99m Technetium-Ethyl-Cysteinate-Dimer Single-Photon Emission CT Can Predict Fatal Ischemic Brain Edema

113

Background and Purpose-Early neurological deterioration (END) is a relatively common unfavorable course after anterior circulation ischemic stroke that can lead to worse clinical outcome. None of the END predictors identified so far is sufficiently reliable to be used in clinical practice and the mechanisms underlying END are not fully understood. We review the evidence from the literature for a role of hemodynamic and perfusion abnormalities, more specifically infarction of the oligemia, in END. Summary of Review-After an overview of the neuroimaging, including perfusion imaging, predictors of END, we review the putative mechanisms of END with a special focus on hemodynamic factors. The evidence relating perfusion abnormalities to END is addressed and potential hemodynamic mechanisms are suggested. Conclusions-Hemodynamic factors and perfusion abnormalities are likely to play a critical role in END. Infarction of the oligemic tissue surrounding the penumbra could be the putative culprit leading to END as a result of perfusion, but also physiological and biochemical abnormalities. Further studies addressing the role of the oligemia in END and developing measures to protect its progression to infarction are now needed. (Stroke. 2009;40:e443-e450.)

Section: Malignant MMImentioning

confidence: 99%

Hemodynamic Factors and Perfusion Abnormalities in Early Neurological Deterioration

Alawneh

Moustafa

Baron

2009

113

“…[3][4][5] However, the critical questions regarding DHC remain: whom to treat and when to treat. Attempts to establish reliable diagnostic tools to identify patients at particular risk of malignant MCA infarction have included determinations of diffusion-and perfusion-weighted MRI parameters, 6,7 of a critical lesion volume on computed tomography (CT), 8,9 of cerebral blood flow by means of single-photon emission CT, 10 or of metabolic measures using positron emission tomography (PET) and microdialysis. 11 Clearly, most of these procedures are relatively time consuming and not always feasible.…”

mentioning

confidence: 99%

Serum S100B Predicts a Malignant Course of Infarction in Patients With Acute Middle Cerebral Artery Occlusion

Foerch

Otto

Singer

et al. 2004

151

Background and Purpose-Early predictors of infarct volume may improve therapeutic decisions in patients with acute cerebral ischemia. We investigated whether measurements of serum astroglial protein S100B can predict a malignant course of infarction in acute middle cerebral artery (MCA) occlusion. Methods-We included 51 patients (24 women, mean age 69.1Ϯ12.4 years) admitted within 6 hours after stroke symptom onset caused by proximal MCA occlusion, as shown by magnetic resonance angiography (nϭ39), intra-arterial angiography (nϭ4), or transcranial duplex sonography (nϭ8). Blood samples were drawn at hospital admission and 8, 12, 16, 20, and 24 hours after symptom onset. Serum S100B concentrations were determined using a fully automated immunoluminometric assay. A malignant course of infarction was defined as the occurrence of clinical signs of cerebral herniation within the first 7 days of treatment or the clinical decision to perform decompressive hemicraniectomy caused by critical space-occupying swelling as detected by repeated neuroimaging. Results-Sixteen patients developed malignant infarction (31%). Beginning with the 12-hour value, mean S100B serum concentrations were significantly higher in patients with a malignant course compared with those without (

“…Other small studies have supported the prognostic role of major CT findings and other neuroimaging data but failed to identify any clinical or laboratory predictors of outcome. 14,15 Therefore, we evaluated the early clinical, laboratory, and radiographic characteristics associated with fatal brain edema after stroke in a larger, broad-based patient population.…”

mentioning

confidence: 99%

Predictors of Fatal Brain Edema in Massive Hemispheric Ischemic Stroke

Kasner

Demchuk

Berrouschot

et al. 2001

Self Cite

299

205

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.)