Enhanced Detection of Edema in Malignant Anterior Circulation Stroke (EDEMA) Score

Abstract

Background and Purpose Rapid recognition of those at high-risk for malignant edema after stroke would facilitate triage for monitoring and potential surgery. Admission data may be insufficient for accurate triage decisions. We developed a risk prediction score using clinical and radiographic variables within 24 hours of ictus to better predict potentially lethal malignant edema (PLME). Methods Patients admitted with diagnosis codes of “Cerebral Edema” and “Ischemic Stroke,” NIHSS ≥ 8, and head CTs within 24 hours of stroke-onset were included. Primary outcome of PLME was defined as death with midline shift (MLS) ≥ 5mm or Decompressive Hemicraniectomy. We performed multivariate analyses on data available within 24 hours of ictus. Bootstrapping was used to internally validate the model and a risk score was constructed from the results. Results 33% of 222 patients developed PLME. The final model c-statistic was 0.76 (CI 0.68-0.82) in the derivation cohort, and 0.75 (0.72-0.77) in the bootstrapping validation sample. The EDEMA score was developed using the following independent predictors: Basal cistern effacement (=3); Glucose ≥150 (=2); No tPA or thrombectomy (=1), MLS >0-3 (=1), 3-6 (=2), 6-9 (=4); >9 (=7); No prior stroke (=1). A score over 7 was associated with 93% positive predictive value. Conclusion The EDEMA score identifies patients at high risk for PLME. While it requires external validation, this scale could help expedite triage decisions in this patient population.

A Web Based Dynamic MANA Nomogram for Predicting the Malignant Cerebral Edema in patients with large hemispheric infarction

“…We identi ed four independent predictors of MCE in this study, The three of which were consistent with previous studies, including NIHSS, MLS and ACA territory involvement (17,18). The association between KAF and MCE is still controversial.…”

“…Furthermore, traditional scoring model of MCE enrolled NHISS and MLS as categorical variables for the convenience of clinical use, which may end up degrading the precision (15)(16)(17)(18). Nomogram can get rid of that limitation but is not as clinically accessible as scoring model.…”

Exploratory analysis of oral glibenclamide in acute ischemic stroke

“…This novel action of GBC has been attributed to the blockage of the Sur1-Trpm4 channel, which, when activated, allows ingress of cations into affected cells, resulting in cytotoxic edema, cell lysis, and blood-brain barrier disruption. 17 As expected, oral GBC treatment seemed to prevent the development of brain edema, as reflected in decrease in CED scores. 28 Retrospective studies in diabetics with acute ischemic stroke and used sulfonylurea around the onset have suggested a protective role of sulfonylurea in blood-brain barrier.…”

“…After matching, the subjects in these two groups had comparable EDEMA score at baseline, indicating that they had similar risks in developing malignant edema. 17 As expected, oral GBC treatment seemed to prevent the development of brain edema, as reflected in decrease in CED scores. Moreover, we observed a slight trend toward less severe disability and death (mRS of 5 and 6) after GBC treatment, which might partly be attributed to the prevention of brain edema.…”

“…20 The stroke subtypes for TOAST and Enhanced Detection of Edema in Malignant Anterior Circulation Stroke (EDEMA) score at admission were obtained to help identifying risk of developing malignant edema at baseline. 17 The severity of brain edema, if presented within 96 hours of admission, was classified into three types based on the radiological appearance: CED 1 (focal edema up to one third of the hemisphere), CED 2 (focal edema greater than one third of the hemisphere), and CED 3 (edema with midline shift). 21 The number of patients receiving antiplatelet and/ or anticoagulant treatment, vasopressor, and mechanical ventilation during hospitalization was also recorded.…”