Subcortical Sparing Associated with Ambulatory Independence after Hemicraniectomy for Malignant Infarction

ObjectiveTo determine the impact of infarct volume before hemicraniectomy in malignant middle cerebral artery infarction (MMI) as an independent predictor for patient selection and outcome prediction, we retrospectively analyzed data of 140 patients from a prospective multi-center study.MethodsPatients from the DESTINY-Registry that underwent hemicraniectomy after ischemic infarction of >50% of the middle cerebral artery territory were included. Functional outcome according to the modified Rankin Scale (mRS) was assessed at 12 months. Unfavorable outcome was defined as mRS 4-6. Infarct size was quantified semi-automatically from computed tomography or magnetic resonance imaging before hemicraniectomy. Subgroup analyses in patients fulfilling inclusion criteria of randomized trials in younger patients (age≤60y) were predefined.ResultsAmong 140 patients with complete datasets (34% female, mean (SD) age 54 (11) years), 105 (75%) had an unfavorable outcome (mRS > 3). Mean (SD) infarct volume was 238 (63) ml. Multivariable logistic regression identified age (OR 1.08 per 1 year increase; 95%-CI 1.02-1.13; p=0.004), infarct size (OR 1.27 per 10ml increase; 95%-CI 1.12-1.44; p<0.001) and NIHSS (OR 1.10; 95%-CI 1.01-1.20; p=0.030) before hemicraniectomy as independent predictors for unfavorable outcome. Findings were reproduced in patients fulfilling inclusion criteria of randomized trials in younger patients. Infarct volume thresholds for prediction of unfavorable outcome with high specificity (94% in overall cohort and 92% in younger patients) were more than 258 ml before hemicraniectomy.ConclusionOutcome in MMI strongly depends on age and infarct size before hemicraniectomy. Standardized volumetry may be helpful in the process of decision making concerning hemicraniectomy.

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Malignant infarction of the middle cerebral artery in a porcine model. A pilot study

PLoS ONE ◽

10.1371/journal.pone.0172637 ◽

2017 ◽

Vol 12 (2) ◽

pp. e0172637 ◽

Cited By ~ 5

Author(s):

Fuat Arikan ◽

Tamara Martínez-Valverde ◽

Ángela Sánchez-Guerrero ◽

Mireia Campos ◽

Marielle Esteves ◽

...

Keyword(s):

Pilot Study ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Porcine Model ◽

Malignant Infarction

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Prediction of Malignant Middle Cerebral Artery Infarction Using Computed Tomography-Based Intracranial Volume Reserve Measurements

Stroke ◽

10.1161/strokeaha.111.619734 ◽

2011 ◽

Vol 42 (12) ◽

pp. 3403-3409 ◽

Cited By ~ 66

Author(s):

Jens Minnerup ◽

Heike Wersching ◽

E. Bernd Ringelstein ◽

Walter Heindel ◽

Thomas Niederstadt ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Predictive Value ◽

Perfusion Ct ◽

Lesion Volume ◽

Intracranial Volume ◽

Ischemic Lesion ◽

Predictive Values ◽

Malignant Infarction ◽

Malignant Mca Infarction

Background and Purpose— Early decompressive surgery in patients with malignant middle cerebral artery (MCA) infarction improves outcome. Elevation of intracranial pressure depends on both the space occupying brain edema and the intracranial volume reserve (cerebrospinal fluid [CSF]). However, CSF volume was not investigated as a predictor of malignant infarction so far. We hypothesize that assessment of CSF volume in addition to admission infarct size improves early prediction of malignant MCA infarction. Methods— Stroke patients with carotid-T or MCA main stem occlusion and ischemic lesion (reduced cerebral blood volume [CBV]) on perfusion CT were considered for the analysis. The end point malignant MCA infarction was defined by clinical signs of herniation. Volumes of CSF and CBV lesion were determined on admission. Receiver-operator characteristics analysis was used to calculate predictive values for radiological and clinical measurements. Results— Of 52 patients included, 26 (50%) developed malignant MCA infarction. Age, a decreased level of consciousness on admission, CBV lesion volume, CSF volume, and the ratio of CBV lesion volume to CSF volume were significantly different between malignant and nonmalignant groups. The best predictor of a malignant course was the ratio of CBV lesion volume to CSF volume with a cut-off value of 0.92 (96.2% sensitivity, 96.2% specificity, 96.2% positive predictive value, and 96.2% negative predictive value). Conclusions— Based on admission native CT and perfusion CT measurements, the ratio of ischemic lesion volume to CSF volume predicts the development of malignant MCA infarction with higher accuracy than other known predictors, including ischemic lesion volume or clinical characteristics.

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