Abstract
Background : Malignant middle cerebral artery (MCA) infarction is leading cause of death for acute MCA infarction patients. Early detection of patients who can develop the malignant MCA infarction (MMI) is important for timely decision for life-saving treatment such as an decompressive surgery. So we studied to figure out a reliable predicting parameters for developing MMI using acute stroke magnetic resonance imaging (MRI) such as diffusion and perfusion images. Methods : We included 209 MCA infarction patients with main MCA occlusion within 6 hours of symptom onset between January 2007 and December 2010 in Dong-A University Stroke center. All patients were performed brain MRI including diffusion and perfusion images. Vessel occlusion was diagnosed by MR angiography. We used regional cerebral blood volume (rCBV) ratio as a representing parameters of perfusion image. The rCBV ratio was calculated by comparing the blood volume of the ischemic lesion with that of the corresponding unaffected contralateral region.Definition of the malignanat MCA infarction was as following : 1) deterioration of neurological and consciousness with clinical signs of uncal herniation and mass effect, 2) large space-occupying MCA infarction or at least two-third of the MCA territory with compression of ventricles of midline shifting. We observed any changes of neurological deterioration within 7 days of symptom onset. Severity of neurological symptom and clinical outcome were assessed by using National Institute Stroke Severity Scale (NIHSS) and the modified Rankin Scale (mRS). Results : Among 209 pts, 84 (40.2%) developed MMI, and 125 (59.8%) did not (non-MMI). In a univariate analysis, MMI group was more older (69.08 vs 63.54), more additional lesion in ACA or PCA territory (13.1% vs 1.6%), higher NIHSS score. In MMI group, MCA with ipsilateral ICA occlusion was more frequent (76.2% vs 40.0%), and larger diffusion volume (99.13 vs 21.57), lower rCBV ratio (0.53 vs 0.87). Also, the presence of diffusion-perfusion mismatch (DPM) was more common in non-MMI group (80.8% vs 46.4%). In MMI group, large portion of patients were included in mRS 5-6 group (61.4%) compared with non-MMI group (15.8%). In a multivariate analysis, these parameters were identified as a predicting factors of MMI : larger diffusion volume (OR :1.02, 1.01-1.04, p<0.001), lower rCBV ratio (OR :0.97, 0.95-0.99, p<0.001), higher NIHSS on admission (OR: 1.31, 1.16-1.47, p<0.001). The cutoff value of diffusion volume, NIHSS on admission and rCBV ratio were 69ml, 15 point and 0.66 respectively. Conclusion : Brain MRI including diffusion and perfusion image, especially diffusion volume and rCBV ratio can predict malignant course in MCA infarction with main MCA occlusion patients within 6 hours of symptom onset.
Published Version
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