Predictors of outcome in 1-month survivors of large middle cerebral artery infarcts treated by decompressive hemicraniectomy

BackgroundDecompressive hemicraniectomy (DH) increases survival without severe dependency in patients with large middle cerebral artery (LMCA) infarcts. The objective was to identify predictors of 1-year outcome after DH for LMCA infarct.MethodsWe conducted this study in consecutive patients who underwent DH for LMCA infarcts, in a tertiary stroke centre. Using multivariable logistic regression analyses, we evaluated predictors of (1) 30-day mortality and (2) poor outcome after 1 year (defined as a modified Rankin Scale score of 4–6) in 30-day survivors.ResultsOf 212 patients (133 men, 63%; median age 51 years), 35 (16.5%) died within 30 days. Independent predictors of mortality were infarct volume before DH (OR 1.10 per 10 mL increase, 95% CI 1.04 to 1.16), delay between symptom onset and DH (OR 0.41, 95% CI 0.23 to 0.73 per 12 hours increase) and midline shift after DH (OR 2.59, 95% CI 1.09 to 6.14). The optimal infarct volume cut-off to predict death was 210 mL or more. Among the 177 survivors, 77 (43.5%) had a poor outcome at 1 year. Independent predictors of poor outcome were age (OR 1.08 per 1 year increase, 95% CI 1.03 to 1.12) and weekly alcohol consumption of 300 g or more (OR 5.30, 95% CI 2.20 to 12.76), but not infarct volume.ConclusionIn patients with LMCA infarcts treated by DH, stroke characteristics (infarct volume before DH, midline shift after DH and early DH) predict 30-day mortality, while patients’ characteristics (age and excessive alcohol intake) predict 1-year outcome survivors.

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CT pattern of Infarct location and not infarct volume determines outcome after decompressive hemicraniectomy for Malignant Middle Cerebral Artery Stroke

Scientific Reports ◽

10.1038/s41598-019-53556-w ◽

2019 ◽

Vol 9 (1) ◽

Author(s):

Saadat Kamran ◽

Naveed Akhtar ◽

Abdul Salam ◽

Ayman Alboudi ◽

Kainat Kamran ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Functional Outcome ◽

Cerebral Artery ◽

Infarct Volume ◽

Favourable Outcome ◽

Lesion Volume ◽

Decompressive Hemicraniectomy ◽

Significant Difference ◽

Poor Outcomes ◽

The Relationship

AbstractMalignant middle cerebral artery [MMCA] infarction has a different topographic distribution that might confound the relationship between lesion volume and outcome. Retrospective study to determine the multivariable relationship between computerized tomographic [CT] infarct location, volume and outcomes in decompressive hemicraniectomy [DHC] for MMCA infarction. The MCA infarctions were classified into four subgroups by CT, subtotal, complete MCA [co-MCA], Subtotal MCA with additional infarction [Subtotal MCAAI] and co-MCA with additional infarction [Co-MCAAI]. Maximum infarct volume [MIV] was measured on the pre-operative CT. Functional outcome was measured by the modified Rankin Scale [mRS] dichotomized as favourable 0–3 and unfavourable ≥4, at three months. In 137 patients, from least favourable to favourable outcome were co-MCAAI, subtotal MCAAI, co-MCA and subtotal MCA infarction. Co-MCAAI had the worst outcome, 56/57 patients with additional infarction had mRS ≥ 4. Multiple comparisons Scheffe test showed no significant difference in MIV of subtotal infarction, co-MCA, Subtotal MCAAI but the outcome was significantly different. Multivariate analysis confirmed MCAAI [7.027 (2.56–19.28), p = 0.000] as the most significant predictor of poor outcomes whereas MIV was not significant [OR, 0.99 (0.99–01.00), p = 0.594]. Other significant independent predictors were age ≥ 55 years 12.14 (2.60–56.02), p = 0.001 and uncal herniation 4.98(1.53–16.19), p = 0.007]. Our data shows the contribution of CT infarction location in determining the functional outcome after DHC. Subgroups of patients undergoing DHC had different outcomes despite comparable infarction volumes.

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Abstract TP137: Increased Survival of Malignant Middle Cerebral Artery Stroke Patients with Midline Shift and High Glasgow Coma Scale Undergoing Decompressive Hemicraniectomy

Stroke ◽

10.1161/str.44.suppl_1.atp137 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Chris Ojeda ◽

Nitya Chitravanshi ◽

Patrick C Reid ◽

Ennis J Duffis ◽

Charles J Prestigiacomo ◽

...

Keyword(s):

Regression Analysis ◽

Survival Rate ◽

Glasgow Coma Scale ◽

Medical Treatment ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Midline Shift ◽

Coma Scale ◽

Decompressive Hemicraniectomy ◽

Neurological Surgery

Intro: Ischemic stroke of the middle cerebral artery often results in malignant cerebral edema leading to rapid clinical decline and midline shift. Decompressive hemicraniectomy (DHC) has been shown to improve clinical outcome in cases of malignant infarct but indications of when to perform it have not been well classified. This study focuses on patients who suffered malignant middle cerebral artery (MMCA) infarct and entered with mild brain injury (initial Glasgow Coma Scale≥13). Survival rates were compared among patients who received DHC versus medical treatment with a focus on midline shift. Hypothesis: Patients entering for MMCA with a Glascow Coma Scale ≥13who develop midline shift will have reduced mortality due to DHC relative to those with an entirely medical treatment. Methods: Retrospective review was performed on all cases consulted for neurological surgery from 2007-2012 at University Hospital. Patients were selected on the criteria of MMCA infarct. Midline shifts used were recorded prior to surgery or in the absence of surgery, 2-4 days post infarct. The primary endpoint was mortality at discharge. Multiple regression analysis was performed comparing the patient outcome to the degree of midline shift and if DHC occurred. Results: In total, 91 patients were referred to neurological surgery and 34 qualified with an initial Glasgow Coma Scale ≥13. Of those, 10 received a DHC, all with a midline shift and a survival rate of 70% (7/10). Exclusively medical treatment was done on 24 patients, 7 had midline shift reported with a survival rate of 29% (2/7) and 17 with no shift had a survival rate of 100% (17/17).The total medical survival rate was 79% (19/24). Regression analysis showed statistical significance (p<0.05) with mortality as the dependent variable and degree of midline shift (mm) and if DHC occurred as independent variables with GraphPad InStat 3.10. Conclusion: A statistically significant increase in survival has been found with use of DHC for MMCA infarct patients with a high Glasgow Coma Scale who have midline shift.

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Intracranial Pressure Soon After Hemicraniectomy in Malignant Middle Cerebral Artery Infarction

Journal of Intensive Care Medicine ◽

10.1177/0885066616675598 ◽

2016 ◽

Vol 33 (5) ◽

pp. 310-316 ◽

Cited By ~ 3

Author(s):

Sang-Beom Jeon ◽

Jung Cheol Park ◽

Sun U. Kwon ◽

Yeon-Jung Kim ◽

Seungjoo Lee ◽

...

Keyword(s):

Intracranial Pressure ◽

Glasgow Coma Scale ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Secondary Brain Injury ◽

Midline Shift ◽

Middle Cerebral Artery Infarction ◽

Term Survival ◽

Coma Scale ◽

Decompressive Hemicraniectomy

Background: Decompressive hemicraniectomy reduces secondary brain injury related to brain edema and increased intracranial pressure (ICP) in patients with malignant middle cerebral artery infarction (MMI). However, a substantial proportion of patients still die despite hemicraniectomy due to refractory brain swelling. Objective: We aim to investigate whether ICP measured immediately after hemicraniectomy may indicate decompression effects and predict survival in patients with MMI. Methods: We included 25 patients with MMI who underwent ICP monitoring and brain computed tomography within the first hour of hemicraniectomy. Midline shifts were measured as radiological surrogates of decompression. The Glasgow Coma Scale and pupillary enlargements during the first day after hemicraniectomy were assessed as clinical surrogates of decompression. Long-term survival status at 6 months was used as the final outcome. We analyzed the relationships between early ICP and findings of midline shift, Glasgow Coma Scale, pupillary enlargement, and survival. Results: Initial ICP was correlated with mean ICP ( P < .001) and maximal ICP ( P < .001) during the first postoperative day. Intracranial pressure was associated with midline shifts ( P = .009), lower Glasgow Coma Scale scores ( P = .025), and the pupillary enlargement ( P = .015). Sixteen (64.0%) patients survived at 6 months. In a Cox proportional hazard model, elevated ICP was associated with mortality at 6 months (hazard ratio: 1.13; 95% confidence interval: 1.03-1.24; P = .008). Conclusion: Increase in ICP soon after hemicraniectomy was associated with midline shift, poor neurological status, and mortality in patients with MMI. Measurements of ICP soon after hemicraniectomy may permit earlier interventions as well as more refined clinical assessments.

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Reduction of Midline Shift Following Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction

Journal of Stroke ◽

10.5853/jos.2016.00262 ◽

2016 ◽

Vol 18 (3) ◽

pp. 328-336 ◽

Cited By ~ 14

Author(s):

Sang-Beom Jeon ◽

Sun U. Kwon ◽

Jung Cheol Park ◽

Deok Hee Lee ◽

Sung-Cheol Yun ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Midline Shift ◽

Middle Cerebral Artery Infarction ◽

Decompressive Hemicraniectomy

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Bone Flap Necrosis After Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction

Neurocritical Care ◽

10.1007/s12028-013-9892-4 ◽

2013 ◽

Vol 20 (1) ◽

pp. 91-97 ◽

Cited By ~ 13

Author(s):

Christian Ewald ◽

Pedro Duenisch ◽

Jan Walter ◽

Theresa Götz ◽

Otto W. Witte ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Bone Flap ◽

Flap Necrosis ◽

Middle Cerebral Artery Infarction ◽

Decompressive Hemicraniectomy

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MitoKATP opener, diazoxide, reduces neuronal damage after middle cerebral artery occlusion in the rat

AJP Heart and Circulatory Physiology ◽

10.1152/ajpheart.00054.2002 ◽

2002 ◽

Vol 283 (3) ◽

pp. H1005-H1011 ◽

Cited By ~ 74

Author(s):

Katsuyoshi Shimizu ◽

Zsombor Lacza ◽

Nishadi Rajapakse ◽

Takashi Horiguchi ◽

James Snipes ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Middle Cerebral Artery Occlusion ◽

Cerebral Artery ◽

Ischemia Reperfusion Injury ◽

Neuronal Damage ◽

Infarct Volume ◽

Ischemia Reperfusion ◽

Artery Occlusion ◽

Sham Treatment ◽

Cerebral Artery Occlusion

We investigated effects of diazoxide, a selective opener of mitochondrial ATP-sensitive K+ (mitoKATP) channels, against brain damage after middle cerebral artery occlusion (MCAO) in male Wistar rats. Diazoxide (0.4 or 2 mM in 30 μl saline) or saline (sham) was infused into the right lateral ventricle 15 min before MCAO. Neurological score was improved 24 h later in the animals treated with 2 mM diazoxide (13.8 ± 0.7, n = 13) compared with sham treatment (9.5 ± 0.2, n = 6, P < 0.01). The total percent infarct volume (MCAO vs. contralateral side) of sham treatment animals was 43.6 ± 3.6% ( n = 12). Treatment with 2 mM diazoxide reduced the infarct volume to 20.9 ± 4.8% ( n = 13, P < 0.05). Effects of diazoxide were prominent in the cerebral cortex. The protective effect of diazoxide was completely prevented by the pretreatment with 5-hydroxydecanoate (100 mM in 10 μl saline), a selective blocker of mitoKATP channels ( n = 6). These results indicate that selective opening of the mitoKATP channel has neuroprotective effects against ischemia-reperfusion injury in the rat brain.

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Association of Infarct Volume Before Hemicraniectomy and Outcome After Malignant Infarction

Neurology ◽

10.1212/wnl.0000000000011987 ◽

2021 ◽

pp. 10.1212/WNL.0000000000011987

Author(s):

Dominik Lehrieder ◽

Katharina Layer ◽

Hans-Peter Müller ◽

Viktoria Rücker ◽

Jan Kassubek ◽

...

Keyword(s):

Infarct Size ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Randomized Trials ◽

Infarct Volume ◽

Unfavorable Outcome ◽

Inclusion Criteria ◽

Younger Patients ◽

Malignant Infarction ◽

The Impact

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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Abstract 11511: Genetic Variation in Retinal Vascular Patterning Predicts Variation in Pial Collateral Extent and Infarct Volume After Middle Cerebral Artery Occlusion

Circulation ◽

10.1161/circ.130.suppl_2.11511 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Pranay Prabhakar ◽

Hua Zhang ◽

De Chen ◽

Stephen Lockett ◽

James E Faber

Keyword(s):

Genetic Variation ◽

Middle Cerebral Artery ◽

Middle Cerebral Artery Occlusion ◽

Cerebral Artery ◽

Genetic Background ◽

Infarct Volume ◽

Indirect Evidence ◽

Artery Occlusion ◽

Stroke Severity ◽

Cerebral Artery Occlusion

Introduction: The presence of a native (pre-existing) collateral circulation in tissues lessens injury in stroke and other occlusive diseases. However, differences in genetic background are accompanied by wide variation in the number and diameter (extent) of native collaterals in mice, resulting in large variation in protection. Indirect evidence suggests a similar wide variation also exists in humans. However, methods of measurement in humans are indirect, invasive and not widely available. Hypothesis: We sought to determine if differences in genetic background in mice result in variation in branch-patterning of the retinal circulation, and if these differences predict differences in collateral extent and, in turn, differences in severity of ischemic stroke. Methods: Patterning metrics were obtained for the retinal arterial trees of 10 mouse strains (n=8 per strain) that differ widely in collateral extent in brain and other tissues. We also obtained pial collateral number and diameter, and infarct volume 24h after permanent middle cerebral artery occlusion. Forward- and reverse-stepwise multivariate regression analysis was conducted and model performance assessed using K-fold cross-validation. Results: Twenty-one metrics varied significantly with genetic strain (p<0.01). Ten metrics (eg, vessel caliber, bifurcation angle, lacunarity, optimality, branch length) strongly predicted collateral number and diameter across 7 regression models. The best models closely predicted (p<0.0001) collateral number (K-fold R 2 =0.83-0.98), diameter (0.73-0.88) and infarct volume (0.85-0.87). Conclusions: Differences in retinal tree patterning are specified by genetic background and closely predict genetic variation in pial collateral extent and, in turn, stroke severity. If these findings can be confirmed in humans, and given that genetic variation in cerebral collaterals extends to other tissues at least in mice, a similar “retinal predictor index” could be developed as a biomarker for collateral extent in brain and other tissues. This could aid prediction of the risk-severity of tissue injury in occlusive disease as well as stratification of patients for treatment options and enrollment in clinical studies.

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Predictors of Poor Outcome after Successful Mechanical Thrombectomy in Patients with Acute Anterior Circulation Stroke

Journal of Clinical Interventional Radiology ISVIR ◽

10.1055/s-0037-1612600 ◽

2017 ◽

Vol 01 (03) ◽

pp. 139-143 ◽

Cited By ~ 2

Author(s):

Yosuke Tajima ◽

Michihiro Hayasaka ◽

Koichi Ebihara ◽

Masaaki Kubota ◽

Sumio Suda

Keyword(s):

Clinical Outcome ◽

Cerebral Artery ◽

Mechanical Thrombectomy ◽

Infarct Volume ◽

Complete Revascularization ◽

Anterior Circulation ◽

Clinical Imaging ◽

Good Outcome ◽

Poor Outcome ◽

Favorable Clinical Outcome

AbstractSuccessful revascularization is one of the main predictors of a favorable clinical outcome after mechanical thrombectomy. However, even if mechanical thrombectomy is successful, some patients have a poor clinical outcome. This study aimed to investigate the clinical, imaging, and procedural factors that are predictive of poor clinical outcomes despite successful revascularization after mechanical thrombectomy in patients with acute anterior circulation stroke. The authors evaluated 69 consecutive patients (mean age, 74.6 years, 29 women) who presented with acute ischemic stroke due to internal cerebral artery or middle cerebral artery occlusions and who were successfully treated with mechanical thrombectomy between July 2014 and November 2016. A good outcome was defined as a modified Rankin Scale score of 0 to 2 at 3 months after treatment. The associations between the clinical, imaging, and procedural factors and poor outcome were evaluated using logistic regression analyses. Using multivariate analyses, the authors found that the preoperative National Institute of Health Stroke Scale (NIHSS) score (odds ratio [OR], 1.152; 95% confidence interval [CI], 1.004–1.325; p = 0.028), the diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) (OR, 0.604; 95% CI, 0.412–0.882; p = 0.003), and a Thrombolysis in Cerebral Infarction (TICI) 2b classification (OR, 4.521; 95% CI, 1.140–17.885; p = 0.026) were independent predictors of poor outcome. Complete revascularization to reduce the infarct volume should be performed, especially in patients with a high DWI-ASPECTS, to increase the likelihood of a good outcome.

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