Computed Tomography Based Score of Early Ischemic Changes Predicts Malignant Infarction

Background and Purpose: Identification of ischemic stroke patients at high risk of developing life-threatening malignant infarction at an early stage is critical to consider more rigorous monitoring and further therapeutic measures. We hypothesized that a score consisting of simple measurements of visually evident ischemic changes in non-enhanced CT (NEMMI score) predicts malignant middle cerebral artery (MCA) infarctions (MMI) with similar diagnostic power compared to other baseline clinical and imaging parameters.Methods: One hundred and nine patients with acute proximal MCA occlusion were included. Fifteen (13.8%) patients developed MMI. NEMMI score was defined using the sum of the maximum diameter (anterior-posterior plus medio-lateral) of the hypoattenuated lesion in baseline-CT multiplied by a hypoattenuation factor (3-point visual grading in non-enhanced CT, no/subtle/clear hypoattenuation = 1/2/3). Receiver operating characteristic (ROC) curve analysis and multivariable logistic regression analysis were used to calculate the predictive values of the NEMMI score, baseline clinical and other imaging parameters.Results: The median NEMMI score at baseline was 13.6 (IQR: 11.6–31.1) for MMI patients, and 7.7 (IQR: 3.9–11.2) for patients with non-malignant infarctions (p < 0.0001). Based on ROC curve analysis, a NEMMI score >10.5 identified MMI with good discriminative power (AUC: 0.84, sensitivity/specificity: 93.3/70.7%), which was higher compared to age (AUC: 0.76), NIHSS (AUC: 0.61), or ischemic core volume (AUC: 0.80). In multivariable logistic regression analysis, NEMMI score was significantly and independently associated with MMI (OR: 1.33, 95%CI: 1.13–1.56, p < 0.001), adjusted for recanalization status.Conclusion: The NEMMI score is a quick and simple rating tool of early ischemic changes on CT and could serve as an important surrogate marker for developing malignant edema. Its diagnostic accuracy was similar to CTP and clinical parameters.

Association of Infarct Volume Before Hemicraniectomy and Outcome After 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.

Malignant infarction after endovascular treatment: Incidence and prediction

Background Early prediction of malignant infarction may guide treatment decisions. For patients who received endovascular treatment, the risk of malignant infarction is unknown and risk factors are unrevealed. Aims The objective of this study is to estimate the incidence of malignant infarction after endovascular treatment in patients with an occlusion of the anterior circulation, to identify independent risk factors, and to establish a model for prediction. Methods We analyzed patients who received endovascular treatment for a large vessel occlusion in the anterior circulation within 6.5 h after symptom onset, included in the Dutch MR CLEAN Registry between March 2014 and June 2016. We compared patients with and without malignant infarction. Candidate predictors were incorporated in a multivariable binary logistic regression model. The final prediction model was established using backward elimination. Discrimination and calibration were evaluated with the area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow test. Results Of 1445 patients, 82 (6%) developed malignant infarction. Independent predictors were lower age, higher National Institutes of Health Stroke Scale (NIHSS), lower alberta stroke program early CT score (ASPECTS), internal carotid artery occlusion, lower collateral score, longer times from onset to groin puncture, and unsuccessful reperfusion. The AUROC of a prediction model combining these features was 0.83 (95% confidence interval (CI): 0.79–0.88) and the Hosmer-Lemeshow test indicated appropriate calibration (P = 0.937). Conclusion The risk of malignant infarction after endovascular treatment started within 6.5 h of stroke onset is approximately 6%. Successful reperfusion decreases the risk. A prediction model combining easily retrievable measures of age, ASPECTS, collateral status, and reperfusion shows good discrimination between patients who will develop malignant infarction and those who will not.

Abstract P254: Decompressive Hemicraniectomy and Functional Outcomes After Malignant Cerebral Infarction: Real World Experience From a Comprehensive Stroke Center

Background: Decompressive hemicraniectomy (DHC), performed in select patients with malignant infarction (MCI), reduces mortality. However, there is conflicting evidence surrounding the use of DHC in improving disability outcomes in this patient population. This is in part due to differing definitions of functional recovery in prior studies. The purpose of this study is to characterize a cohort of patients with ischemic stroke who underwent DHC and compare the outcomes data with pooled data from three major trials published for DHC (DECIMAL, DESTINY, and HAMLET). Methods: This was a retrospective, observational cohort study of consecutive patients who underwent DHC as part of best clinical care during 2015-2020. We report our cohort using descriptive statistics. Results: Of the 44 patients underwent DHC at our institution, 33 were included for analysis after applying the inclusion and exclusion criteria based on the three major trials. Our DHC cohort tended to have higher rates of comorbidities including hypertension and diabetes (Table 1). A greater number of our DHC patients had unfavorable modified Rankin Scale (mRS) scores of 4 or 5 at 6-month follow-up compared to those who underwent DHC or received conservative therapy at 12-month follow-up in the three prospective trials (Figure 1). Conclusion: DHC in patient cohorts with significant comorbid data is associated with reduced mortality but a worsened functional outcome in survivors. The treating practitioner should consider this procedure only in the context of a lengthy discussion regarding the patient’s baseline functional and health status as well as competing benefits and risks associated with this procedure.

Malignant cerebral infarction (MCI): Review of the benefits of decompression craniectomy (DC)

Background: MCI is caused by occlusion of the middle cerebral artery (MCA) or internal carotid artery. Causing large ischemias, which edema can exert a mass effect, usually between the 2nd and 5th day, resulting in intracranial hypertension, herniation and even death. Objective: Review data related to the benefits of DC, elucidating the procedure, prognosis and indications of the method. Method: Review on MEDLINE and PubMed platforms. The descriptors: “craniectomy” AND “malignant infarction”. Were selected 9 articles dated between 2016 and 2021. Results: MCI has some clinical (Youngs, NIHSS>15, neurological deterioration) and radiological predictors (Impairment> 50% of the ACM territory, midline deviation> 5mm, MRI with DWI> 145 cm3). These patient’s clinical aim is to reduce intracranial pressure (ICP), however, as a consequence of the worse prognosis in clinical therapy, there’s a possibility of intervention by DC, which is a surgical technique that relieves ICP and prevents secondary injuries. It reduces the mortality rate and increases the patient’s survival up 3x compared to clinical management, but at the expense of low quality of life. Patients ≤60 years with loss of consciousness, must have an indication for DC within 48 hours after ictus. The indication should be better evaluated and a thorough discussion with family members. Conclusion: DC minimizes injuries and the risk of herniation. However, despite decreasing mortality, it can lead to complications and poor prognosis, although it isn’t uncommon the indication for the procedure and an approach to palliative care.

Association between flat-panel computed tomography hyperattenuation and clinical outcome after successful recanalization by endovascular treatment

OBJECTIVEHyperattenuation on CT scanning performed immediately after endovascular treatment (EVT) is known to be associated with the final infarct. As flat-panel CT (FPCT) scanning is readily accessible within their angiography suite, the authors evaluated the ability of the extent of hyperattenuation on FPCT to predict clinical outcomes after EVT.METHODSPatients with successful recanalization (modified Thrombolysis in Cerebral Infarction grade 2b or 3) were reviewed retrospectively. The extent of hyperattenuation was assessed by the Alberta Stroke Program Early CT Score on FPCT (FPCT-ASPECTS). FPCT-ASPECTS findings were compared according to functional outcome and malignant infarction. The predictive power of the FPCT-ASPECTS with initial CT images before EVT (CT-ASPECTS) and follow-up diffusion-weighted images (MR-ASPECTS) was also compared.RESULTSA total of 235 patients were included. All patients were treated with mechanical thrombectomy, and 45.5% of the patients received intravenous tissue plasminogen activator. The mean (± SD) time from stroke onset to recanalization was 383 ± 290 minutes. The FPCT-ASPECTS was significantly different between patients with a favorable outcome and those without (mean 9.3 ± 0.9 vs 6.7 ± 2.6) and between patients with malignant infarction and those without (3.4 ± 2.9 vs 8.8 ± 1.4). The FPCT-ASPECTS was an independent factor for a favorable outcome (adjusted OR 3.28, 95% CI 2.12–5.01) and malignant infarction (adjusted OR 0.42, 95% CI 0.31–0.57). The area under the curve (AUC) of the FPCT-ASPECTS for a favorable outcome (0.862, cutoff ≥ 8) was significantly greater than that of the CT-ASPECTS (0.637) (p < 0.001) and comparable to that of the MR-ASPECTS (0.853) (p = 0.983). For malignant infarction, the FPCT-ASPECTS was also more predictive than the CT-ASPECTS (AUC 0.906 vs 0.552; p = 0.001) with a cutoff of ≤ 5.CONCLUSIONSThe FPCT-ASPECTS was highly predictive of clinical outcomes in patients with successful recanalization. FPCT could be a practical method to immediately predict clinical outcomes and thereby aid in acute management after EVT.

Decompressive craniectomy versus conservative treatment: limits and possibilities in malignant stroke

ABSTRACT Background: Malignant infarction of the middle cerebral artery (MCA) occurs in a subgroup of patients with ischemic stroke and early decompressive craniectomy (DC) is one of its treatments. Objective: To investigate the functional outcome of patients with malignant ischemic stroke treated with decompressive craniectomy at a neurological emergency center in Northeastern Brazil. Methods: Prospective cohort study, in which 25 patients were divided into two groups: those undergoing surgical treatment with DC and those who continued to receive standard conservative treatment (CT). Functionality was assessed using the modified Rankin Scale (mRS), at follow-up after six months. Results: A favorable outcome (mRS≤3) was observed in 37.5% of the DC patients and 29.4% of CT patients (p=0.42). Fewer patients who underwent surgical treatment died (25%), compared to those treated conservatively (52.8%); however, with no statistical significance. Nonetheless, the proportion of patients with moderate to severe disability (mRS 4‒5) was higher in the surgical group (37.5%) than in the non-surgical group (17.7%). Conclusion: In absolute values, superiority in the effectiveness of DC over CT was perceived, showing that the reduction in mortality was at the expense of increased disability.