Primary neurocritical care involving therapeutic hypothermia for acute ischemic stroke patients with malignant infarct cores

Abstract

Background: Acute ischemic stroke patients with malignant infarct cores were primarily treated with neurocritical care based on reperfusion and hypothermia. We evaluated the predictors for malignant progression and functional outcomes. Methods: From January 2010 to March 2015 ischemic stroke patients with large vessel occlusion of the anterior circulation with infarct volume >82 mL on baseline diffusion weighted image (DWI) within 6 hours from onset, with National Institutes of Health Stroke Scale ≥15 were included. All patients were managed with intent for reperfusion and neurocritical care. Malignant progression was defined as clinical signs of progressive herniation. Predictive factors for malignant progression and outcomes of decompressive hemicraniectomy (DHC) were evaluated. Results: In total, 49 patients were included in the study. Among them, 33 (67.3%) could be managed with neurocritical care and malignant progression was observed in the remainder. Decompressive surgery was performed in nine patients (18.4%). Factors predictive of malignant progression were initial DWI volumes (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.00 to 1.02; P=0.046) and parenchymal hematoma (OR, 6.77; 95% CI, 1.50 to 30.53; P=0.013) on computed tomography taken at Day 1. Infarct volume of >210 mL predicted malignant progression with 56.3% sensitivity and 90.9% specificity. Among the malignant progressors, 77.7% resulted in grave outcomes even with DHC, while all patients who declined surgery died. Conclusion: Acute ischemic stroke patients with malignant cores between 82 to 209 mL can be primarily treated with neurocritical care based on reperfusion and hypothermia with feasible results. In patients undergoing surgical decompression due to malignant progression, the functional outcomes were not satisfactory.

Optic nerve sheath diameter change in prediction of malignant cerebral edema in ischemic stroke: an observational study

“…For all patients, DHC was usually performed based on clinical signs while managed with neurocritical care. During this period, patients that showed clinical signs such as altered mental status, flexor or extensor motor posturing, pupillary abnormality, repiratory pattern changes, eye movement impairments, or respiratory pattern abnormalities [ 22 ], with evidence of imminent herniation in CT was classified “malignant progressors [ 23 ].” Malignant progression was further divided into early malignant progression if it occurred after CT postprocedure and before CT D1 , and late malignant progression if it occurred after CT D1 . DHC was performed upon consent regardless of age or whether thrombolysis was performed.…”

Selective Brain Cooling: A New Horizon of Neuroprotection

“…TH is a common term for defining intentional cooling in core body temperature and has evolved over decades into a strategy for a more comprehensive control of body temperature. It is now called targeted temperature management (TTM) (11,16,17). Clinical trials have proven that TH is effective in post-cardiac arrest and neonatal hypoxic-ischemic encephalopathy (18)(19)(20).…”

Targeted temperature management for ischemic stroke

“…3). A recent study has shown that neurocritical care treatments including TH are feasible even in patients with a malignant infarct core [39]. Therefore, the strategy reducing reperfusion injury using TH will be another option for vulnerable patients suffering from acute ischemic stroke in the EVT era.…”