Malignant Middle Cerebral Artery Infarction Research Articles

Decompressive craniectomy for patients with malignant infarction of the middle cerebral artery: A pooled analysis of two randomized controlled trials

BackgroundDecompressive craniectomy (DC) reduces mortality without increasing the risk of very severe disability among patients with life-threatening massive cerebral infarction. However, its efficacy was demonstrated before the era of endovascular thrombectomy trials. It remains uncertain whether DC improves the prognosis of patients with malignant middle cerebral artery (MCA) infarction receiving endovascular therapy. MethodsWe pooled data from two trials (DEVT and RESCUE BT studies in China) and patients with malignant MCA infarction were included to assess outcomes and heterogeneity of DC therapy effect. Patients with herniation were dichotomized into DC and conservative groups according to their treatment strategy. The primary outcome was the rate of mortality at 90 days. Secondary outcomes included disability level at 90 days as measured by the modified Rankin Scale score (mRS) and quality-of-life score. The associations of DC with clinical outcomes were performed using multivariable logistic regression. ResultsOf 98 patients with herniation, 37 received DC surgery and 61 received conservative treatment. The median (interquartile range) was 70 (62-76) years and 40.8% of the patients were women. The mortality rate at 90 days was 59.5% in the DC group compared with 85.2% in the conservative group (adjusted odds ratio, 0.31 [95% confidence interval (CI), 0.10-0.94]; P=0.04). There were 21.6% of patients in the DC group and 6.6% in the conservative group who had a mRS score of 4 (moderately severe disability); and 10.8% and 4.9%, respectively, had a score of 5 (severe disability). The quality-of-life score was higher in the DC group (0.00 [0.00-0.14] vs 0.00 [0.00-0.00], P=0.004), but DC treatment was not associated with better quality-of-life score in multivariable analyses (adjusted β Coefficient, 0.02 [95% CI, -0.08-0.11]; p=0.75). ConclusionsDC was associated with decreased mortality among patients with malignant MCA infarction who received endovascular therapy. The majority of survivors remained moderately severe disability and required improvement on quality of life. Clinical Trial RegistrationThe DEVT trial: http://www.chictr.org. Identifier, ChiCTR-IOR-17013568. The RESCUE BT trial: URL: http://www.chictr.org. Identifier, ChiCTR-INR-17014167.

Swiss trial of decompressive craniectomy versus best medical treatment of spontaneous supratentorial intracerebral haemorrhage (SWITCH): an international, multicentre, randomised-controlled, two-arm, assessor-blinded trial.

Decompressive craniectomy (DC) is beneficial in people with malignant middle cerebral artery infarction. Whether DC improves outcome in spontaneous intracerebral haemorrhage (ICH) is unknown. To determine whether DC without haematoma evacuation plus best medical treatment (BMT) in people with ICH decreases the risk of death or dependence at 6 months compared to BMT alone. SWITCH is an international, multicentre, randomised (1:1), two-arm, open-label, assessor-blinded trial. Key inclusion criteria are age ⩽75 years, stroke due to basal ganglia or thalamic ICH that may extend into cerebral lobes, ventricles or subarachnoid space, Glasgow coma scale of 8-13, NIHSS score of 10-30 and ICH volume of 30-100 mL. Randomisation must be performed <66 h after onset and DC <6 h after randomisation. Both groups will receive BMT. Participants randomised to the treatment group will receive DC of at least 12 cm in diameter according to institutional standards. A sample of 300 participants randomised 1:1 to DC plus BMT versus BMT alone provides over 85% power at a two-sided alpha-level of 0.05 to detect a relative risk reduction of 33% using a chi-squared test. The primary outcome is the composite of death or dependence, defined as modified Rankin scale score 5-6 at 6 months. Secondary outcomes include death, functional status, quality of life and complications at 180 days and 12 months. SWITCH will inform physicians about the outcomes of DC plus BMT in people with spontaneous deep ICH, compared to BMT alone. ClinicalTrials.gov Identifier: NCT02258919.

Assessment of the results of treatment of malignant middle cerebral artery infarction

Background. A vast ischemic lesion in cases of malignant middle cerebral artery infarction causes a massive edema of the affected cerebral hemisphere, which leads to development of the dislocation syndrome and, in most cases, death. Decompressive hemicraniectomy is a more effective method for treatment of malignant ischemic infarction, than conservative therapy.Aim. Evaluation of the effectiveness of treatment of malignant middle cerebral artery infarction.Materials and methods. Analysis was carried out of the case histories of 57 patients with malignant middle cerebral artery infarction, out of which number 64.9 % were women and 35.1 % were men. The patients’ ages varied from 49 to 90 years, with the average of 72.7 year. All patients were divided into two groups: Group 1 patients (n = 47, 82.5 %) received only conservative therapy, while Group 2 patients (n = 10, 17.5 %) were subjected to surgical treatment.Results. The in-hospital stay of Group 1 patients varied from 2 to 73 days (the mean stay being 14.4 ± 1.8 days). Lethality in the conservative therapy patients was 46.8 % during the in-hospital stay varying from 2 to 21 days, with the average of 7.7 ± 1.7 days. Based on the postmortem examination, dislocation syndrome and its consequences were the cause of death in 90.9 % of the patients, who received in-hospital conservative therapy.The in-hospital stay of Group 2 patients varied from 22 to 33 days, with the average of 19.6 ± 4.3 days. The postoperative mortality was 40 %. The postmortem examination showed that the cause of the deaths was exacerbation of the dislocation syndrome and its consequences.Conclusion. Malignant ischemic syndrome in the territory supplied by the middle cerebral artery is the most severe form of ischemic infarction accompanied by constant disability of patients. Despite decompressive hemicraniectomy, lethality for the patients with malignant ischemic syndrome remains high, the principal cause being development of the dislocation syndrome.

Prognostic variables predict clinical outcome after decompressive craniectomy: A single institute experience; A retrospective study.

Decompressive craniectomy (DC) is a well-established neurosurgical intervention in patients with high intracranial pressure who fail to respond to medical treatment. Data on predictive factors for functional outcomes in patients with DC who have malignant middle cerebral artery (MCA) infarction as opposed to intracranial hemorrhage (ICH) are scarce. Eighty-four patients who underwent DC treatment for ICH and malignant MCA infarction were examined. All patients underwent surgery in the Bahrain Salmaniya Medical Complex Neurosurgery Unit between January 2017 and June 2021. To determine whether any of these demonstrated a link to the functional outcome, radiographic factors were compared with clinical data. The postsurgical midline shift (MLS) (ICH group) showed the strongest correlation (ρ = 0.434; P = .006), as in the MCA infarction group as well (ρ = 0.46; P = .005). Further analyses using binary logistic regression with postsurgical basal cistern status and ∆ MLS, and it was observed to be statistically significant (odds ratios: 0.067, 95% CI: 0.007, 0.67; P = .021). The initial Glasgow coma scale, postsurgical MLS, basal cistern status, and ∆ are Measurable variables that can be used to predict outcomes in the groups with ICH and MCA infarction.

Decompressive hemicraniectomy versus medical treatment for malignant middle cerebral artery infarction: Eleven years experience in a Tunisian center

Decompressive hemicraniectomy versus medical treatment for malignant middle cerebral artery infarction: Eleven years experience in a Tunisian center

Retracted: Stereotactic Aspiration Acts as an Effective Treatment for Malignant Middle Cerebral Artery Infarction.

[This retracts the article DOI: 10.1155/2022/4373404.].

Efficacy and safety of bridging therapy and direct mechanical thrombectomy in large vessel occlusions: a meta-analysis.

Efficacy and safety of bridging therapy and direct mechanical thrombectomy in large vessel occlusions: a meta-analysis.

Outcomes of decompressive craniectomy for malignant middle cerebral artery stroke in an academic hospital in Brazil.

Ischemic stroke is an important cause of death in the world. The malignant middle cerebral artery infarction (MMCAI) has mortality as high as 80% when clinically treated. In this setting, decompressive craniectomy is a life-saving measure, in spite of high morbidity among survivors. To evaluate the outcomes of patients with MMCAI treated with decompressive craniectomy in a Brazilian academic tertiary stroke center. A prospective stroke database was retrospectively evaluated, and all patients treated with decompressive craniectomy for MMCAI between January 2014 and December 2017 were included. The demographics and clinical characteristics were evaluated. The functional outcome, measured by the modified Rankin Scale (mRS), was assessed at hospital discharge, after 3-months and 1-year of follow-up. We included 53 patients on the final analysis. The mean age was 54.6 ± 11.6 years and 64.2% were males. The median time from symptoms to admission was 4.8 (3-9.7) hours and the mean time from symptoms to surgery was 36 ± 17 hours. The left hemisphere was the affected in 39.6%. The median NIHSS at admission was 20 (16-24). The in-hospital mortality was 30.2%. After a median of 337 [157-393] days, 47.1% of patients had achieved favorable outcome (mRS ≤ 4) and 39.6% had died. Decompressive craniectomy is a life-saving measure in the setting of MMCAI, and its effects remains important in the scenario of a middle-income country in real-world situations.

Prior Thrombectomy Does Not Affect the Surgical Complication Rate of Decompressive Hemicraniectomy in Patients with Malignant Ischemic Stroke

BackgroundEven though mechanical recanalization techniques have dramatically improved acute stroke care since the pivotal trials of decompressive hemicraniectomy for malignant courses of ischemic stroke, decompressive hemicraniectomy remains a mainstay of malignant stroke treatment. However, it is still unclear whether prior thrombectomy, which in most cases is associated with application of antiplatelets and/or anticoagulants, affects the surgical complication rate of decompressive hemicraniectomy and whether conclusions derived from prior trials of decompressive hemicraniectomy are still valid in times of modern stroke care.MethodsA total of 103 consecutive patients who received a decompressive hemicraniectomy for malignant middle cerebral artery infarction were evaluated in this retrospective cohort study. Surgical and functional outcomes of patients who had received mechanical recanalization before surgery (thrombectomy group, n = 49) and of patients who had not received mechanical recanalization (medical group, n = 54) were compared.ResultsThe baseline characteristics of the two groups did significantly differ regarding preoperative systemic thrombolysis (63.3% in the thrombectomy group vs. 18.5% in the medical group, p < 0.001), the rate of hemorrhagic transformation (44.9% vs. 24.1%, p = 0.04) and the preoperative Glasgow Coma Score (median of 7 in the thrombectomy group vs. 12 in the medical group, p = 0.04) were similar to those of prior randomized controlled trials of decompressive hemicraniectomy. There was no significant difference in the rates of surgical complications (10.2% in the thrombectomy group vs. 11.1% in the medical group), revision surgery within the first 30 days after surgery (4.1% vs. 5.6%, respectively), and functional outcome (median modified Rankin Score of 4 at 5 and 14 months in both groups) between the two groups.ConclusionsA prior mechanical recanalization with possibly associated systemic thrombolysis does not affect the early surgical complication rate and the functional outcome after decompressive hemicraniectomy for malignant ischemic stroke. Patient characteristics have not changed significantly since the introduction of mechanical recanalization; therefore, the results from former large randomized controlled trials are still valid in the modern era of stroke care.

Strokectomy in Malignant Middle Cerebral Artery Infarction: A 20-Year Experience from a Tertiary Center in Taiwan

Strokectomy in Malignant Middle Cerebral Artery Infarction: A 20-Year Experience from a Tertiary Center in Taiwan

Large diameter hemicraniectomy does not improve long-term outcome in malignant infarction

IntroductionIn malignant cerebral infarction decompressive hemicraniectomy has demonstrated beneficial effects, but the optimum size of hemicraniectomy is still a matter of debate. Some surgeons prefer a large-sized hemicraniectomy with a diameter of more than 14 cm (HC > 14). We investigated whether this approach is associated with reduced mortality and an improved long-term functional outcome compared to a standard hemicraniectomy with a diameter of less than 14 cm (HC ≤ 14).MethodsPatients from the DESTINY (DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY) registry who received hemicraniectomy were dichotomized according to the hemicraniectomy diameter (HC ≤ 14 cm vs. HC > 14 cm). The primary outcome was modified Rankin scale (mRS) score ≤ 4 after 12 months. Secondary outcomes were in-hospital mortality, mRS ≤ 3 and mortality after 12 months, and the rate of hemicraniectomy-related complications. The diameter of the hemicraniectomy was examined as an independent predictor of functional outcome in multivariable analyses.ResultsAmong 130 patients (32.3% female, mean (SD) age 55 (11) years), the mean hemicraniectomy diameter was 13.6 cm. 42 patients (32.3%) had HC > 14. There were no significant differences in the primary outcome and mortality by size of hemicraniectomy. Rate of complications did not differ (HC ≤ 14 27.6% vs. HC > 14 36.6%, p = 0.302). Age and infarct volume but not hemicraniectomy diameter were associated with outcome in multivariable analyses.ConclusionIn this post-hoc analysis, large hemicraniectomy was not associated with an improved outcome or lower mortality in unselected patients with malignant middle cerebral artery infarction. Randomized trials should further examine whether individual patients could benefit from a large-sized hemicraniectomy.Clinical trial registration informationGerman Clinical Trials Register (URL: https://www.drks.de; Unique Identifier: DRKS00000624).

Postoperative management following decompressive hemicraniectomy for malignant middle cerebral artery infarction-AGerman nationwide survey study

Malignant middle cerebral artery infarction is apotentially life-threatening disease. Decompressive hemicraniectomy constitutes an evidence-based treatment practice, especially in patients under 60years of age; however, recommendations with respect to postoperative management and particularly duration of postoperative sedation lack standardization. This survey study aimed to analyze the current situation of patients with malignant middle cerebral artery infarction following hemicraniectomy in the neurointensive care setting. From 20 September 2021 to 31 October 2021, 43members of the initiative of German neurointensive trial engagement (IGNITE) network were invited to participate in astandardized anonymous online survey. Descriptive data analysis was performed. Out of 43centers 29 (67.4%) participated in the survey, including 24university hospitals. Of the hospitals 21 have their own neurological intensive care unit. While 23.1% favored astandardized approach regarding postoperative sedation, the majority utilized individual criteria (e.g., intracranial pressure increase, weaning parameters, complications) to assess the need and duration. The timing of targeted extubation varied widely between hospitals (≤ 24 h 19.2%, ≤ 3days in 30.8%, ≤ 5days in 19.2%, > 5days in 15.4%). Early tracheotomy (≤ 7days) is performed in 19.2% and 80.8% of the centers aim for tracheotomy within 14days. Hyperosmolar treatment is used on aregular basis in 53.9% and 22 centers (84.6%) agreed to participate in aclinical trial addressing the duration of postoperative sedation and ventilation. The results of this nationwide survey among neurointensive care units in Germany reflect aremarkable heterogeneity in the treatment practices of patients with malignant middle cerebral artery infarction undergoing hemicraniectomy, especially with respect to the duration of postoperative sedation and ventilation. Arandomized trial in this matter seems warranted.

Clinical Analysis of Microvascular Reconstruction Combined With Decompressive Craniectomy in Patients With Malignant Middle Cerebral Artery Infarctions

This study aimed to evaluate the safety and efficacy of microvascular reconstruction combined with decompressive craniectomy in patients with MMCA. We searched for patients with MMCA ,and age＜60 years old, postoperative survival of more than 3 months, consistent with decompression of bone flap removal. Patients were divided into experimental group and control group according to whether they underwent emergency vascular revascularization within 5 days after onset of ischemic stroke. A total of 6 patients were included in the treatment group and 12 patients in the control group. The NIHSS score of the treatment group was lower than that of the control group 7 days after operation, but the difference was not statistically significant;3 months after surgery, mRs score in the treatment group was lower than that in the control group, the difference was statistically significant (P=0.002); mRs scores of the treatment group 3 months after surgery were significantly different from those before surgery (P<0.05), but no such difference was found in the control group. Compared with DHC, open surgical revascularization can improve early cerebral perfusion in MMCA patients, and neurological recovery is better at 3 months after operation. By ensuring that surgeons are properly trained and hospitals are equipped, open surgical revascularization can be a treatment option for patients with MMCA.

Time course of hemispheric cerebral volume after decompressive craniectomy in malignant middle cerebral artery stroke

Brain edema is the leading cause of death in patients with malignant middle cerebral artery (MCA) infarction. Midline shift (MLS) has been used as a monohemispheric brain edema marker in several studies; however, it does not precisely measure brain edema. It is now possible to directly measure hemisphere brain volume. Knowledge about the time course of brain edema after malignant middle cerebral artery infarction may contribute to the condition's management. Therefore, our goal was to evaluate the course of brain edema in patients with malignant MCA infarction treated with decompressive craniectomy (DC) using hemispheric volumetric measurements. Patients were selected consecutively from a single tertiary hospital between 2013 and 2019. All patients were diagnosed with malignant middle cerebral artery infarction and underwent a decompressive craniectomy (DC) to treat the ischemic event. All computed tomography (CT) exams performed during the clinical care of these patients were analyzed, and the whole ischemic hemisphere volume was calculated for each CT scan. We analyzed 43 patients (197 CT exams). Patients' mean age at DC was 51.72 [range: 42-68] years. The mean time between the ischemic ictus and DC was 41.88 (range: 6-77) hours. The mean time between the ischemic event and the peak of hemisphere volume was 168.84 (95% confidence interval [142.08, 195.59]) hours. In conclusion, the peak of cerebral edema in malignant MCA infarction after DC occurred on the 7th day (168.84 h) after stroke symptoms onset. Further studies evaluating therapies for brain edema even after DC should be investigated.

564 The Influence of Presenting Glucose and Glycated Hemoglobin on Outcomes Following Mechanical Thrombectomy for Anterior Circulation Large Vessel Occlusion

INTRODUCTION: Elevated presenting glucose and glycated hemoglobin (HbA1C) values may be associated with worse outcomes following mechanical thrombectomy (MT) for anterior circulation large vessel occlusion (ACLVO). METHODS: All patients who underwent MT for ACLVO between 2015 – 2021 at a single institution were reviewed. The outcomes included favorable functional status (modified Rankin Scale [mRS] 0 – 2) at 90 days, any intracranial hemorrhage (ICH), parenchymal hemorrhage, and malignant middle cerebral artery infarction (MMI). Multivariate logistic regression analyses adjusting for age, premorbid mRS, admission NIHSS, ASPECTS, collateral score, tPA administration, onset to reperfusion time, and TICI grade were performed. Youden’s index was used to identify thresholds for glucose and HbA1C that optimized area under the receiving operator characteristic curve for predicting outcomes. RESULTS: A total of 332 patients were included. The mean (SD) age was 70.9 years (15.1), 50.3% of patients were female, and 26.9% of patients had a history of diabetes. The median (IQR) presenting glucose, SGR, and HbA1C values were 118 mg/dL (40), 1.0 (0.35), and 5.7% (1.0), respectively. Presenting glucose was associated with any ICH (OR 1.38, 95% 1.08 – 1.80) and MMI (OR 1.48, 95% CI 1.06 – 2.03), but not functional status. SGR was not associated with any outcome. Presenting HbA1C was associated with MMI (OR 1.43, 95% 1.02 – 2.02) but not functional status or ICH. The optimal threshold among glucose values for predicting ICH and MMI were 167 mg/dL and 128 mg/dL, respectively. For HbA1c, the threshold for predicting MMI was 6.0. CONCLUSIONS: Presenting glucose and HbA1C were associated with MMI, and glucose was associated with ICH after MT for ACLVO. Improved glucose control prior to admission could decrease the odds of these events.

Long-term outcome after decompressive hemicraniectomy for malignant middle cerebral artery infarction

BackgroundAlthough decompressive hemicraniectomy (DHC) is a lifesaving treatment strategy for patients with malignant middle cerebral artery infarction (mMCAi), only one in four patients achieves low to moderate post-stroke disability according to previous studies. However, the short follow-up periods in prior studies could have overestimated the poor clinical prognosis. This study therefore examined the long-term outcome after DHC for mMCAi.MethodsWe retrospectively included all patients who had undergone DHC after mMCAi at the University Hospital Graz between 2006 and 2019. Demographics, clinical data and complications were collected from electronic clinical patient records. To investigate long-term prognosis, all patients were followed up to 14 years after stroke including quality of life (QOL) assessment. Post-stroke disability was rated according to the modified Rankin Scale (mRS).ResultsOf 47 patients that had undergone DHC for mMCAi, follow-up data were available in 40 patients (mean age: 48 years; 40% female). Six months after the mMCAi, 14 patients had died (35%) and nine (23%) had a low to moderate post-stroke disability (mRS 0–3). Of 26 stroke survivors, half (50%) showed further mRS improvement (≥ 1 point) during the long-term follow-up period (mean follow-up time: 8 years). At last follow-up, 17 patients had achieved an mRS score of ≤ 3 (65% versus 35% after 6 months; p = 0.008) and 55% had no signs of depression and anxiety, and 50% no signs of pain or discomfort in QOL assessment.ConclusionThis study shows substantial long-term improvement of functional disability and reasonable QOL in mMCAi patients after DHC.

Subdural evacuating port system with subdural thrombolysis for the treatment of chronic subdural hematoma in patients older than 80 years.

The subdural evacuating port system (SEPS) is a minimally invasive approach that can be performed under local anesthesia for the treatment of chronic subdural hematoma (CSDH). Subdural thrombolysis has been described as an exhaustive drainage strategy and found to be safe and effective for improving drainage. We aim to analyze the effectiveness of SEPS with subdural thrombolysis in patients older than 80 years. Consecutive patients aged ≥80 years old who presented with symptomatic CSDH and underwent SEPS followed by subdural thrombolysis between January 2014 and February 2021 were retrospectively studied. Outcome measures included complications, mortality, recurrence, and modified Rankin Scale (mRS) scores at discharge and 3 months. In total, 52 patients with CSDH in 57 hemispheres were operated on, with a mean age of 83.9 ± 3.3 years, and 40 (76.9%) patients were men. The preexisting medical comorbidities were observed in 39 patients (75.0%). Postoperative complications occurred in nine patients (17.3%), with two having significant complications (3.8%). The complications observed included pneumonia (11.5%), acute epidural hematoma (3.8%), and ischemic stroke (3.8%). One patient experienced contralateral malignant middle cerebral artery infarction and died of subsequent severe herniation, contributing to a perioperative mortality rate of 1.9%. Discharge and 3 months of favorable outcomes (mRS score 0-3) were achieved in 86.5% and 92.3% of patients, respectively. CSDH recurrence was observed in five patients (9.6%), and repeat SEPS was performed. As an exhaustive drainage strategy, SEPS followed by thrombolysis is safe and effective with excellent outcomes among elderly patients. It is a technically easy and less invasive procedure with similar complications, mortality, and recurrence rates compared with burr-hole drainage in the literature.

Abstract TMP9: Covid-19 Increases The Risk Of Malignant Middle Cerebral Artery Infarction In Acute Stroke

Introduction: Stroke as a presenting feature of COVID-19 infection is being increasingly recognized. The prevalence of malignant middle cerebral artery syndrome (MMC) in acute stroke associated with COVID-19 is yet unknown. Methods: This is a retrospective cohort study of ischemic stroke patients admitted in a health center in Brazil. We investigated the prevalence of malignant middle cerebral artery syndrome in COVID-19 and associated stroke patients. Results: We included 881 ischemic stroke patients (53% male). COVID-19 patients represented 5.3% (N = 47). Mean age was 65.6 years (SD 13.2). COVID-19 patients were significantly younger (mean: 61.4 years; SD: 13.5; p = 0.025) and disclosed a higher odds of previous ischemic heart disease (OR: 4.1 - CI: 1.98-8.16). The frequency of main stroke risk factors was similar for both groups. COVID-19 patients had significantly higher NIHSS (11 points vs 8.2 in non-Covid-19 group - p = 0.006). MMC occurred more frequently in COVID-19 patients (19.5% vs 4.1% of non-covid-19 group - p &lt; 0.001) (Risk ratio: 5.1; CI: 2.63-10.01 - p &lt; 0.001). COVID-19 stroke patients had a longer hospital stay (p &lt; 0.001) and disclosed a higher risk for in-hospital infection (Risk ratio: 4.3 - CI: 2.47-7.53). Rankin scale at 90 days was significantly higher for COVID-19 patients (p &lt;0.001). Case-fatality was higher among COVID-19 stroke patients (49.4% vs 2.5% in non-covid-19 group; p &lt; 0.0001). Among those patients with MMC, the lethality was significantly higher among COVID-19 patients (66.6% vs 41.3% in non-covid-19 group; p&lt; 0.0001). Multivariate logistic regression with MMC as outcome and adjusted for age, sex, NIHSS and comorbidity index, disclosed COVID-19 infection as the main independent preditor for MMC (OR: 6.3 - CI: 2.26-17.52 - p &lt; 0.0001 - adjusted R2 = 0.2623). Conclusion: In this cohort study, COVID-19 infection was an independent predictor for malignant middle cerebral artery syndrome in ischemic stroke.

Machine learning prediction of malignant middle cerebral artery infarction after mechanical thrombectomy for anterior circulation large vessel occlusion

ObjectivePrediction of malignant middle cerebral artery infarction (MMI) could identify patients for early intervention. We trained and internally validated a ML model that predicts MMI following mechanical thrombectomy (MT) for ACLVO. MethodsAll patients who underwent MT for ACLVO between 2015 – 2021 at a single institution were reviewed. Data was divided into 80% training and 20% test sets. 10 models were evaluated on the training set. The top 3 models underwent hyperparameter tuning using grid search with nested 5-fold CV to optimize the area under the receiver operating curve (AUROC). Tuned models were evaluated on the test set and compared to logistic regression. ResultsA total of 381 patients met the inclusion criteria. There were 50 (13.1%) patients who developed MMI. Out of the 10 ML models screened on the training set, the top 3 performing were neural network (median AUROC 0.78, IQR 0.72 – 0.83), support vector machine ([SVM] median AUROC 0.77, IQR 0.72 – 0.83), and random forest (median AUROC 0.75, IQR 0.68 – 0.81). On the test set, random forest (median AUROC 0.78, IQR 0.73 – 0.83) and neural network (median AUROC 0.78, IQR 0.73 – 0.83) were the top performing models, followed by SVM (median AUROC 0.77, IQR 0.70 – 0.83). These scores were significantly better than those for logistic regression (AUROC 0.72, IQR 0.66 – 0.78), individual risk factors, and the Malignant Brain Edema score (p < 0.001 for all). ConclusionML models predicted MMI with good discriminative ability. They outperformed standard statistical techniques and individual risk factors.

Effect of decompressive hemicraniectomy performed within the first 48 hours on mortality in the treatment of malignant infarction of the middle cerebral artery

To evaluate the clinical outcomes of patients with malignant middle cerebral artery (MCA) infarction who underwent wide decompressive hemicraniectomy. Fifty-two patients with large MCA infarcts were retrospectively evaluated, and 12 patients who underwent extensive decompressive hemicraniectomy and duraplasty with a bone flap extending beyond the infarct borders were included in the study. The degree of stroke (stroke volume), preoperative and postoperative midline shift of the craniectomy area and improvement in midline shift were calculated on computed tomography. Preoperative and postoperative neurologic examination scores were determined using the modified Rankin Scale. The mean age was 63 (min: 41, max: 79) years. There was left MCA infarction in one patient and right MCA infarction in 11 patients. The postoperative follow-up period of the operated patients ranged from 14 to 90 days. The neurological examination of seven patients (58.3%) showed significant improvement. Eight (66.6%) patients survived. Postoperatively, the mean midline deviation value of 12 patients decreased from 11.04 to 4.8. It is considered that wide decompressive craniectomy performed in young patients in the early period with strict radiological and clinical follow-up can increase survival and functional recovery.