What is the Role of Hyperosmolar Therapy in Hemispheric Stroke Patients?

Mohney, Nathaniel; Alkhatib, Omar; Koch, Sebastian; O’Phelan, Kristine; Merenda, Amedeo

doi:10.1007/s12028-019-00782-9

Cited by 10 publications

(4 citation statements)

References 89 publications

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“…This requires an intact blood-brain barrier (BBB), and thus hyperosmolar therapy predominantly reduces the volume of normal, uninfarcted tissue [67,68]. Although both are effective at acutely reducing ICP, neither has been shown to improve functional outcomes or mortality after stroke [69][70][71][72]. Consequently, 20-25% mannitol (0.25-2 g/kg as a bolus infusion over 10 min) and 23.4% hypertonic saline (30 mL over 2-5 min) are frequently given to rapidly deteriorating patients with MCE as preparations for DHC are underway.…”

Section: Management Of Mcementioning

confidence: 99%

Current and Emerging Endovascular and Neurocritical Care Management Strategies in Large-Core Ischemic Stroke

Migdady,

Johnson-Black,

Leslie-Mazwi

et al. 2023

JCM

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The volume of infarcted tissue in patients with ischemic stroke is consistently associated with increased morbidity and mortality. Initial studies of endovascular thrombectomy for large-vessel occlusion excluded patients with established large-core infarcts, even when large volumes of salvageable brain tissue were present, due to the high risk of hemorrhagic transformation and reperfusion injury. However, recent retrospective and prospective studies have shown improved outcomes with endovascular thrombectomy, and several clinical trials were recently published to evaluate the efficacy of endovascular management of patients presenting with large-core infarcts. With or without thrombectomy, patients with large-core infarcts remain at high risk of in-hospital complications such as hemorrhagic transformation, malignant cerebral edema, seizures, and others. Expert neurocritical care management is necessary to optimize blood pressure control, mitigate secondary brain injury, manage cerebral edema and elevated intracranial pressure, and implement various neuroprotective measures. Herein, we present an overview of the current and emerging evidence pertaining to endovascular treatment for large-core infarcts, recent advances in neurocritical care strategies, and their impact on optimizing patient outcomes.

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Section: Management Of Mcementioning

confidence: 99%

Current and Emerging Endovascular and Neurocritical Care Management Strategies in Large-Core Ischemic Stroke

Migdady,

Johnson-Black,

Leslie-Mazwi

et al. 2023

JCM

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“…Approved treatments for brain edema/swelling are limited. There is a long history of the use of hyperosmolar therapies, including mannitol and hypertonic saline, in ischemic stroke [ 7 , 8 ]. Although both agents can reduce intracranial pressure and may increase cerebral blood flow in non-ischemic tissues acutely [ 9 , 10 ], neither agent was shown to improve patient outcomes in a randomized clinical trial [ 11 ].…”

Section: Introductionmentioning

confidence: 99%

Brain Swelling versus Infarct Size: A Problematizing Review

Simard,

Wilhelmy,

Tsymbalyuk

et al. 2024

Brain Sciences

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In human stroke, brain swelling is an important predictor of neurological outcome and mortality, yet treatments to reduce or prevent brain swelling are extremely limited, due in part to an inadequate understanding of mechanisms. In preclinical studies on cerebroprotection in animal models of stroke, historically, the focus has been on reducing infarct size, and in most studies, a reduction in infarct size has been associated with a corresponding reduction in brain swelling. Unfortunately, such findings on brain swelling have little translational value for treating brain swelling in patients with stroke. This is because, in humans, brain swelling usually becomes evident, either symptomatically or radiologically, days after the infarct size has stabilized, requiring that the prevention or treatment of brain swelling target mechanism(s) that are independent of a reduction in infarct size. In this problematizing review, we highlight the often-neglected concept that brain edema and brain swelling are not simply secondary, correlative phenomena of stroke but distinct pathological entities with unique molecular and cellular mechanisms that are worthy of direct targeting. We outline the advances in approaches for the study of brain swelling that are independent of a reduction in infarct size. Although straightforward, the approaches reviewed in this study have important translational relevance for identifying novel treatment targets for post-ischemic brain swelling.

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“…In addition, preliminary trials and studies have shown promise for multiple additional therapies, including intravenous glyburide, strokectomy (compared with hemicraniectomy), selective cerebral hypothermia, and hyperosmolar therapy ( 2–4 ). A barrier to the further development of therapeutics for patients with ACA occlusion and patients with ICA occlusion and large ischemic core is that the only available pragmatic assessment of initial and early ischemic injury extent is the Alberta Stroke Program Early Computed Tomography score (ASPECTS), a clinician-performed, semi-quantitative, 10-point topographic imaging assessment ( 5–11 ).…”

Section: Introductionmentioning

confidence: 99%

AC-ASPECTS, ACh-ASPECTS, and H-ASPECTS: new imaging scales to assess territorial and total cerebral hemispheric ischemic injury

Rodriguez,

Taleb,

Lee

et al. 2024

Front. Neurol.

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BackgroundThe extent of ischemic injury in acute stroke is assessed in clinical practice using the Acute Stroke Prognosis Early CT Score (ASPECTS) rating system. However, current ASPECTS semi-quantitative topographic scales assess only the middle cerebral artery (MCA) (original ASPECTS) and posterior cerebral (PC-ASPECTS) territories. For treatment decision-making in patients with anterior cerebral artery (ACA) occlusions and internal carotid artery (ICA) occlusions with large ischemic cores, measures of all hemispheric regions are desirable.MethodsIn this cohort study, anatomic rating systems were developed for the anterior cerebral (AC-ASPECTS, 3 points) and anterior choroidal artery (ACh-ASPECTS, 1 point) territories. In addition, a total supratentorial hemisphere (H-ASPECTS, 16 points) score was calculated as the sum of the MCA ASPECTS (10 regions), supratentorial PC-ASPECTS (2 regions), AC-ASPECTS (3 regions), and ACh-ASPECTS (1 region). Three raters applied these scales to initial and 24 h CT and MR images in consecutive patients with ischemic stroke (IS) due to ICA, M1-MCA, and ACA occlusions.ResultsImaging ratings were obtained for 96 scans in 50 consecutive patients with age 74.8 (±14.0), 60% female, NIHSS 15.5 (9.25–20), and occlusion locations ICA 34%; M1-MCA 58%; and ACA 8%. Treatments included endovascular thrombectomy +/− thrombolysis in 72%, thrombolysis alone in 8%, and hemicraniectomy in 4%. Among experienced clinicians, inter-rater reliability for AC-, ACh-, and H-ASPECTS scores was substantial (kappa values 0.61–0.80). AC-ASPECTS abnormality was present in 14% of patients, and ACh-ASPECTS abnormality in 2%. Among patients with ACA and ICA occlusions, H-ASPECTS scores compared with original ASPECTS scores were more strongly associated with disability level at discharge, ambulatory status at discharge, discharge destination, and combined inpatient mortality and hospice discharge.ConclusionAC-ASPECTS, ACh-ASPECTS, and H-ASPECTS expand the scope of acute IS imaging scores and increase correlation with functional outcomes. This additional information may enhance prognostication and decision-making, including endovascular thrombectomy and hemicraniectomy.

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What is the Role of Hyperosmolar Therapy in Hemispheric Stroke Patients?

Cited by 10 publications

References 89 publications

Current and Emerging Endovascular and Neurocritical Care Management Strategies in Large-Core Ischemic Stroke

Current and Emerging Endovascular and Neurocritical Care Management Strategies in Large-Core Ischemic Stroke

Brain Swelling versus Infarct Size: A Problematizing Review

AC-ASPECTS, ACh-ASPECTS, and H-ASPECTS: new imaging scales to assess territorial and total cerebral hemispheric ischemic injury

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