Recommendations for the Management of Cerebral and Cerebellar Infarction With Swelling

Wijdicks, Eelco F. M.; Sheth, Kevin N; Carter, Bob S.; Greer, David M.; Kasner, Scott E.; Kimberly, W. Taylor; Schwab, Stefan; Smith, Eric E.; Tamargo, Rafael J.; Wintermark, Max

doi:10.1161/01.str.0000441965.15164.d6

Cited by 410 publications

(215 citation statements)

References 180 publications

(219 reference statements)

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“…Furthermore, pupillary dilation can develop within the first 3 to 5 days and may indicate the presence of significant brainstem shift and clinical deterioration. 33 Patients with pupillary abnormalities were significantly more likely to have poor outcomes. Waiting for evidence of pupillary dilation can impede early intervention and worsens prognosis.…”

Section: Discussionmentioning

confidence: 97%

Decompressive hemicraniectomy: predictors of functional outcome in patients with ischemic stroke

Daou

Kent

Montaño

et al. 2016

JNS

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P atients presenting with large ischemic strokes may develop uncontrollable, progressive brain edema that puts them at risk for compression of brain parenchyma and cerebral herniation. 23 There are a limited number of therapeutic options, but research has shown that operative procedures, such as decompressive hemicraniectomy (DH), decrease patient mortality.32 Malignant infarction treated only by conservative approaches results in a mortality rate of 80% within the 1st week of the stroke. 15Edema that does not respond to medical treatment necessitates DH as a life-saving procedure. Studies have demonstrated that DH surgery can result in a reduction of mortality rate to 30% and, if decompression is performed within 24 hours of stroke onset, to 10%. 7,12,18,24,32 While DH imabbreviatioNs BMI = body mass index; DH = decompressive hemicraniectomy; DVT = deep vein thrombosis; ICA = internal carotid artery; IVC = inferior vena cava; MCA = middle cerebral artery; MI = myocardial infarction; MLS = midline shift; mRS = modified Rankin Scale; NIHSS = National Institutes of Health Stroke Scale; tPA = tissue plasminogen activator. obJective Patients presenting with large-territory ischemic strokes may develop intractable cerebral edema that puts them at risk of death unless intervention is performed. The purpose of this study was to identify predictors of outcome for decompressive hemicraniectomy (DH) in ischemic stroke. methods The authors conducted a retrospective electronic medical record review of 1624 patients from 2006 to 2014. Subjects were screened for DH secondary to ischemic stroke involving the middle cerebral artery, internal carotid artery, or both. Ninety-five individuals were identified. Univariate and multivariate analyses were performed for an array of clinical variables in relationship to functional outcome according to the modified Rankin Scale (mRS). Clinical outcome was assessed at 90 days and at the latest follow-up (mean duration 16.5 months). results The mean mRS score at 90 days and at the latest follow-up post-DH was 4. Good functional outcome was observed in 40% of patients at 90 days and in 48% of patient at the latest follow-up. The mortality rate at 90 days was 18% and at the last follow-up 20%. Univariate analysis identified a greater likelihood of poor functional outcome (mRS scores of 4-6) in patients with a history of stroke .66]; p = 0.017), peak midline shift (MLS) > 10 mm ]; p = 0.011), or a history of myocardial infarction ]; p = 0.04). Multivariate analysis demonstrated elevated odds of poor functional outcome associated with a history of stroke .05]; p = 0.008), MLS > 10 mm ; p = 0.007), a history of diabetes .88]; p = 0.01), delayed time from onset of stroke to DH (OR 1.32 [95% CI 1.02-1.72]; p = 0.037), and evidence of pupillary dilation prior to DH .51]; p = 0.04). Patients with infarction involving the dominant hemisphere had higher odds of unfavorable functional outcome at 90 days ]; p = 0.014), but at the latest follow-up, cerebral dominance was not significantly related to outc...

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Section: Discussionmentioning

confidence: 97%

Decompressive hemicraniectomy: predictors of functional outcome in patients with ischemic stroke

Daou

Kent

Montaño

et al. 2016

JNS

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“…''Malignant'' cerebral edema (i.e., brain swelling) can cause significant neurological morbidity or even death after large hemispheric ischemic strokes 1,2 and is an independent predictor of poor outcome after ischemic stroke.…”

Section: Introductionmentioning

confidence: 99%

Deletion of the WNK3-SPAK kinase complex in mice improves radiographic and clinical outcomes in malignant cerebral edema after ischemic stroke

Zhao

Nepomuceno

Gào

et al. 2016

J Cereb Blood Flow Metab

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The WNK-SPAK kinase signaling pathway controls renal NaCl reabsorption and systemic blood pressure by regulating ion transporters and channels. A WNK3-SPAK complex is highly expressed in brain, but its function in this organ remains unclear. Here, we investigated the role of this kinase complex in brain edema and white matter injury after ischemic stroke. Wild-type, WNK3 knockout, and SPAK heterozygous or knockout mice underwent transient middle cerebral artery occlusion. One cohort of mice underwent magnetic resonance imaging. Ex-vivo brains three days postischemia were imaged by slice-selective spin-echo diffusion tensor imaging magnetic resonance imaging, after which the same brain tissues were subjected to immunofluorescence staining. A second cohort of mice underwent neurological deficit analysis up to 14 days post-transient middle cerebral artery occlusion. Relative to wild-type mice, WNK3 knockout, SPAK heterozygous, and SPAK knockout mice each exhibited a >50% reduction in infarct size and associated cerebral edema, significantly less demyelination, and improved neurological outcomes. We conclude that WNK3-SPAK signaling regulates brain swelling, gray matter injury, and demyelination after ischemic stroke, and that WNK3-SPAK inhibition has therapeutic potential for treating malignant cerebral edema in the setting of middle cerebral artery stroke.

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“…This early finding may predict early deterioration, worse prognosis and greater risk of hemorrhage following thrombolysis (46). Distal MCA branch occlusions have less swelling and mass effect compared to internal carotid artery (ICA) and proximal MCA occlusions with less serious clinical implications (48). Early hypoattenuation on a CT reflects severe hypoperfusion and possible irreversible damage (49).…”

Section: Neuroimaging For Diagnosismentioning

confidence: 99%

“…Detection of MCA territory hypodensity on hyperacute CT scans is a sensitive, prognostic, and reliable indicator of the amount of MCA territory undergoing infarction (50).VonKummar et al showed that less than 33% of the MCA territory parenchymal hypoattenuation predicted a good response to rtPA (51). Frank hypodensity within 6 hours or damage to one third or more of the MCA territory predicts poor prognosis and malignant edema (48). Other early parenchymal signs include attenuation of lentiform nucleus, hemispheric sulcal effacement and a midline shift (52).…”

Section: Neuroimaging For Diagnosismentioning

confidence: 99%

“…It reduces mortality and is recommended in patients <60 years of age with unilateral MCA occlusion who deteriorate within 48 hours despite medical therapy. While it improves survival, most patients continue to have permanent disabilities (48 (78). Abnormalities on the non-contrast head CT scan remains the first-line imaging study in suspected stroke patients due to its ubiquity and exquisite sensitivity for ruling out hemorrhagic strokes (46).…”

Section: Treatmentmentioning

confidence: 99%

See 1 more Smart Citation

Acute Ischemic Stroke Management Review for the Hospitalist

Haldal¹,

Beary²,

Nattanmai³

et al. 2018

Am J Hosp Med

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Recommendations for the Management of Cerebral and Cerebellar Infarction With Swelling

Cited by 410 publications

References 180 publications

Decompressive hemicraniectomy: predictors of functional outcome in patients with ischemic stroke

Decompressive hemicraniectomy: predictors of functional outcome in patients with ischemic stroke

Deletion of the WNK3-SPAK kinase complex in mice improves radiographic and clinical outcomes in malignant cerebral edema after ischemic stroke

Acute Ischemic Stroke Management Review for the Hospitalist

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