical Centre, Tallinn (V.-M.R.)
| | - Danilo Toni
- Unità di Trattamento Neurovascolare, University La Sapienza Rome, Italy (D.T.)
| | - Aleksandras Vilionskis
- Department of Neurology, Institute of Clinical Medicine, Vilnius University, Republican Vilnius University hospital, Lithuania (A.V.)
| | - Nils Wahlgren
- Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.)
| | - Niaz Ahmed
- From the Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden (M.T., N.A.)
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Wu S, Yuan R, Wang Y, Wei C, Zhang S, Yang X, Wu B, Liu M. Early Prediction of Malignant Brain Edema After Ischemic Stroke. Stroke 2019; 49:2918-2927. [PMID: 30571414 DOI: 10.1161/strokeaha.118.022001] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background and Purpose- Malignant brain edema after ischemic stroke has high mortality but limited treatment. Therefore, early prediction is important, and we systematically reviewed predictors and predictive models to identify reliable markers for the development of malignant edema. Methods- We searched Medline and Embase from inception to March 2018 and included studies assessing predictors or predictive models for malignant brain edema after ischemic stroke. Study quality was assessed by a 17-item tool. Odds ratios, mean differences, or standardized mean differences were pooled in random-effects modeling. Predictive models were descriptively analyzed. Results- We included 38 studies (3278 patients) with 24 clinical factors, 7 domains of imaging markers, 13 serum biomarkers, and 4 models. Generally, the included studies were small and showed potential publication bias. Malignant edema was associated with younger age (n=2075; mean difference, -4.42; 95% CI, -6.63 to -2.22), higher admission National Institutes of Health Stroke Scale scores (n=807, median 17-20 versus 5.5-15), and parenchymal hypoattenuation >50% of the middle cerebral artery territory on initial computed tomography (n=420; odds ratio, 5.33; 95% CI, 2.93-9.68). Revascularization (n=1600, odds ratio, 0.37; 95% CI, 0.24-0.57) were associated with a lower risk for malignant edema. Four predictive models all showed an overall C statistic >0.70, with a risk of overfitting. Conclusions- Younger age, higher National Institutes of Health Stroke Scale, and larger parenchymal hypoattenuation on computed tomography are reliable early predictors for malignant edema. Revascularization reduces the risk of malignant edema. Future studies with robust design are needed to explore optimal cutoff age and National Institutes of Health Stroke Scale scores and to validate and improve existing models.
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Affiliation(s)
- Simiao Wu
- From the Department of Neurology, West China Hospital, Sichuan University, Chengdu (S.W., R.Y., Y.W., C.W., S.Z., B.W., M.L.)
| | - Ruozhen Yuan
- From the Department of Neurology, West China Hospital, Sichuan University, Chengdu (S.W., R.Y., Y.W., C.W., S.Z., B.W., M.L.)
| | - Yanan Wang
- From the Department of Neurology, West China Hospital, Sichuan University, Chengdu (S.W., R.Y., Y.W., C.W., S.Z., B.W., M.L.)
| | - Chenchen Wei
- From the Department of Neurology, West China Hospital, Sichuan University, Chengdu (S.W., R.Y., Y.W., C.W., S.Z., B.W., M.L.)
| | - Shihong Zhang
- From the Department of Neurology, West China Hospital, Sichuan University, Chengdu (S.W., R.Y., Y.W., C.W., S.Z., B.W., M.L.)
| | - Xiaoyan Yang
- West China Biomedical Big Data Center, West China Hospital/West China School of Medicine, Sichuan University, Chengdu (X.Y.)
| | - Bo Wu
- From the Department of Neurology, West China Hospital, Sichuan University, Chengdu (S.W., R.Y., Y.W., C.W., S.Z., B.W., M.L.)
| | - Ming Liu
- From the Department of Neurology, West China Hospital, Sichuan University, Chengdu (S.W., R.Y., Y.W., C.W., S.Z., B.W., M.L.)
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Lee SJ, Lee KS, Lee JS, Choi MH, Lee SE, Hong JM. Primary neurocritical care involving therapeutic hypothermia for acute ischemic stroke patients with malignant infarct cores. JOURNAL OF NEUROCRITICAL CARE 2019. [DOI: 10.18700/jnc.190076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Subacute Infarct Volume With Edema Correction in Computed Tomography Is Equivalent to Final Infarct Volume After Ischemic Stroke: Improving the Comparability of Infarct Imaging Endpoints in Clinical Trials. Invest Radiol 2019; 53:472-476. [PMID: 29668493 DOI: 10.1097/rli.0000000000000475] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Final infarct volume is regularly used as an end point of tissue outcome in stroke trials; however, the reported volumes are most commonly derived from early follow-up imaging. Those volumes are significantly impaired by ischemic edema, which causes an overestimation of the true final lesion volume. As net water uptake within ischemic brain can be quantified densitometrically in computed tomography (CT) as recently described, we hypothesized that the final lesion volume can be better estimated by correcting the lesion volume in early follow-up for the corresponding proportion of edema. MATERIALS AND METHODS After retrospective consecutive screening of the local registry, 20 patients with acute middle cerebral artery large vessel occlusion met the inclusion criteria with early and late follow-up CT; the latter acquired at least 4 weeks after admission. In early follow-up imaging 24 hours after onset, the proportion of edema contributing to the infarct lesion was calculated by quantifying the total volume of ischemic net water uptake. Edema volume was then subtracted from the total lesion volume to obtain edema-corrected lesion volumes. Finally, these corrected lesion volumes were compared with the final lesion volume on late follow-up serving as ground truth. RESULTS The median lesion volume in the early follow-up was 115.1 mL (range, 21.9-539.9 mL) and significantly exceeded the median final lesion volume in the late follow-up CT, which was 86.6 mL (range, 11.2-399.0 mL; p < 0.001). The calculated mean proportion of edema within the early lesion volume was 25.8% (±5.9%; range, 11.1%-35.9%. The median edema-corrected lesion volume measured after 24 hours was 87.1 mL (range, 18.2-376.3 mL). The estimation of final lesion volume in the early follow-up CT was therefore improved by a mean of 31.4% (±2.1%) when correcting for the proportion of edema and did not differ significantly from the true final infarct volume (p = 0.2). CONCLUSIONS Edema-corrected volumes of early follow-up infarct lesion in CT were in close agreement with the actual final infarct volumes. Computed tomography-based edema correction of subacute infarct lesions improves the estimation of final tissue outcome. This could especially improve the comparability of imaging end points and facilitate patient recruitment in clinical trials.
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Elsayed A, Elsayed A. Decompressive craniectomy in malignant hemispheric infarction: favorable outcome and disability. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2019. [DOI: 10.1186/s41983-019-0077-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Computed Tomography-Based Imaging of Voxel-Wise Lesion Water Uptake in Ischemic Brain: Relationship Between Density and Direct Volumetry. Invest Radiol 2019; 53:207-213. [PMID: 29200013 DOI: 10.1097/rli.0000000000000430] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Net water uptake per volume of brain tissue may be calculated by computed tomography (CT) density, and this imaging biomarker has recently been investigated as a predictor of lesion age in acute stroke. However, the hypothesis that measurements of CT density may be used to quantify net water uptake per volume of infarct lesion has not been validated by direct volumetric measurements so far. The purpose of this study was to (1) develop a theoretical relationship between CT density reduction and net water uptake per volume of ischemic lesions and (2) confirm this relationship by quantitative in vitro and in vivo CT image analysis using direct volumetric measurements. MATERIALS AND METHODS We developed a theoretical rationale for a linear relationship between net water uptake per volume of ischemic lesions and CT attenuation. The derived relationship between water uptake and CT density was tested in vitro in a set of increasingly diluted iodine solutions with successive CT measurements. Furthermore, the consistency of this relationship was evaluated using human in vivo CT images in a retrospective multicentric cohort. In 50 edematous infarct lesions, net water uptake was determined by direct measurement of the volumetric difference between the ischemic and normal hemisphere and was correlated with net water uptake calculated by ischemic density measurements. RESULTS With regard to in vitro data, water uptake by density measurement was equivalent to direct volumetric measurement (r = 0.99, P < 0.0001; mean ± SD difference, -0.29% ± 0.39%, not different from 0, P < 0.0001). In the study cohort, the mean ± SD uptake of water within infarct measured by volumetry was 44.7 ± 26.8 mL and the mean percent water uptake per lesion volume was 22.7% ± 7.4%. This was equivalent to percent water uptake obtained from density measurements: 21.4% ± 6.4%. The mean difference between percent water uptake by direct volumetry and percent water uptake by CT density was -1.79% ± 3.40%, which was not significantly different from 0 (P < 0.0001). CONCLUSIONS Volume of water uptake in infarct lesions can be calculated quantitatively by relative CT density measurements. Voxel-wise imaging of water uptake depicts lesion pathophysiology and could serve as a quantitative imaging biomarker of acute infarct lesions.
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Dimitriadis K, Wenzel M, Buchholz G, Straube A. Does Pretreatment with a Tumor Necrosis Factor Alpha-inhibitor Improve the Outcome After Ischemic Cerebral Infarction? A Case Report. Cureus 2019; 11:e4089. [PMID: 31032149 PMCID: PMC6472869 DOI: 10.7759/cureus.4089] [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] [Indexed: 11/12/2022] Open
Abstract
Tumor necrosis factor-α (TNFα) plays a major role in inflammatory and vascular processes after cerebral ischemia. TNFa-Inhibitors have, on the one hand, been associated with thromboembolic events; on the other hand, they may prevent brain edema after stroke or injury. Here, we report on a 38-year old Caucasian male with a history of Crohn´s disease, treated with adalimumab, who presented without brain edema and only minor sequelae after a major ischemic stroke. This case report illustrates two interesting aspects: 1) the treatment with adalimumab could, in that case, be the etiology for the thromboembolic event; and (2) pretreatment with this TNFa-Inhibitor was the most likely reason why the formation of brain edema was suppressed.
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Affiliation(s)
- Konstantinos Dimitriadis
- Department of Neurology, University Hospital, Ludwig Maximilian University of Munich, Munich, DEU
| | - Michael Wenzel
- Department of Neurology, University Hospital, Ludwig Maximilian University of Munich, Munich, DEU
| | - Grete Buchholz
- Department of Neurology, University Hospital, Ludwig Maximilian University of Munich, Munich, DEU
| | - Andreas Straube
- Department of Neurology, University Hospital, Ludwig Maximilian University of Munich, Munich, DEU
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Predicting cerebral edema in ischemic stroke patients. Neurol Sci 2019; 40:745-752. [PMID: 30659418 DOI: 10.1007/s10072-019-3717-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 01/10/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To produce a scoring system for predicting the development of edema in ischemic stroke patients without edema on admission. METHODS This retrospective study included 572 ischemic stroke patients (73.3 ± 13.0 years, 300 male) without signs of cerebral edema on the first CT scan, which was performed on admission. Another scan was normally performed 3 days later, and subsequently whenever needed. Edema was defined as cerebral hypodensity with compression of lateral ventricles. The main clinical, laboratory, and instrumental variables obtained during the first 24 h were related to the appearance of edema on the CT scans performed after the first one. RESULTS Cerebral edema occurred in 158 patients (27.6%) after a median time of 4 days. The variables independently associated with edema development were (odds ratio, 95% CI) the following: (1) total anterior circulation syndrome (4.20, 2.55-6.93; P < 0.0001), (2) hyperdense appearance of middle cerebral artery (4.12, 2.03-8.36; P = 0.0001), (3) closed eyes (2.53, 1.39-4.60; P = 0.002), (4) vomiting (3.53, 1.45-8.60; P = 0.006), (5) lacunar cerebral syndrome (0.36, 0.17-0.77; P = 0.008); and (6) white matter lesions (0.53, 0.33-0.86; P = 0.01). Counting one positive point for the first four variables and one negative point for the last two variables, a scoring system (E-score) was built. Cerebral edema could be predicted when the score was ≥ 1 (positive predictive value 61.6%, specificity 85.3%, sensitivity 62.0%). The area under the receiver operating characteristic curve was 0.78. CONCLUSIONS In ischemic stroke patients, six variables obtained during the first 24 h of hospitalization were predictive of subsequent cerebral edema development.
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Decompressive Hemicraniectomy in Elderly Patients With Space-Occupying Infarction (DECAP): A Prospective Observational Study. Neurocrit Care 2018; 31:97-106. [DOI: 10.1007/s12028-018-0660-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Li J, Zhang P, Tao W, Yi X, Zhang J, Wang C. Age-specific clinical characteristics and outcome in patients over 60 years old with large hemispheric infarction. Brain Behav 2018; 8:e01158. [PMID: 30566281 PMCID: PMC6305916 DOI: 10.1002/brb3.1158] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 09/24/2018] [Accepted: 10/14/2018] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE We aimed to investigate age-specific clinical characteristics in patients aged >60 years with large hemispheric infarction (LHI). METHODS We prospectively enrolled consecutive patients with LHI. Patients were divided into two groups: ≤60 vs. >60 years, and demographics, vascular risk factors, clinical feature, in-hospital treatment, 3-month mortality, and unfavorable outcome (defined as a mRS score of 4-6) rate were compared. RESULTS Of the 256 cases included, 140 (54.7%) were older than 60 years. Compared with the younger, the older patients had higher rates of hypertension (66.4% vs. 31.0%), coronary heart disease (19.3% vs. 2.6%), atrial fibrillation (53.6% vs. 31.0%; all p < 0.001), more history of stroke (21.4% vs. 5.2%, p < 0.001), less history of rheumatic heart disease (16.4% vs. 30.1%, p = 0.009), and alcohol consumption (12.1% vs. 21.6%, p = 0.043). Cardio-embolism is the most common stroke etiology regardless of age (55.7% and 38.8%, respectively). Furthermore, the elderly less frequently received decompressive hemicraniectomy (4.3% vs. 15.5%, p = 0.005) and mechanical ventilation (7.9% vs. 16.4%, p = 0.035) and had a higher frequency of stroke-related complication (83.6% vs. 66.4%, p = 0.001). A total of 26 (18.6%) older patients and 15 (12.9%) younger patients died during hospitalization (p = 0.221), and 59 (42.1%) older patients and 35 (30.2%) younger patients died at 3 months (p = 0.061). Patient aged >60 years had significantly higher unfavorable outcome rate at 3 months (adjusted odds ratio, OR 4.30, 95% confidence interval [CI] 2.08-8.88; p < 0.05]. However, older age is not independently associated with 3-month mortality (42.1% vs. 30.2%, p = 0.095 [log-rank test]). CONCLUSIONS Large hemispheric infarction patients over 60 years old were a little more than those aged ≤60 years and constitute more than half of those suffered from malignant brain edema and two thirds of in-hospital death and 3-month mortality. The elderly had more cardio-origin risk factors, received less aggressive hospital treatment, and showed higher risk of unfavorable outcome than the younger.
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Affiliation(s)
- Jie Li
- Department of Neurology, People's Hospital of Deyang City, Deyang, China
| | - Ping Zhang
- Department of Neurology, People's Hospital of Deyang City, Deyang, China
| | - Wendan Tao
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Xingyang Yi
- Department of Neurology, People's Hospital of Deyang City, Deyang, China
| | - Jing Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chun Wang
- Department of Neurology, People's Hospital of Deyang City, Deyang, China
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Fuhrer H, Schönenberger S, Niesen WD, Seide S, Meyne J, Gerner ST, Vollmuth C, Beck C, Meckel S, Schocke M, Wodarg F, Huttner HB, Möhlenbruch MA, Kieser M, Ringleb P, Neugebauer H. Endovascular stroke treatment's impact on malignant type of edema (ESTIMATE). J Neurol 2018; 266:223-231. [PMID: 30470996 DOI: 10.1007/s00415-018-9127-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/12/2018] [Accepted: 11/14/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE In patients with acute ischemic stroke and large vessel occlusion, the prognosis has improved tremendously since the implementation of endovascular thrombectomy (EVT). The effect of EVT on the incidence of malignant middle cerebral artery infarctions (MMI) has not been studied before. METHODS ESTIMATE, a multicenter retrospective study, evaluates data of ischemic stroke patients with occlusion in the anterior circulation in the years of 2007-2015 comparing three treatment options (no therapy; IV-TPA; IV-TPA plus EVT or EVT only). Primary endpoint of the study was the incidence of MMI on follow-up imaging and mortality rates. Secondary endpoints were functional outcome, further clinical and imaging data. Logistic and Cox-regression models with a propensity score weighting approach were applied to evaluate differences between treatment groups. RESULTS In 2161 patients over 9 years, EVT reduced the MMI rates significantly: patients without acute stroke treatment had increased odds for MMI of 1.57 [95% confidence interval (CI) 1.49-1.65]. In contrast, after treatment with IV-TPA, only we observed an OR of 0.88 (95% CI 0.83-0.94, p < 0.001), and after EVT an OR of 0.80 (95% CI 0.76-0.85, p < 0.001). This was more pronounced in larger pretreatment infarctions (ASPECTS < 5, p < 0.01). IV-TPA also lowers the MMI rates but not to the same extent. EVT-treated patients had increased survival rates (p < 0.05) and the best functional outcome at discharge. CONCLUSIONS The findings of this study illustrate that occurrence of MMI and mortality rates was significantly reduced in patients treated with EVT.
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Affiliation(s)
- Hannah Fuhrer
- Department of Neurology, University Hospital Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.
| | - Silvia Schönenberger
- Department of Neurology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology, University Hospital Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
| | - Svenja Seide
- Institute of Medical Biometry and Informatics, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Johannes Meyne
- Department of Neurology, University Hospital Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Christoph Vollmuth
- Department of Neurology, University Hospital Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - Christopher Beck
- Department of Neuroradiology, University Hospital Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.,Department of Nuclear medicine, University Hospital Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Stephan Meckel
- Department of Neuroradiology, University Hospital Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
| | - Michael Schocke
- Department of Neuroradiology, University Hospital Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - Fritz Wodarg
- Department of Neuroradiology, University Hospital Kiel, Arnold-Heller-Straße 9, 24105, Kiel, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry and Informatics, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Hermann Neugebauer
- Department of Neurology, University Hospital Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
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Wu S, Yuan R, Xiong Y, Zhang S, Wu B, Liu M. Clinical features, management and outcomes of severe ischaemic stroke in tertiary hospitals in China: protocol for a prospective multicentre registry-based observational study. BMJ Open 2018; 8:e024900. [PMID: 30373783 PMCID: PMC6224739 DOI: 10.1136/bmjopen-2018-024900] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Severe ischaemic stroke is a devastating condition with high mortality and morbidity; however, there is insufficient evidence on its management. The aim of this study is to investigate causes, risk factors, clinical course, management and outcomes of severe ischaemic stroke in a real-world setting in tertiary hospitals in China. METHODS AND ANALYSIS This is a prospective, multicentre, registry-based observational study. We will recruit 2500 patients with acute ischaemic stroke from nine tertiary hospitals in Western China. Patients with acute ischaemic stroke admitted to the Department of Neurology within 30 days of stroke onset will be included. Patients will be visited within 24 hours after admission, on day 3, day 7 and at discharge, to collect data on their clinical state, blood biomarkers and brain imaging. Severe stroke is defined as severe neurological deficits (National Institute of Health Stroke Scale (NIHSS) ≥15 or in coma) on admission or clinical worsening (NIHSS increased by ≥4 scores) during hospitalisation. Patients will be followed up by structured telephone interviews at 3 months and 1 year after stroke onset. In-hospital outcomes include symptomatic haemorrhagic transformation and brain oedema by day 7 of admission, and survival status (death or survival) by discharge; follow-up outcomes will include survival status and functional outcome (assessed by modified Rankin Scale) at 3 months and 1 year. The current study will improve our knowledge about the development of severe ischaemic stroke at acute phase and factors influencing its outcomes, which will eventually facilitate optimisation of individualised interventions for its prevention and treatment. ETHICS AND DISSEMINATION Ethics approval is obtained from The Biomedical Research Ethics Committee of West China Hospital, Sichuan University (Reference No. 2017(130)). We will present our findings at the national and international conferences and peer-reviewed journals in stroke and neurology. TRIAL REGISTRATION NUMBER NCT03222024; Pre-results.
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Affiliation(s)
- Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- Centre of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, China
| | - Ruozhen Yuan
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- Centre of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, China
| | - Yao Xiong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- Department of Neurology, The Third People’s Hospital of Chengdu, Chengdu, China
| | - Shihong Zhang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- Centre of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, China
| | - Bo Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- Centre of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, China
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- Centre of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, China
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