Abstract
Objectives: To assess the hemispheric differences in characteristics, stroke-related complications, and outcomes of patients with large hemisphere infarctions (LHI).Methods: We enrolled consecutive patients admitted within 24 h after the diagnosis of LHI (defined as an ischemic stroke involving more than 50% of the territory of the middle cerebral artery in computed tomography and/or magnetic resonance imaging). Univariate and multivariate analysis were performed to explore the association between lateralization and stroke-related complications and clinical outcomes.Results: A total of 314 patients with LHI were enrolled, with 171 (54.5%) having right hemispheric involvement. Right-sided patients with LHI had lower baseline National Institutes of Health Stroke Scale (NIHSS) score (18 vs. 22, p < 0.001), higher frequency of atrial fibrillation (69.0 vs. 52.4%, p = 0.003), and higher proportion of cardio-embolism (73.1 vs. 56.6%, p = 0.013) than the left. Right-sided LHI had higher incidence rates of malignant brain edema (MBE) (48.5 vs. 30.8%, p = 0.001) and a composite of cardiovascular events (29.8 vs. 17.5%, p = 0.011) during hospitalization. The incidence rate of 1-month mortality (34.5 vs. 23.8%, p = 0.036) was higher in right-sided patients with LHI, but there were no hemispheric differences in the incidence rates of 3-month mortality and unfavorable outcome (both p > 0.05). Multivariate analyses suggested right hemisphere involvement was independently associated with increased risk of MBE (adjusted OR 2.37, 95% CI 1.26–4.43, p = 0.007) and composite of cardiovascular events (adjusted OR 2.04, 95% CI 1.12–3.72, p = 0.020). However, it was not independently associated with 1-month death, 3-month mortality, and 3-month unfavorable outcome (all p > 0.05).Conclusions: Right-sided patients with LHI had higher frequency of atrial fibrillation and cardio-embolism than the left-sided patients. Right hemisphere involvement was independently associated with increased risk of MBE and composite of cardiovascular events during hospitalization, whereas stroke lateralization was not an independent predictor of mortality and unfavorable outcome in patients with LHI.
Highlights
Large hemispheric infarction (LHI), which usually results from occlusion of the internal carotid artery or proximal middle cerebral artery (MCA), is a devastating condition with a high mortality rate [1, 2]
After adjusting for age, baseline National Institutes of Health Stroke Scale (NIHSS) score and other confounders in multivariate analyses, right hemisphere involvement was independently associated with increased risk of malignant brain edema (MBE)
The incidence rate of 1-month mortality (34.5 vs. 23.8%, p = 0.036) was higher among LHI patients with right hemisphere involvement, but there were no hemispheric differences in the incidence rates of 3-month mortality (37.4 vs. 28.0%, p = 0.086) and 3-month unfavorable outcome (73.7 vs. 66.4%, p = 0.196) (Figure 2; Table 2)
Summary
Large hemispheric infarction (LHI), which usually results from occlusion of the internal carotid artery or proximal middle cerebral artery (MCA), is a devastating condition with a high mortality rate [1, 2]. Decompressive hemicraniectomy (DHC) conducted within 48 h after symptom onset has been proven effective for patients with LHI with MBE [5]. Only 0.3% of highly selected ischemic stroke patients would be eligible for DHC based on the strict eligibility criteria in the DHC trials [6]. It has been reported that that poststroke complications are the leading cause of death and unfavorable outcomes in ischemic stroke patients [7, 8]. Our previous work has demonstrated that stroke-related complication occurred in more than three fourths of the patients with LHI and was related to unfavorable outcome, whereas only MBE and pneumonia are independent predictors of a 3-month unfavorable outcome [10]. It is reasonable to suspect that strokerelated complications might frequently occur in left hemisphere stroke and result in poor outcomes. There is no consensus on the impact of the stroke hemisphere on outcomes of AIS [12,13,14,15]
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