Baroreflex Sensitivity to Predict Malignant Middle Cerebral Artery Infarction

Abstract

Background and Purpose-Hemicraniectomy has been shown to be an effective treatment of life-threatening edema (LTE) in malignant middle cerebral artery infarction when performed early. Identifying patients who will develop LTE is therefore imperative. We hypothesize that autonomic shift toward sympathetic dominance may relate to LTE formation. We aimed to investigate the predictive potential of baroreflex sensitivity (BRS) as a marker of autonomic balance for calculating the course of large middle cerebral artery infarction. Methods-Patients with middle cerebral artery infarction Ͼ2/3 of the territory and BRS measurement at admission were analyzed. BRS was estimated using the cross-correlational method. Demographic, clinical, and radiological data including stroke severity, infarct size, and basal ganglia involvement were recorded. Malignant course with LTE was defined as clinical deterioration and midline shift Ն5 mm in the first 48 hours. Results-Eighteen

Imaging Findings Associated with Space-Occupying Edema in Patients with Large Middle Cerebral Artery Infarcts

“…16 On day 3 Ϯ 2 of follow-up, the infarct size was classified with ASPECTS and the presence of prominent space-occupying edema was defined as a midline shift of Ն5 mm (Fig 2). 11,18,19 Any hemorrhagic transformation on the follow-up scan was classified according to the ECASS criteria to identify patients with a parenchymal hemorrhage type 2 (hemorrhage of Ͼ30% of the infarcted area with substantial space-occupying effect), because the midline shift in those patients is considered secondary to the large hemorrhage. 17 CTP.…”

“…20 Involvement of the lentiform nucleus and additional anterior cerebral artery (ACA) vascular territory (including the caudate nucleus) was also evaluated separately. 11,21 Reperfusion was evaluated quantitatively by assessment of the change in MTT abnormality (Soares et al 22 ) and categorized into reperfusion and no-reperfusion groups. Reperfusion was defined as a resolution of Ն75% of the abnormality on the MTT maps comparing admission and follow-up CTP.…”

Recommendations for the Management of Cerebral and Cerebellar Infarction With Swelling

“…22 One series reported altered baroreceptor sensitivity as an early predictor of life-threatening edema; however, this observation has not been prospectively confirmed. 47 …”

“…29,61,62 Other descriptions include effacement of the ipsilateral sulci and lateral ventricle 63 and CT signs of elevated ICP. 64 Most commonly, the degree of midline shift is used as the benchmark for radiographic deterioration, either undefined 16,60,65 or specified as >5 mm at the level of septum pellucidum, 19,41,47,[66][67][68] >2 mm at the level of septum pellucidum or pineal gland, 69,70 or >10 mm. 71 Although all these arbitrary parameters are indicative of tissue shift, further development and validation of serial CT measures that identify patients at highest risk of clinical deterioration are required.…”

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

“…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.…”