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Nadzri AN, Nik Mohamed NA, Payne SJ, Mohamed Mokhtarudin MJ. Poroelastic modelling of brain tissue swelling and decompressive craniectomy treatment in ischaemic stroke. Comput Methods Biomech Biomed Engin 2024:1-11. [PMID: 38461460 DOI: 10.1080/10255842.2024.2326972] [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: 11/07/2023] [Accepted: 03/01/2024] [Indexed: 03/12/2024]
Abstract
Brain oedema or tissue swelling that develops after ischaemic stroke can cause detrimental effects, including brain herniation and increased intracranial pressure (ICP). These effects can be reduced by performing a decompressive craniectomy (DC) operation, in which a portion of the skull is removed to allow swollen brain tissue to expand outside the skull. In this study, a poroelastic model is used to investigate the effect of brain ischaemic infarct size and location on the severity of brain tissue swelling. Furthermore, the model will also be used to evaluate the effectiveness of DC surgery as a treatment for brain tissue swelling after ischaemia. The poroelastic model consists of two equations: one describing the elasticity of the brain tissue and the other describing the changes in the interstitial tissue pressure. The model is applied on an idealized brain geometry, and it is found that infarcts with radius larger than approximately 14 mm and located near the lateral ventricle produce worse brain midline shift, measured through lateral ventricle compression. Furthermore, the model is also able to show the positive effect of DC treatment in reducing the brain midline shift by allowing part of the brain tissue to expand through the skull opening. However, the model does not show a decrease in the interstitial pressure during DC treatment. Further improvement and validation could enhance the capability of the proposed poroelastic model in predicting the occurrence of brain tissue swelling and DC treatment post ischaemia.
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Affiliation(s)
- Aina Najwa Nadzri
- Faculty of Manufacturing and Mechatronics Engineering Technology, Universiti Malaysia Pahang, Pekan, Pahang, Malaysia
| | - Nik Abdullah Nik Mohamed
- Faculty of Engineering, Technology and Built Environment, UCSI University Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Stephen J Payne
- Institute of Applied Mechanics, National Taiwan University, Taipei, Taiwan
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2
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Huang J, Chen J, Wang X, Hao L, Zhang J, Zhang X, Sheng Z, Liu K. The diagnostic value of quantitative parameters on dual-layer detector-based spectral CT in identifying ischaemic stroke. Front Neurol 2023; 14:1056941. [PMID: 36908613 PMCID: PMC9996291 DOI: 10.3389/fneur.2023.1056941] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/03/2023] [Indexed: 02/25/2023] Open
Abstract
Objective To investigate the diagnostic value of quantitative parameters of spectral computed tomography (CT) in ischaemic stroke areas. Methods The medical records of 57 patients with acute ischaemic stroke (AIS) who underwent plain computed tomography (CT) head scans, CT angiography (CTA), and CT perfusion (CTP) were retrospectively reviewed. The ischaemic areas (including the core infarct area and penumbra) and non-ischaemic areas in each patient were quantitatively analyzed using F-STROKE software. Two independent readers measured the corresponding values of the spectroscopic quantitative parameters (effective atomic number [Zeff value], iodine density value, and iodine-no-water value) in the ischaemic area and contralateral normal area alone. The differences in spectroscopic quantitative parameters between the two groups were compared, and their diagnostic efficacy was obtained. Results The Zeff, iodine-no-water value, and iodine density value of the ischaemic area all showed significant lower than those of non-ischaemic tissue (P < 0.001). For differentiating the ischaemic area from non-ischaemic tissue, the area under the curve (AUC) of the Zeff value reached 0.869 (cut-off value: 7.385; sensitivity: 93.0%; specificity: 70.2%), the AUC of the iodine density value reached 0.932 (cut-off value: 0.235; sensitivity: 91.2%; specificity: 82.5%), and the AUC of the iodine-no-water value reached 0.922 (cut-off value: 0.205; sensitivity: 96.5%; specificity: 78.9%). Conclusion The study showed the spectral CT would be a potential novel rapid method for identifying AIS. The spectral CT quantitative parameters (Zeff, iodine density values, and iodine-no-water values) can effectively differentiate the ischaemic area from non-ischaemic tissue in stroke patients.
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Affiliation(s)
- Jian Huang
- Department of Radiology, Taicang Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Taicang, Jiangsu, China.,Department of Radiology, Taicang Hospital, The Affiliated Hospital of Jiangsu Vocational College of Medicine, Yancheng, Jiangsu, China
| | - Jinghua Chen
- Department of Radiology, Taicang Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Taicang, Jiangsu, China.,Department of Radiology, Taicang Hospital, The Affiliated Hospital of Jiangsu Vocational College of Medicine, Yancheng, Jiangsu, China
| | - Ximing Wang
- Department of Radiology, First Affiliated Hospital of Suzhou University, Suzhou, Jiangsu, China
| | - Ling Hao
- Department of Radiology, Taicang Hospital, The Affiliated Hospital of Jiangsu Vocational College of Medicine, Yancheng, Jiangsu, China
| | - Jinfeng Zhang
- Department of Neurology, Taicang Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Taicang, Jiangsu, China
| | - Xiaohui Zhang
- Clinical Science, Philips Healthcare, Shanghai, China
| | | | - Kefu Liu
- Department of Radiology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, Jiangsu, China
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3
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Variability assessment of manual segmentations of ischemic lesion volume on 24-h non-contrast CT. Neuroradiology 2021; 64:1165-1173. [PMID: 34812917 DOI: 10.1007/s00234-021-02855-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/04/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Infarct lesion volume (ILV) may serve as an imaging biomarker for clinical outcomes in the early post-treatment stage in patients with acute ischemic stroke. The aim of this study was to evaluate the inter- and intra-rater reliability of manual segmentation of ILV on follow-up non-contrast CT (NCCT) scans. METHODS Fifty patients from the Prove-IT study were randomly selected for this analysis. Three raters manually segmented ILV on 24-h NCCT scans, slice by slice, three times. The reference standard for ILV was generated by the Simultaneous Truth And Performance Level estimation (STAPLE) algorithm. Intra- and inter-rater reliability was evaluated, using metrics of intraclass correlation coefficient (ICC) regarding lesion volume and the Dice similarity coefficient (DSC). RESULTS Median age of the 50 subjects included was 74.5 years (interquartile range [IQR] 67-80), 54% were women, median baseline National Institutes of Health Stroke Scale was 18 (IQR 11-22), median baseline ASPECTS was 9 (IQR 6-10). The mean reference standard ILV was 92.5 ml (standard deviation (SD) ± 100.9 ml). The manually segmented ILV ranged from 88.2 ± 91.5 to 135.5 ± 119.9 ml (means referring to the variation between readers, SD within readers). Inter-rater ICC was 0.83 (95%CI: 0.76-0.88); intra-rater ICC ranged from 0.85 (95%CI: 0.72-0.92) to 0.95 (95%CI: 0.91-0.97). The mean DSC among the three readers ranged from 65.5 ± 22.9 to 76.4 ± 17.1% and the mean overall DSC was 72.8 ± 23.0%. CONCLUSION Manual ILV measurements on follow-up CT scans are reliable to measure the radiological outcome despite some variability.
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External Validation and Modification of the EDEMA Score for Predicting Malignant Brain Edema After Acute Ischemic Stroke. Neurocrit Care 2021; 32:104-112. [PMID: 31549349 DOI: 10.1007/s12028-019-00844-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Accurate prediction of malignant brain edema (MBE) after stroke is paramount to facilitate close monitoring and timely surgical intervention. The Enhanced Detection of Edema in Malignant Anterior Circulation Stroke (EDEMA) score was useful to predict potentially lethal malignant edema in Western populations. We aimed to validate and modify it to achieve a better predictive value for MBE in Chinese patients. METHODS Of ischemic stroke patients consecutively admitted in the Department of Neurology, West China Hospital between January 2010 and December 2017, we included patients with anterior circulation stroke, early signs of brain edema on computed tomography within 24 h of onset, and admission National Institutes of Health Stroke Scale (NIHSS) score ≥ 8. MBE was defined as the development of signs of herniation (including decrease in consciousness and/or anisocoria), accompanied by midline shift ≥ 5 mm on follow-up imaging. The EDEMA score consisted of five parameters: glucose, stroke history, reperfusion therapy, midline shift, and cistern effacement. We created a modified score by adding admission NIHSS score to the original EDEMA score. The discrimination of the score was assessed by the area under the receiver operating characteristics curve (AUC). Calibration was assessed by Hosmer-Lemeshow test and calibration plot. We compared the discrimination of the original and modified score by AUC, net reclassification improvement (NRI), and integrated discrimination improvement (IDI). Clinical usefulness of the two scores was compared by plotting net benefits at different threshold probabilities in the decision curve analysis. RESULTS Of the 478 eligible patients (mean age 67.3 years; median NIHSS score 16), 93 (19%) developed MBE. The EDEMA score showed moderate discrimination (AUC 0.72, 95% confidence interval [CI] 0.67-0.76) and good calibration (Hosmer-Lemeshow test, P = 0.77). The modified score showed an improved discriminative ability (AUC 0.80, 95% CI 0.76-0.84, P < 0.001; NRI 0.67, 95% CI 0.55-0.78, P < 0.001; IDI 0.07, 95% CI 0.06-0.09, P < 0.001). Decision curves showed that the modified score had a higher net benefit than the original score in a range of threshold probabilities lower than 60%. CONCLUSIONS The original EDEMA score showed an acceptable predictive value for MBE in Chinese patients. By adding the admission NIHSS score, the modified score allowed for a more accurate prediction and clinical usefulness. Further validation in large cohorts of different ethnicities is needed to confirm our findings.
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Fu B, Qi S, Tao L, Xu H, Kang Y, Yao Y, Yang B, Duan Y, Chen H. Image Patch-Based Net Water Uptake and Radiomics Models Predict Malignant Cerebral Edema After Ischemic Stroke. Front Neurol 2021; 11:609747. [PMID: 33424759 PMCID: PMC7786250 DOI: 10.3389/fneur.2020.609747] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/26/2020] [Indexed: 12/12/2022] Open
Abstract
Malignant cerebral edema (MCE) after an ischemic stroke results in a poor outcome or death. Early prediction of MCE helps to identify subjects that could benefit from a surgical decompressive craniectomy. Net water uptake (NWU) in an ischemic lesion is a predictor of MCE; however, CT perfusion and lesion segmentation are required. This paper proposes a new Image Patch-based Net Water Uptake (IP-NWU) procedure that only uses non-enhanced admission CT and does not need lesion segmentation. IP-NWU is calculated by comparing the density of ischemic and contralateral normal patches selected from the middle cerebral artery (MCA) area using standard reference images. We also compared IP-NWU with the Segmented Region-based NWU (SR-NWU) procedure in which segmented ischemic regions from follow-up CT images are overlaid onto admission images. Furthermore, IP-NWU and its combination with imaging features are used to construct predictive models of MCE with a radiomics approach. In total, 116 patients with an MCA infarction (39 with MCE and 77 without MCE) were included in the study. IP-NWU was significantly higher for patients with MCE than those without MCE (p < 0.05). IP-NWU can predict MCE with an AUC of 0.86. There was no significant difference between IP-NWU and SR-NWU, nor between their predictive efficacy for MCE. The inter-reader and interoperation agreement of IP-NWU was exceptional according to the Intraclass Correlation Coefficient (ICC) analysis (inter-reader: ICC = 0.92; interoperation: ICC = 0.95). By combining IP-NWU with imaging features through a random forest classifier, the radiomics model achieved the highest AUC (0.96). In summary, IP-NWU and radiomics models that combine IP-NWU with imaging features can precisely predict MCE using only admission non-enhanced CT images scanned within 24 h from onset.
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Affiliation(s)
- Bowen Fu
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang, China
| | - Shouliang Qi
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang, China.,Key Laboratory of Intelligent Computing in Medical Image, Ministry of Education, Northeastern University, Shenyang, China
| | - Lin Tao
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Haibin Xu
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yan Kang
- College of Health Science and Environment Engineering, Shenzhen Technology University, Shenzhen, China
| | - Yudong Yao
- Department of Electrical and Computer Engineering, Stevens Institute of Technology, Hoboken, NJ, United States
| | - Benqiang Yang
- Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yang Duan
- Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Huisheng Chen
- Department of Electrical and Computer Engineering, Stevens Institute of Technology, Hoboken, NJ, United States
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Abstract
Background and Purpose:
Basilar artery occlusion (BAO) is associated with a high risk of disability and mortality. The objective of this study was to investigate prognostic factors in patients with acute basilar artery occlusion treated with mechanical thrombectomy, focusing on collateral status and recanalization time from symptom onset.
Methods:
Eligible patients from January 2012 to October 2019 who underwent endovascular treatment due to acute BAO were reviewed. The baseline posterior circulation collateral status was assessed with the basilar artery on computed tomography angiography score and posterior circulation collateral score. Good outcomes were defined as a modified Rankin Scale score of ≤2 at 3 months and successful recanalization as Thrombolysis in Cerebral Infarction grades 2b, 3. The associations between baseline and clinical parameters and favorable outcomes were evaluated with logistic regression.
Results:
Our sample included a total of 81 eligible patients (49 males, mean age 70.3 years) with a median baseline and discharge National Institutes of Health Stroke Scale score of 12. Patients with good outcomes showed a lower baseline National Institutes of Health Stroke Scale score, a greater proportion of distal BAO, and a higher basilar artery on computed tomography angiography and posterior circulation collateral score (
P
<0.001). According to subgroup analysis of patients within and over 6 or 12 hours, the time from symptom onset to recanalization was not correlated with good outcomes. Multivariable logistic analysis showed baseline National Institutes of Health Stroke Scale <15 (odds ratio, 8.49 [95% CI, 2.01–35.82];
P
=0.004), posterior circulation collateral score ≥6 (odds ratio, 3.79 [95% CI, 1.05–13.66];
P
=0.042), and distal BAO (odds ratio, 3.67 [95% CI, 1.10–12.26];
P
=0.035) were independent predictors of good outcomes.
Conclusions:
This study suggested that good collateral circulation and distal BAO are independent predictors of clinical outcome after endovascular treatment in patients with acute BAO. In particular, patients with good initial collateral status and distal BAO may consider endovascular treatment even if the treatment is started beyond the standard time limits.
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Affiliation(s)
- Hyo Sung Kwak
- Department of Radiology (H.S.K.), Research Institute of Clinical Medicine of Chonbuk National University, Biomedical Research Institute of Chonbuk National University Hospital
| | - Jung Soo Park
- Department of Neurosurgery (J.S.P.), Research Institute of Clinical Medicine of Chonbuk National University, Biomedical Research Institute of Chonbuk National University Hospital
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Garcia-Cazares R, Merlos-Benitez M, Marquez-Romero JM. Role of the physical examination in the determination of etiology of ischemic stroke. Neurol India 2020; 68:282-287. [PMID: 32415006 DOI: 10.4103/0028-3886.284386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The actual investigation of the body of a patient by the clinician in search for the signs of the disease beginning with the primary vital signs and continues with the careful and attentive observation of the patient. This article reviews the key findings in the physical examination of patients with ischemic stroke that have the potential to indicate the etiology of the infarct and to help to choose the use of ancillary tests. Through a systematic search of articles published in English related to the physical examination of patients with stroke, we identified key findings in the vital signs and classic components of the physical exam (appearance of the patient, auscultation, and eye examination) that have shown clinical significance when determining ischemic stroke etiology. We further suggest that the prompt identification of such findings can translate into better use of diagnostic tools and selection of ancillary confirmatory tests, thus, reducing the time to etiology based treatment and secondary prevention of ischemic stroke. in this manuscript, we aim to show that even though nowadays the clinical skills tend to be overlooked due to the overreliance on technology, the physical exam continues to be a valuable tool in the clinician armamentarium when facing the challenge of a patient with ischemic stroke.
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8
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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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9
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Du M, Huang X, Li S, Xu L, Yan B, Zhang Y, Wang H, Liu X. A Nomogram Model to Predict Malignant Cerebral Edema in Ischemic Stroke Patients Treated with Endovascular Thrombectomy: An Observational Study. Neuropsychiatr Dis Treat 2020; 16:2913-2920. [PMID: 33293816 PMCID: PMC7719319 DOI: 10.2147/ndt.s279303] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Malignant cerebral edema (MCE) in patients undergoing endovascular thrombectomy (EVT) is not uncommon and can reduce the benefit of EVT. We aimed to develop a nomogram model to predict the risk of MCE in ischemic stroke patients after EVT. PATIENTS AND METHODS We retrospectively collected patients treated with EVT caused by anterior circulation large vessel occlusion stroke at two comprehensive stroke centers. MCE was defined as midline shift >5 mm at the septum pellucidum or pineal gland with obliteration of the basal cisterns or the need for early decompressive hemicraniectomy. A multivariate logistic model was utilized to construct the best-fit nomogram model. The discrimination and calibration of the nomogram were estimated using the area under the receiver operating characteristic curve (AUC-ROC) and Hosmer-Lemeshow test. RESULTS A total of 370 patients (mean age, 67.2±11.9 years; male, 56.8%) were enrolled in the final analysis. Among them, 71 (19.2%) patients experienced MCE after EVT treatment. After adjustment for potential confounders, age, baseline National Institutes of Health Stroke Scale score, collateral circulation, fast blood glucose level and recanalization were independent predictors of MCE and were incorporated into the nomogram. The AUC-ROC value of the nomogram was 0.805 (95% confidence interval [CI]: 0.750-0.860). The Hosmer-Lemeshow goodness-of-fit test showed good calibration of the nomogram (P = 0.681). CONCLUSION The nomogram composed of age, baseline National Institutes of Health Stroke Scale score, blood glucose level, collateral circulation and recanalization may predict the probability of MCE in anterior circulation large vessel occlusion stroke patients treated with EVT.
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Affiliation(s)
- Mingyang Du
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China.,Department of Cerebrovascular Disease Treatment Center, Nanjing Brain Hospital Affiliated to Nanjing Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China
| | - Xianjun Huang
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui Province, People's Republic of China.,Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China
| | - Shun Li
- Department of Cerebrovascular Disease Treatment Center, Nanjing Brain Hospital Affiliated to Nanjing Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China
| | - Lili Xu
- Department of Cerebrovascular Disease Treatment Center, Nanjing Brain Hospital Affiliated to Nanjing Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China
| | - Bin Yan
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China
| | - Yi Zhang
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China
| | - Huaiming Wang
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China.,Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, Jiangsu Province, People's Republic of China.,Department of Neurology, The 80th Group Army Hospital of People's Liberation Army, Weifang, Shandong Province, People's Republic of China
| | - Xinfeng Liu
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China.,Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China
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10
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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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11
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Liebeskind DS, Jüttler E, Shapovalov Y, Yegin A, Landen J, Jauch EC. Cerebral Edema Associated With Large Hemispheric Infarction. Stroke 2019; 50:2619-2625. [DOI: 10.1161/strokeaha.118.024766] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- David S. Liebeskind
- From the Department of Neurology, Neurovascular Imaging Research Core and UCLA Stroke Center, University of California Los Angeles (D.S.L.)
| | - Eric Jüttler
- Department of Neurology, University of Heidelberg, Germany (E.J.)
- Department of Neurology, University of Ulm, University and Rehabilitation Hospitals, Ulm, and the Center for Stroke Research Berlin, Germany (E.J.)
| | | | | | | | - Edward C. Jauch
- Mission Research Institute, Mission Health System, Asheville, NC (E.C.J.)
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12
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Evans NR, Tarkin JM, Buscombe JR, Markus HS, Rudd JHF, Warburton EA. PET imaging of the neurovascular interface in cerebrovascular disease. Nat Rev Neurol 2017; 13:676-688. [PMID: 28984315 DOI: 10.1038/nrneurol.2017.129] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cerebrovascular disease encompasses a range of pathologies that affect different components of the cerebral vasculature and brain parenchyma. Large artery atherosclerosis, acute cerebral ischaemia, and intracerebral small vessel disease all demonstrate altered metabolic processes that are key to their pathogenesis. Although structural imaging techniques such as MRI are the mainstay of clinical care and research in cerebrovascular disease, they have limited ability to detect these pathophysiological processes in vivo. By contrast, PET can detect and quantify metabolic processes that are relevant to each facet of cerebrovascular disease. Information obtained from PET studies has helped to shape the understanding of key concepts in cerebrovascular medicine, including vulnerable atherosclerotic plaque, salvageable ischaemic penumbra, neuroinflammation and selective neuronal loss after ischaemic insult. PET has also helped to elucidate the relationships between chronic hypoxia, neuroinflammation, and amyloid-β deposition in cerebral small vessel disease. This Review describes how PET-based imaging of metabolic processes at the neurovascular interface has contributed to our understanding of cerebrovascular disease.
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Affiliation(s)
- Nicholas R Evans
- Department of Clinical Neurosciences, University of Cambridge, Box 83, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Jason M Tarkin
- Division of Cardiovascular Medicine, Department of Medicine, University of Cambridge, Box 157, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - John R Buscombe
- Department of Nuclear Medicine, Box 219, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
| | - Hugh S Markus
- Department of Clinical Neurosciences, University of Cambridge, Box 83, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - James H F Rudd
- Division of Cardiovascular Medicine, Department of Medicine, University of Cambridge, Box 157, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Elizabeth A Warburton
- Department of Clinical Neurosciences, University of Cambridge, Box 83, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
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Kamran S, Salam A, Akhtar N, Alboudi A, Ahmad A, Khan R, Nazir R, Nadeem M, Inshasi J, ElSotouhy A, Al Sulaiti G, Shuaib A. Predictors of In-Hospital Mortality after Decompressive Hemicraniectomy for Malignant Ischemic Stroke. J Stroke Cerebrovasc Dis 2017; 26:1941-1947. [PMID: 28694110 DOI: 10.1016/j.jstrokecerebrovasdis.2017.06.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 10/27/2016] [Accepted: 06/11/2017] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The purpose of this retrospective multicenter, pooled-data analysis was to determine the factors associated with in-hospital mortality in decompressive hemicraniectomy (DHC) for malignant middle cerebral artery (MMCA) stroke. PATIENTS AND METHODS The authors reviewed pooled DHC database from 3 countries for patients with MMCA with hospital mortality in spite of DHC to identify factors that predicted in-hospital mortality after DHC. The identified factors were applied to the group of patients who were selected for DHC but either refused surgery and died or stabilized and did not undergo DHC. FINDINGS There were 137 patients who underwent DHC. Multiple logistic regression analysis showed middle cerebral artery (MCA) with additional infarcts (odds ratio [OR], 7.9: 95% confidence interval [CI], 2.4-26; P = .001), preoperative midline shift of septum pellucidum of 1 cm or more (OR, 3.83: 95% CI, 1.13-12.96; P = .031), and patients who remained unconscious on day 7 postoperatively (8.82: 95% CI; OR, 1.08-71.9; P = .042) were significant independent predictors for in-hospital mortality. The identified factors were applied to the group of MMCA patients not operated (n = 19 refused, n = 47 stabilized) single (P < .001), and two predictive factors (P < .001) were significantly more common in patients who died. Whereas two predicative factors were identified in only 9%-18.2% of survivors, the presence of all three predictive factors was seen only in patients who expired (P < .001). The Hosmer-Lemeshow goodness-of-fit statistics (chi-square = 4.65; P value = .589) indicate that the model adequately describes the data. CONCLUSION Direct physical factors, such as MCA with additional territory infarct, extent of midline shift, and postoperative consciousness level, bore a significant relationship to in-hospital mortality in MMCA patients undergoing DHC.
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Affiliation(s)
- Saadat Kamran
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Weill Cornell School of Medicine, Qatar.
| | - Abdul Salam
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Naveed Akhtar
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Weill Cornell School of Medicine, Qatar
| | - Aymen Alboudi
- Department of Neurology, Rashid Hospital, Dubai, United Arab Emirates
| | - Arsalan Ahmad
- Department of Neurology and Neurosurgery, Shifa International Hospital, Islamabad, Pakistan
| | - Rabia Khan
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Rashed Nazir
- Department of Neurology and Neurosurgery, Shifa International Hospital, Islamabad, Pakistan
| | - Muhammad Nadeem
- Department of Neurology and Neurosurgery, Shifa International Hospital, Islamabad, Pakistan
| | - Jihad Inshasi
- Department of Neurology, Rashid Hospital, Dubai, United Arab Emirates
| | - Ahmed ElSotouhy
- Department of Radiology, Hamad General Hospital, Hamad Medical Corporation, Qatar
| | - Ghanim Al Sulaiti
- Department of Neurosurgery, The Neuroscience Institute Hamad General Hospital, Medical Corporation, Doha, Qatar
| | - Ashfaq Shuaib
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Stroke Program, University of Alberta, Canada
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Volny O, Cimflova P, Lee TY, Menon BK, d'Esterre CD. Permeability surface area product analysis in malignant brain edema prediction - A pilot study. J Neurol Sci 2017; 376:206-210. [PMID: 28431614 DOI: 10.1016/j.jns.2017.03.035] [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: 10/16/2016] [Revised: 03/17/2017] [Accepted: 03/21/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Using an extended CT perfusion acquisition (150s), we sought to determine the association between perfusion parameters and malignant edema after ischemic stroke. METHODS Patients (from prospective study PROVE-IT, NCT02184936) with terminal internal carotid artery±proximal middle cerebral occlusion were involved. CTA was assessed for clot location and status of leptomeningeal collaterals. The following CTP parameters were calculated within the ischemic territory and contralaterally: permeability surface area product (PS), cerebral blood flow (CBF) and cerebral blood volume (CBV). PS was calculated using the adiabatic approximation to the Johnson and Wilson model. Outcome was evaluated by midline shift and infarction volume on follow-up imaging. RESULTS Of 200 patients enrolled, 7 patients (3.5%) had midline shift≥5mm (2 excluded for poor-quality scans). Five patients with midline shift and 5 matched controls were analysed. There was no significant difference in mean PS, CBF and CBV within the ischemic territory between the two groups. A CBV threshold of 1.7ml/100g had the highest AUC=0.72, 95% CI=0.54-0.90 for early midline shift prediction, sensitivity and specificity were 0.83 and 0.67 respectively. CONCLUSION Our preliminary results did not show significant differences in permeability surface area analysis if analysed for complete ischemic region. CBV parameter had the highest accuracy and there was a trend for the mean PS values for midline shift prediction.
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Affiliation(s)
- O Volny
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic; First Department of Neurology, Medical Faculty of Masaryk University, St. Anne's University Hospital, Brno, Czech Republic.
| | - P Cimflova
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic; Department of Medical Imaging, Medical Faculty of Masaryk University, St. Anne's University Hospital, Brno, Czech Republic
| | - T-Y Lee
- Imaging Research Labs, Robarts Research Institute, Ontario, Canada
| | - B K Menon
- Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Canada
| | - C D d'Esterre
- Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Canada
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15
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Jeon SB, Kwon SU, Park JC, Lee DH, Yun SC, Kim YJ, Ahn JS, Kwun BD, Kang DW, Choi HA, Lee K, Kim JS. Reduction of Midline Shift Following Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction. J Stroke 2016; 18:328-336. [PMID: 27733025 PMCID: PMC5066438 DOI: 10.5853/jos.2016.00262] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 06/04/2016] [Accepted: 06/30/2016] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose Hemicraniectomy is a decompressive surgery used to remove a large bone flap to allow edematous brain tissue to bulge extracranially. However, early indicators of the decompressive effects of hemicraniectomy are unclear. We investigated whether reduction of midline shift following hemicraniectomy is associated with improved consciousness and survival in patients with malignant middle cerebral artery infarctions. Methods We studied 70 patients with malignant middle cerebral artery infarctions (MMI) who underwent hemicraniectomies. Midline shift was measured preoperatively and postoperatively using computed tomography (CT). Consciousness level was evaluated using the Glasgow Coma Scale on postoperative day 1. Patient survival was assessed six months after stroke onset. Results The median time interval between preoperative and postoperative CT was 8.3 hours (interquartile range, 6.1–10.2 hours). Reduction in midline shift was associated with higher postoperative Glasgow Coma Scale scores (P<0.05). Forty-three patients (61.4%) were alive at six months after the stroke. Patients with reductions in midline shifts following hemicraniectomy were more likely to be alive at six months post-stroke than those without (P<0.001). Reduction of midline shift was associated with lower mortality at six months after stroke, after adjusting for age, sex, National Institutes of Health Stroke Scale score, and preoperative midline shift (adjusted hazard ratio, 0.71; 95% confidence interval, 0.62–0.81; P<0.001). Conclusions Reduction in midline shift following hemicraniectomy was associated with improved consciousness and six-month survival in patients with MMI. Hence, it may be an early indicator of effective decompression following hemicraniectomy.
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Affiliation(s)
- Sang-Beom Jeon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok Hee Lee
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Cheol Yun
- Division of Epidemiology and Biostatistics Clinical Research Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeon-Jung Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Sung Ahn
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung-Duk Kwun
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - H Alex Choi
- Departments of Neurology and Neurosurgery, TheUniversity of Texas Medical School at Houston, Houston, Texas, USA
| | - Kiwon Lee
- Departments of Neurology and Neurosurgery, TheUniversity of Texas Medical School at Houston, Houston, Texas, USA
| | - Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Volny O, Cimflova P, Mikulik R. Ipsilateral Sinus Hypoplasia and Poor Leptomeningeal Collaterals as Midline Shift Predictors. J Stroke Cerebrovasc Dis 2016; 25:1792-1796. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 04/02/2016] [Indexed: 10/21/2022] Open
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17
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Horsch AD, Dankbaar JW, Stemerdink TA, Bennink E, van Seeters T, Kappelle LJ, Hofmeijer J, de Jong HW, van der Graaf Y, Velthuis BK. Imaging Findings Associated with Space-Occupying Edema in Patients with Large Middle Cerebral Artery Infarcts. AJNR Am J Neuroradiol 2016; 37:831-7. [PMID: 26797136 DOI: 10.3174/ajnr.a4637] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 10/30/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Prominent space-occupying cerebral edema is a devastating complication occurring in some but not all patients with large MCA infarcts. It is unclear why differences in the extent of edema exist. Better knowledge of factors related to prominent edema formation could aid treatment strategies. This study aimed to identify variables associated with the development of prominent edema in patients with large MCA infarcts. MATERIALS AND METHODS From the Dutch Acute Stroke Study (DUST), 137 patients were selected with large MCA infarcts on follow-up NCCT (3 ± 2 days after stroke onset), defined as ASPECTS ≤4. Prominent edema was defined as a midline shift of ≥5 mm on follow-up. Admission patient and treatment characteristics were collected. Admission CT parameters used were ASPECTS on NCCT and CBV and MTT maps, and occlusion site, clot burden, and collaterals on CTA. Permeability on admission CTP, and day 3 recanalization and reperfusion statuses were obtained if available. Unadjusted and adjusted (age and NIHSS) odds ratios were calculated for all variables in relation to prominent edema. RESULTS Prominent edema developed in 51 patients (37%). Adjusted odds ratios for prominent edema were higher with lower ASPECTS on NCCT (adjusted odds ratio, 1.32; 95% CI, 1.13-1.55) and CBV (adjusted odds ratio, 1.26; 95% CI, 1.07-1.49), higher permeability (adjusted odds ratio, 2.35; 95% CI, 1.30-4.24), more proximal thrombus location (adjusted odds ratio, 3.40; 95% CI, 1.57-7.37), higher clot burden (adjusted odds ratio, 2.88; 95% CI, 1.11-7.45), and poor collaterals (adjusted odds ratio, 3.93; 95% CI, 1.78-8.69). CONCLUSIONS Extensive proximal occlusion, poor collaterals, and larger ischemic deficits with higher permeability play a role in the development of prominent edema in large MCA infarcts.
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Affiliation(s)
- A D Horsch
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - J W Dankbaar
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - T A Stemerdink
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - E Bennink
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - T van Seeters
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - L J Kappelle
- Neurology (L.J.K.), Utrecht Stroke Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J Hofmeijer
- Department of Neurology (J.H.), Rijnstate Hospital, Arnhem, the Netherlands
| | - H W de Jong
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - Y van der Graaf
- Julius Center for Health Sciences and Primary Care (Y.v.d.G.), Utrecht, the Netherlands
| | - B K Velthuis
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
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Tong E, Komlosi P, Wintermark M. One-stop-shop stroke imaging with functional CT. Eur J Radiol 2015; 84:2425-31. [DOI: 10.1016/j.ejrad.2014.11.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/19/2014] [Accepted: 11/24/2014] [Indexed: 10/24/2022]
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19
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Maciel CB, Sheth KN. Malignant MCA Stroke: an Update on Surgical Decompression and Future Directions. Curr Atheroscler Rep 2015; 17:40. [DOI: 10.1007/s11883-015-0519-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Chen R, Deng Z, Song Z. The prediction of malignant middle cerebral artery infarction: a predicting approach using random forest. J Stroke Cerebrovasc Dis 2015; 24:958-64. [PMID: 25804564 DOI: 10.1016/j.jstrokecerebrovasdis.2014.12.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 12/04/2014] [Accepted: 12/12/2014] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Malignant middle cerebral artery infarction (MMI) is always associated with high mortality rates. Early decompressive craniectomy is crucial to its treatment. The purpose of this study was to establish a reliable model for an early prediction of MMI. METHODS Using a retrospective survey, we have collected the data of 132 patients with middle cerebral artery infarction. According to a prognosis, the patients are divided into the MMI group (n = 36) and the non-MMI group (n = 96). All the patients are represented by their clinical, biochemical, and imaging features. Then a random forest (RF) prediction model is established on the clinical data. Meanwhile, 3 traditional prediction models, including univariate linear discriminant analysis (LDA) model, multivariate LDA model, and binary logistic regression analysis (BLRA), are built to compare with the RF model. The prediction performance of different models is assessed by the area under the receiver operating characteristic curves (AUCs). RESULTS Four parameters, Glasgow Coma Scale, midline shifting, area, and volume of focus, selected as predictors in all models. As independent predictors, their AUCs are .72-.80, and when the sensitivities are high (.91-.95), the specificities are low (.32-.53). The AUC of RF model is .96, 95% confidence interval (CI) is (.93-.99), sensitivity is 1, and specificity is .85. The AUC of the multivariate LDA model is .87 and 95% CI is (.80-.93). The AUC of the BLRA model is .86 and 95% CI is (.80-.93). CONCLUSIONS The RF performs very well in the given clinical data set, which indicates that the RF is applicable to the early prediction of the MMI.
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Affiliation(s)
- Ru Chen
- Neurological Department, The Third Xiangya Hospital of Central South University, Hunan, China
| | - Zelin Deng
- Department of software engineering, School of Computer and Communication Engineering, Changsha University of Science and Technology, Hunan, China
| | - Zhi Song
- Neurological Department, The Third Xiangya Hospital of Central South University, Hunan, China.
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Abstract
Neuroimaging has expanded beyond its traditional diagnostic role and become a critical tool in the evaluation and management of stroke. The objectives of imaging include prompt accurate diagnosis, treatment triage, prognosis prediction, and secondary preventative precautions. While capitalizing on the latest treatment options and expanding upon the "time is brain" doctrine, the ultimate goal of imaging is to maximize the number of treated patients and improve the outcome of one the most costly and morbid disease. A broad overview of comprehensive multimodal stroke imaging is presented here to affirm its utilization.
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Affiliation(s)
- Elizabeth Tong
- Neuroradiology Division, Department of Radiology, University of Virginia, Charlottesville, Virginia
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Soinne L, Sundararajan S, Strbian D. Malignant hemispheric infarction: diagnosis and management by hemicraniectomy. Stroke 2014; 45:e185-7. [PMID: 25013023 DOI: 10.1161/strokeaha.114.006076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lauri Soinne
- From the Department of Neurology and Stroke Unit, Helsinki University Central Hospital, Helsinki, Finland (L.S., D.S.); and University Hospitals of Cleveland/Case Medical Center, OH (S.S.)
| | - Sophia Sundararajan
- From the Department of Neurology and Stroke Unit, Helsinki University Central Hospital, Helsinki, Finland (L.S., D.S.); and University Hospitals of Cleveland/Case Medical Center, OH (S.S.)
| | - Daniel Strbian
- From the Department of Neurology and Stroke Unit, Helsinki University Central Hospital, Helsinki, Finland (L.S., D.S.); and University Hospitals of Cleveland/Case Medical Center, OH (S.S.)
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Lin LC, Lee JD, Hung YC, Chang CH, Yang JT. Bun/creatinine ratio-based hydration for preventing stroke-in-evolution after acute ischemic stroke. Am J Emerg Med 2014; 32:709-12. [DOI: 10.1016/j.ajem.2014.03.045] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 03/28/2014] [Accepted: 03/29/2014] [Indexed: 11/29/2022] Open
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Neugebauer H, Jüttler E. Hemicraniectomy for malignant middle cerebral artery infarction: current status and future directions. Int J Stroke 2014; 9:460-7. [PMID: 24725828 DOI: 10.1111/ijs.12211] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 09/08/2013] [Indexed: 12/01/2022]
Abstract
Malignant middle cerebral artery infarction is a life-threatening sub-type of ischemic stroke that may only be survived at the expense of permanent disability. Decompressive hemicraniectomy is an effective surgical therapy to reduce mortality and improve functional outcome without promoting most severe disability. Evidence derives from three European randomized controlled trials in patients up to 60 years. The recently finished DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY - II trial gives now high-level evidence for the effectiveness of decompressive hemicraniectomy in patients older than 60 years. Nevertheless, pressing issues persist that need to be answered in future clinical trials, e.g. the acceptable degree of disability in survivors of malignant middle cerebral artery infarction, the importance of aphasia, and the best timing for decompressive hemicraniectomy. This review provides an overview of the current diagnosis and treatment of malignant middle cerebral artery infarction with a focus on decompressive hemicraniectomy and outlines future perspectives.
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Affiliation(s)
- Hermann Neugebauer
- Department of Neurology, RKU - University and Rehabilitation Hospitals, Ulm, Germany
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25
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A simple brain atrophy measure improves the prediction of malignant middle cerebral artery infarction by acute DWI lesion volume. J Neurol 2014; 261:1097-103. [DOI: 10.1007/s00415-014-7324-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Revised: 03/20/2014] [Accepted: 03/20/2014] [Indexed: 12/01/2022]
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Shimoyama T, Kimura K, Uemura J, Yamashita S, Saji N, Shibazaki K, Iguchi Y. The DASH score: A simple score to assess risk for development of malignant middle cerebral artery infarction. J Neurol Sci 2014; 338:102-6. [DOI: 10.1016/j.jns.2013.12.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Revised: 11/26/2013] [Accepted: 12/13/2013] [Indexed: 10/25/2022]
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27
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Wijdicks EFM, Sheth KN, Carter BS, Greer DM, Kasner SE, Kimberly WT, Schwab S, Smith EE, Tamargo RJ, Wintermark M. Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:1222-38. [PMID: 24481970 DOI: 10.1161/01.str.0000441965.15164.d6] [Citation(s) in RCA: 311] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE There are uncertainties surrounding the optimal management of patients with brain swelling after an ischemic stroke. Guidelines are needed on how to manage this major complication, how to provide the best comprehensive neurological and medical care, and how to best inform families facing complex decisions on surgical intervention in deteriorating patients. This scientific statement addresses the early approach to the patient with a swollen ischemic stroke in a cerebral or cerebellar hemisphere. METHODS The writing group used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. The panel reviewed the most relevant articles on adults through computerized searches of the medical literature using MEDLINE, EMBASE, and Web of Science through March 2013. The evidence is organized within the context of the American Heart Association framework and is classified according to the joint American Heart Association/American College of Cardiology Foundation and supplementary American Heart Association Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive American Heart Association internal peer review. RESULTS Clinical criteria are available for hemispheric (involving the entire middle cerebral artery territory or more) and cerebellar (involving the posterior inferior cerebellar artery or superior cerebellar artery) swelling caused by ischemic infarction. Clinical signs that signify deterioration in swollen supratentorial hemispheric ischemic stroke include new or further impairment of consciousness, cerebral ptosis, and changes in pupillary size. In swollen cerebellar infarction, a decrease in level of consciousness occurs as a result of brainstem compression and therefore may include early loss of corneal reflexes and the development of miosis. Standardized definitions should be established to facilitate multicenter and population-based studies of incidence, prevalence, risk factors, and outcomes. Identification of patients at high risk for brain swelling should include clinical and neuroimaging data. If a full resuscitative status is warranted in a patient with a large territorial stroke, admission to a unit with neurological monitoring capabilities is needed. These patients are best admitted to intensive care or stroke units attended by skilled and experienced physicians such as neurointensivists or vascular neurologists. Complex medical care includes airway management and mechanical ventilation, blood pressure control, fluid management, and glucose and temperature control. In swollen supratentorial hemispheric ischemic stroke, routine intracranial pressure monitoring or cerebrospinal fluid diversion is not indicated, but decompressive craniectomy with dural expansion should be considered in patients who continue to deteriorate neurologically. There is uncertainty about the efficacy of decompressive craniectomy in patients ≥60 years of age. In swollen cerebellar stroke, suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically. Ventriculostomy to relieve obstructive hydrocephalus after a cerebellar infarct should be accompanied by decompressive suboccipital craniectomy to avoid deterioration from upward cerebellar displacement. In swollen hemispheric supratentorial infarcts, outcome can be satisfactory, but one should anticipate that one third of patients will be severely disabled and fully dependent on care even after decompressive craniectomy. Surgery after a cerebellar infarct leads to acceptable functional outcome in most patients. CONCLUSIONS Swollen cerebral and cerebellar infarcts are critical conditions that warrant immediate, specialized neurointensive care and often neurosurgical intervention. Decompressive craniectomy is a necessary option in many patients. Selected patients may benefit greatly from such an approach, and although disabled, they may be functionally independent.
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MacCallum C, Churilov L, Mitchell P, Dowling R, Yan B. Low Alberta Stroke Program Early CT Score (ASPECTS) Associated with Malignant Middle Cerebral Artery Infarction. Cerebrovasc Dis 2014; 38:39-45. [DOI: 10.1159/000363619] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 05/15/2014] [Indexed: 11/19/2022] Open
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Siegler JE, Boehme AK, Albright KC, George AJ, Monlezun DJ, Beasley TM, Martin-Schild S. A proposal for the classification of etiologies of neurologic deterioration after acute ischemic stroke. J Stroke Cerebrovasc Dis 2013; 22:e549-56. [PMID: 23867039 DOI: 10.1016/j.jstrokecerebrovasdis.2013.06.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 05/27/2013] [Accepted: 06/08/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Neurologic deterioration (ND) occurs in one third of patients with ischemic stroke and contributes to morbidity and mortality in these patients. Etiologies of ND and clinical outcome according to ND etiology are incompletely understood. METHODS We conducted a retrospective investigation of all patients with ischemic stroke admitted to our center (July 2008 to December 2010), who were known to be last seen normal less than 48 hours before arrival. First-time episodes of ND during hospitalization were collected in which a patient experienced a 2-point increase or more in National Institutes of Health Stroke Scale score within a 24-hour period. Proposed etiologies of reversible ND include infectious, metabolic, hemodynamic, focal cerebral edema, fluctuation, sedation, and seizure, whereas new stroke, progressive stroke, intracerebral hemorrhage, and cardiopulmonary arrest were nonreversible. RESULTS Of 366 included patients (median age 65 years, 41.4% women, 68.3% black), 128 (34.9%) experienced ND (median age 69 years, 42.2% women, 68.7% black). Probable etiologies of ND were identified in 90.6% of all first-time ND events. The most common etiology of ND, progressive stroke, was highly associated with poor outcome but not death. Etiologies most associated with mortality included edema (47.8%), new stroke (50%), and intracerebral hemorrhage (42.1%). CONCLUSIONS In the present study, the authors identified probable etiologies of ND after ischemic stroke. Delineating the cause of ND could play an important role in the management of the patient and help set expectations for prognosis after ND has occurred. Prospective studies are needed to validate these proposed definitions of ND.
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Affiliation(s)
- James E Siegler
- Stroke Program, Department of Neurology, Tulane University Hospital, New Orleans, Louisiana
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