Predictors of malignant brain edema in middle cerebral artery infarction observed on CT angiography

Kim, Hoon; Jin, Seon Tak; Kim, Young Woo; Kim, Seong Rim; Park, Ik Seong; Jo, Kwang Wook

doi:10.1016/j.jocn.2014.08.021

Cited by 46 publications

(44 citation statements)

References 18 publications

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“…The involvement of additional vas- [22,23] and carotid occlusion [24] additionally predicted a fatal outcome. The extent of collateral circulation to the ischemic territory can be analyzed by CT angiography: a collateral score of less than 2 derived from these images was shown to be an independent predictor of malignant brain edema in addition to an NIHSS score of >18 [25] .…”

Section: Ctmentioning

confidence: 99%

Malignant MCA Infarction: Pathophysiology and Imaging for Early Diagnosis and Management Decisions

Heiss

2015

Cerebrovasc Dis

111

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Background: Malignant middle cerebral artery infarction is a devastating condition, with up to 80% mortality in conservatively treated patients. The pathophysiology of this stroke is characterized by a large core of severe ischemia and only a relatively small rim of penumbra. Due to the fast development of irreversible morphological damage, cytotoxic edema occurs immediately in a large portion of the ischemic territory. The subsequent damage of the tight junctions leads to the breakdown of the blood brain barrier and vasogenic brain edema, resulting in space-occupying brain swelling. The progressive vasogenic edema reaches its maximum after 1 to several days and exerts a mechanical force on surrounding tissue structures leading to midline shift and transtentorial herniation and finally brain stem compression and death. Summary: Early severe neurological symptoms - hemiparesis, gaze deviation, higher cortical signs - followed by headache, vomiting, papillo edema and reduced consciousness may predict the deleterious course. Imaging supports the suspected diagnosis with hypodense changes on CT extending beyond 50% of the MCA territory. The size of the probably infarcted tissue and a midline shift on CT as well as the size of the lesion on diffusion-weighted MRI are predictive of a malignant course. Reduction of cerebral blood flow below a critical value and volume of irreversible tissue damage detected by positron emission tomography in the early hours after the stroke are indicative of progression to malignant infarction with increased intracranial pressure (ICP) and decreased tissue oxygen tension observed by multimodal neuromonitoring in the later course. Treatment options of malignant infarction include general measures to limit the extent of space-occupying edema, but these therapies have not been efficacious. Only surgical intervention with decompressive hemicraniectomy (DHC) was successful in relieving the effects of increased ICP and of the deleterious shifts of brain tissue. Several controlled clinical trials have proven the efficacy of DHC with a significant decrease in mortality and improved functional outcome. However, DHC must be performed early and with a large diameter, regardless of the age of patients, but in patients beyond 60 years, the higher likelihood of resulting severe disability should be taken into consideration. Key Messages: Malignant MCA infarction can be predicted early with a high sensitivity by neuroimaging. The early diagnosis is mandatory for DHC, which was shown to reduce mortality and improve functional outcome in several controlled clinical trials.

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Section: Ctmentioning

confidence: 99%

Malignant MCA Infarction: Pathophysiology and Imaging for Early Diagnosis and Management Decisions

Heiss

2015

Cerebrovasc Dis

111

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“…Thirty percent of the cohort had left-sided strokes. Mean NIHSS was 19, [IQR [13][14][15][16][17][18][19][20][21][22][23][24]. Twelve of 30 patients (40 %) had expired by discharge.…”

Section: Resultsmentioning

confidence: 99%

“…NIHSS is a well-established marker of clinical stroke severity and predictor of malignant edema [15][16][17], leading to its role as an important inclusion criterion in the previous DHC trials [7][8][9]. However, among these studies, definitions of severe stroke varied between NIHSS of 16 and 21, and a standardized cutoff has not been explicitly studied.…”

Section: Discussionmentioning

confidence: 99%

The Role of Osmotic Therapy in Hemispheric Stroke

2015

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Our results suggest that patients with moderate size hemispheric infarcts on presentation and those who do not require OT within the first 24 h of stroke may survive until discharge with medical management alone. Black race was also associated with conservative management failure, a finding that may reflect a cultural preference toward aggressive management. Further prospective studies are needed to better establish the utility of medical management of hemispheric edema in the setting of moderate size hemispheric infarcts.

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“…Meta-analysis attempts have been made difficult by large differences in inclusion criteria of these studies, different cutoffs for infarct size and perfusion area, and heterogeneity on midline shift measurements [37]. As expected, patients with life-threatening edema tend to have higher National Institute of Health Stroke Scale (NIHSS) scores on admission [6,34,[38][39][40][41], are younger [34,[40][41][42][43], and more often had combined occlusion of MCA and either internal carotid artery, anterior cerebral artery, or posterior cerebral artery [3,6,34,37,41,42,44]. Carotid occlusions with ipsilateral abnormal circle of Willis as well as marginal leptomeningeal collateral supply have also been suggested as risk factors [42].…”

Section: Predictors Of a Malignant Coursementioning

confidence: 94%

“…Infarct volume size [6,34,37,38,40,41,44,47,48], intracranial volume reserve [6,43,49], infarct permeability area [40], severity of ischemia [34,50], collateral supply [39,48], clot burden [39,48], presence of a prominent anterior temporal artery on imaging [51], lower extracellular levels of nontransmitter amino acids in the perilesional tissue [33], multimodality monitoring to assess cerebral autoregulation [45,52], impairment of autonomic regulation [53], specific electroencephalographic patterns [54,55], and pathologic brainstem auditory evoked potential responses [46] have all been proposed as potential biomarkers of developing MMI. Several different studies strived to identify the most accurate methods for quantifying the infarct extent, collateral supply, and surrogates for pre-existing atrophy.…”

Section: Predictors Of a Malignant Coursementioning

confidence: 99%

Malignant MCA Stroke: an Update on Surgical Decompression and Future Directions

Maciel

Sheth

2015

Curr Atheroscler Rep

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Despite a decline over the past decade in overall stroke mortality, hemispheric strokes retain a strikingly high mortality due to their potential for malignant edema and herniation. The pathogenesis of ischemic cerebral edema is steered by disruption of ionic homeostasis in the neurogliovascular unit. Significant effort has been made to identify potential medical therapies targeting edema formation with promising results. To date, decompressive craniectomy remains the therapy with the most robust impact on mortality. Historically, patient selection for surgical treatment of malignant supratentorial strokes has focused on a strict age cutoff and hemispheric dominance. Recent evidence supports a significant mortality benefit in elderly population, although the impact in morbidity is modest. Careful patient selection for surgical treatment in conjunction with comprehensive neurocritical care and inclusion of family in the educated decision making process remain the mainstay of care for such shattering disease.

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Predictors of malignant brain edema in middle cerebral artery infarction observed on CT angiography

Cited by 46 publications

References 18 publications

Malignant MCA Infarction: Pathophysiology and Imaging for Early Diagnosis and Management Decisions

Malignant MCA Infarction: Pathophysiology and Imaging for Early Diagnosis and Management Decisions

The Role of Osmotic Therapy in Hemispheric Stroke

Malignant MCA Stroke: an Update on Surgical Decompression and Future Directions

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