Rapid revascularization is highly effective for acute stroke, but animal studies suggest that reperfusion edema may attenuate its beneficial effects. We investigated the relationship between reperfusion and edema in patients from the Echoplanar Imaging Thrombolysis Evaluation Trial (EPITHET) and Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE) cohorts. Reperfusion percentage was measured as the difference in perfusion-weighted imaging lesion volume between baseline and follow-up (day 3-5 for EPITHET; day 6-8 for MR RESCUE). Midline shift (MLS) and swelling volume were quantified on follow-up MRI. We found that reperfusion was associated with less MLS (EPITHET: Spearman ρ = -0.46; P < 0.001, and MR RESCUE: Spearman ρ = -0.49; P < 0.001) and lower swelling volume (EPITHET: Spearman ρ = -0.56; P < 0.001, and MR RESCUE: Spearman ρ = -0.27; P = 0.026). Multivariable analyses performed in EPITHET and MR RESCUE demonstrated that reperfusion independently predicted both less MLS (ß coefficient = -0.056; P = 0.025, and ß coefficient = -0.38; P = 0.028, respectively) and lower swelling volumes (ß coefficient = -4.7; P = 0.007, and ß coefficient = -10.7; P = 0.009, respectively), after adjusting for age, sex, NIHSS, admission glucose and follow-up lesion size. Taken together, our data suggest that even modest improvement in perfusion is associated with less brain edema in EPITHET and MR RESCUE.

The ratio of ipsilateral to contralateral hemisphere volume, baseline lesion volume and lesional swelling volume best predicted poor outcome across a spectrum of stroke sizes.

Background Deterioration in the National Institutes of Health Stroke Scale (NIHSS) in the early days after stroke is associated with progressive infarction, brain edema and/or hemorrhage, leading to worse outcome. Aims We sought to determine whether a stable NIHSS score represents an adverse or favorable course. Methods Brain magnetic resonance images (MRI) from a research cohort of acute ischemic stroke patients were analyzed. Using NIHSS scores at baseline and follow-up (day 3-5), patients were categorized into early neurological deterioration (END, ΔNIHSS ≥4), early neurological recovery (ENR, ΔNIHSS, ≥−4) or early neurological stability (ENS, ΔNIHSS between −3 and 3). The association between these categories and the volume of infarct growth, volume of swelling, parenchymal hematoma (PH) and 3 month modified Rankin Scale (mRS) score were evaluated. Results Patients with END or ENS were less likely to be independent (mRS 0-2) at 3 months compared to those with ENR (P<0.001). Patients with END or ENS were observed to have significantly greater infarct growth and swelling volumes than those with ENR (P=0.03; P<0.001, respectively). Brain edema was more common than the other imaging markers investigated and was independently associated with a stable or worsening NIHSS score after adjustment for age, baseline stroke volume, infarct growth volume, presence of PH, and reperfusion (P<0.0001). Conclusions Stable NIHSS score in the subacute period after ischemic stroke may not be benign, and is associated with tissue injury including infarct growth and brain edema. Early improvement is considerably more likely to occur in the absence of these factors.

Background and Purpose— Sulfonylurea medications have been linked to reduced brain edema and improved outcome following ischemic stroke, but their effects on primary intracerebral hemorrhage (pICH) have not been thoroughly explored. Increasing ICH volume and perihematomal edema (PHE) volume are predictors of poor outcome in pICH. We investigated whether preexisting sulfonylurea use influenced ICH volume, PHE volume, and discharge disposition in patients with type 2 diabetes mellitus presenting with pICH. Methods— We performed a retrospective chart review of all diabetic patients presenting with pICH to 2 tertiary academic centers from 2006 to 2016. All patients with diabetes mellitus, pICH, admission computed tomography scan, and sulfonylurea use on admission were included in our study. For each case, 2-matched controls (admission date, age, hematoma location [deep versus lobar], use of antiplatelet, or anticoagulant) with diabetes mellitus and pICH were consecutively selected. ICH and PHE volumes were measured via region of interest analysis on admission computed tomography. To mitigate the influence of ICH volume on PHE, the PHE/ICH surface area ratio was calculated. Hospital discharge disposition was determined via chart abstraction. We used the Wilcoxon rank-sum test and Fisher exact test to compare cases and controls. Results— Of 317 patients screened, 21 sulfonylurea cases and 42-matched controls met criteria for study inclusion. Sulfonylurea cases had significantly lower admission ICH volumes (median, 4 mL; interquartile range [IQR], 2–30 versus median, 25 mL; IQR, 6–60; P =0.011), PHE volumes (median, 4 mL; IQR, 0.9–24 versus median, 17; IQR, 6–37; P =0.0095), and PHE/ICH surface area ratios (median, 0.28; IQR, 0.1–0.4 versus median, 0.43; IQR, 0.3–0.6; P =0.013) as compared with controls. Sulfonylureas were associated with improved discharge disposition ( P =0.0062). Conclusions— In patients with diabetes mellitus and pICH, sulfonylurea use predicted lower ICH and PHE volumes, lower relative PHE, and improved discharge disposition. Given the paucity of treatment options for pICH, further study of sulfonylureas is warranted.