Predicting Mortality in Patients With “Malignant” Middle Cerebral Artery Infarction Using Susceptibility-Weighted Magnetic Resonance Imaging

Abstract

To evaluate malignant middle cerebral artery (MCA) infarction (defined as space-occupying edema in more than 50% to 75% of the MCA territory) on magnetic resonance imaging (MRI) with susceptibility-weighted imaging (SWI) sequence and assess the usefulness of SWI findings, diffusion-weighted imaging (DWI) findings, and apparent diffusion coefficient (ADC) as predictors of clinical outcome.Data from 16 patients with large MCA infarction previously admitted to our institution between December 2009 and October 2012 were retrospectively collected and analyzed. Within 7 days after stroke onset, 1 neurologist and 1 neuroradiologist estimated the area of infarction on DWI/ADC and extent of prominent vessel sign (PVS) on SWI images using the Stroke Program Early MR Score (SPEMRS). The PVS on SWI was defined as a local prominence of hypointense vessels with either increased vessel number or diameter in the target area, when compared with the number or diameter of the contralateral MCA territory vessels.Six patients died and 10 survived. Although the DWI/ADC-SPEMRS and clinical profiles were similar between the nonsurvivor and survivor groups, SWI-SPEMRS was significantly lower in the nonsurvivor group (P < 0.001).The area of deoxygenation on SWI in patients with malignant MCA infarction can predict mortality. Lower SWI-SPEMRS is a potentially better predictor of poor outcome than lower DWI-SPEMRS. A larger prospective study is needed to clarify the role of SWI as a therapeutic guide in malignant MCA.

Functional Outcome After Decompressive Craniectomy in Patients with Dominant or Non-Dominant Malignant Middle Cerebral Infarcts

“…Space-occupying edema in more than 50% to 75% of the middle cerebral artery region is known as malignant cerebral infarction [2]. Decompressive craniectomy (DC) is a life-saving surgery for patients with space-occupying hemispheric infarction due to limited medical treatments [3-5].…”

Fewer peripheral asymmetrical cortical veins is a predictor of favorable outcome in MCA infarctions with SWI‐DWI mismatch

“…Cerebral infarction in the middle cerebral artery (MCA) territories, the most devastating brain infarction, accounts for about 73.3% of ischemic strokes . The discrimination between the two categories, benign and malignant cerebral infarctions, is critical for early and effective prediction of the evolution of cerebral infarctions in MCA territories . There are three ischemic tissue compartments: the ischemia core, the area oligemia, and the peneumbra .…”

“…Susceptibility‐weighted imaging (SWI) is a magnetic resonance imaging (MRI) sequence that results from an increased contrast and conspicuity of ‐lesions via combining the phase mask and the gradient echo magnitude map . It does not require the application of contrast agents and has been demonstrated to have great utility, such as cerebral microbleeds or intracranial hemorrhage, intra‐arterial clot, prediction of hemorrhage transformation, assessment of brain tissue viability, as well as collateral circulation . Previous studies had shown that prominent or increased asymmetrical prominent cortical veins (APCVs) seen on SWI were more likely to develop later brain edema and had lower rates of a favorable outcome .…”

“…1 The discrimination between the two categories, benign and malignant cerebral infarctions, is critical for early and effective prediction of the evolution of cerebral infarctions in MCA territories. 2 There are three ischemic tissue compartments: the ischemia core, the area oligemia, and the peneumbra. 3 The area of oligemia and the penumbra can turn into infarction and then the volume of infarction lesions increases if there is repeated and more serious hypoperfusion.…”

“…[11][12][13] It does not require the application of contrast agents and has been demonstrated to have great utility, such as cerebral microbleeds or intracranial hemorrhage, intraarterial clot, prediction of hemorrhage transformation, assessment of brain tissue viability, as well as collateral circulation. 2,14 Previous studies had shown that prominent or increased asymmetrical prominent cortical veins (APCVs) seen on SWI were more likely to develop later brain edema and had lower rates of a favorable outcome. 2,[14][15][16] It was further noted that the change of APCVs, mainly the prominent APCVs, was correlated with clinical outcomes, although the correlation was inconsistent.…”