Predictors of Fatal Brain Edema in Massive Hemispheric Ischemic Stroke

Abstract

Background and Purpose-Early identification of stroke patients at risk for fatal brain edema may be useful in selecting patients for aggressive interventions. Prior studies suggested that early nausea/vomiting and major hypodensity on baseline computed tomography (CT) were predictive of herniation. Methods-This study was a retrospective multicenter case-control study of patients with large middle cerebral artery (MCA) strokes admitted within 48 hours of symptom onset. Medical records, laboratory data, and CT scans were analyzed. Cases, defined as patients who died of massive brain swelling, were compared with all remaining patients as controls. Results-Two hundred one patients with large MCA strokes were identified: 94 (47%) died of brain swelling, 12 (6%) died of non-neurological causes, and 95 (47%) survived at day 30. Multivariable analysis, adjusted for age and clustered by center, identified the following predictors of fatal brain edema: history of hypertension (OR 3.0, 95% CI 1.2 to 7.6, Pϭ0.02), history of heart failure (OR 2.1, 95% CI 1.5 to 3.0, PϽ0.001), elevated white blood cell count (OR 1.08 per 1000 white blood cells/L, 95% CI 1.01 to 1.14, Pϭ0.02), Ͼ50% MCA hypodensity (OR 6.3, 95% CI 3.5 to 11.6, PϽ0.001), and involvement of additional vascular territories (anterior cerebral artery, posterior cerebral artery, or anterior choroidal artery; OR 3.3, 95% CI 1.2 to 9.4, Pϭ0.02). Initial level of consciousness, National Institutes of Health Stroke Scale score, early nausea/vomiting, and serum glucose were associated with neurological death in bivariable but not multivariable analyses. Conclusions-Among patients with large MCA infarctions, an increased risk of fatal brain edema is associated with history of hypertension or heart failure, increased baseline white blood cell count, major early CT hypodensity involving Ͼ50% of the MCA territory, and involvement of additional vascular territories. These data confirm and expand on prior research with a broad-based patient population. The presence of these risk factors identifies those stroke patients who may require aggressive therapeutic approaches. (Stroke. 2001;32:2117-2123.)

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

“…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.…”

Multimodal Reperfusion Therapy for Large Hemispheric Infarcts in Octogenarians: Is Good Outcome a Realistic Goal?

“…[3][4][5][6] In most cases, mortality is caused by brain herniation secondary to increased intracranial pressure resulting from stroke-associated edema. [7][8][9] The only way to prevent such a malignant course of events seems to be rapid tissue reperfusion after arterial recanalization. The chances of recanalizing the occluded vessel and restoring perfusion appear to be somewhat higher with endovascular approaches that combine more than one treatment technique, [10][11][12][13][14][15][16][17][18][19][20] and this is now considered a valid therapeutic approach in many patients with large strokes.…”

The role of imaging in acute ischemic stroke

“…28,44,46,141,143,216 NCHCT findings that predict malignant edema and poor prognosis include frank hypodensity on NCHCT within the first 6 hours and involvement of one-third of the MCA territory or more. 101,115,117,142 The presence of a dense MCA sign 142 or midline shift of 5 mm or more within the first 2 days 45 are also associated with neurological deterioration and early mortality. Blood-brain barrier permeability measurement on admission PCT have been shown to be highly sensitive in predicting malignant edema and hemorrhagic transformation (100% sensitivity and 79% specificity).…”