Malignant Middle Cerebral Artery Infarction Research Articles

Is Spreading Depolarization a Risk Factor for Late Epilepsy? A Prospective Study in Patients with Traumatic Brain Injury and Malignant Ischemic Stroke Undergoing Decompressive Craniectomy.

Spreading depolarizations (SDs) have been described in patients with ischemic and haemorrhagic stroke, traumatic brain injury, and migraine with aura, among other conditions. The exact pathophysiological mechanism of SDs is not yet fully established. Our aim in this study was to evaluate the relationship between the electrocorticography (ECoG) findings of SDs and/or epileptiform activity and subsequent epilepsy and electroclinical outcome. This was a prospective observational study of 39 adults, 17 with malignant middle cerebral artery infarction (MMCAI) and 22 with traumatic brain injury, who underwent decompressive craniectomy and multimodal neuromonitoring including ECoG in penumbral tissue. Serial electroencephalography (EEG) recordings were obtained for all surviving patients. Functional disability at 6 and 12months after injury were assessed using the Barthel, modified Rankin (mRS), and Extended Glasgow Outcome (GOS-E) scales. SDs were recorded in 58.9% of patients, being more common-particularly those of isoelectric type-in patients with MMCAI (p < 0.04). At follow-up, 74.7% of patients had epileptiform abnormalities on EEG and/or seizures. A significant correlation was observed between the degree of preserved brain activity on EEG and disability severity (R [mRS]: + 0.7, R [GOS-E, Barthel]: - 0.6, p < 0.001), and between the presence of multifocal epileptiform abnormalities on EEG and more severe disability on the GOS-E at 6months (R: - 0.3, p = 0.03) and 12months (R: - 0.3, p = 0.05). Patients with more SDs and higher depression ratios scored worse on the GOS-E (R: - 0.4 at 6 and 12months) and Barthel (R: - 0.4 at 6 and 12months) disability scales (p < 0.05). The number of SDs (p = 0.064) and the depression ratio (p = 0.1) on ECoG did not show a statistically significant correlation with late epilepsy. SDs are common in the cortex of ischemic or traumatic penumbra. Our study suggests an association between the presence of SDs in the acute phase and worse long-term outcome, although no association with subsequent epilepsy was found. More comprehensive studies, involving ECoG and EEG could help determine their association with epileptogenesis.

Association Between Preoperative Midline Shift Growing Rate and Outcomes of Decompressive Craniectomy in Patients with Malignant Middle Cerebral Artery Infarction.

Whether preoperative midline shift and its growing rate are associated with outcomes of decompressive craniectomy in patients with malignant middle cerebral artery infarction is unknown. We retrospectively included patients: 1) who underwent decompressive craniectomy for malignant middle cerebral artery infarction in West China Hospital from August 2010 to December 2, 2018) who had at least two brain computed tomography scans before decompressive craniectomy. Midline shift was measured on the first and last preoperative computed tomography scans. Midline shift growing rate was calculated by dividing Δmidline shift value using Δ time. The primary outcome was inadequate decompression of the mass effect. Secondary outcomes were 3 month death and unfavorable outcomes. Sixty-one patients (mean age 53.7 years, 57.4% (35/61) male) were included. Median time from onset to decompressive craniectomy was 51.8 h (interquartile range: 39.7-77.8). Rates of inadequate decompression, 3 month death, 3 month modified Rankin Scale 5-6 and 4-6 were 50.8% (31/61), 50.9% (29/57), 64.9% (37/57) and 84.2% (48/57), respectively. The inadequate decompression group had a higher midline shift growing rate than the adequate decompression group (median: 2.7 mm/8 h vs. 1.4 mm/8 h, P=0.041). No intergroup difference of 3 month outcomes was found in terms of preoperative midline shift growing rate. Higher preoperative midline shift growing rate was associated with inadequate decompression of decompressive craniectomy in patients with malignant middle cerebral artery infarction.

Fifteen-Year Institutional Retrospective Case Series of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction

In the present study, we updated our previously reported case series of patients who had undergone decompressive craniectomy for malignant middle cerebral artery infarction (mMCAI) (2005-2020). To the best of our knowledge, the present case series constitutes the largest reported series from a UK neurosurgical unit of decompressive craniectomy for mMCAI. We extracted data regarding the clinical discriminators, surgical timescales, and functional outcomes of patients. A total of 67 patients had undergone decompressive craniectomy. The 30-day mortality was 17.9% (n= 12). Of the 67 patients, 31 were male (46.3%) and 36 were female (53.7%). Their mean age was 45 years (range, 16-64 years). The mean age of the survivors was 43 years (range, 16-62 years) compared with 50 years (range, 38-64 years) for those who had died. The median ictal and preoperative Glasgow coma scale score was 14 (range, 7-15) and 8 (range, 3-15), respectively. The corresponding motor scores were 6 and 5. The mean interval from ictus to neurosurgical unit admission was 18.25 hours (range, 0.5-66 hours) and from admission to decompressive craniotomy was 7.30 hours (range, 0.5-46 hours). Of the 67 patients, 63% had undergone "early" craniectomy (<48 hours from mMCAI evolution), with 89% of these patients having undergone craniectomy <24hours after neurosurgical unit admission. The mean maximum anteroposterior craniectomy diameter was 13.01 cm (range, 10.29-15.56 cm), and mean surface area was 94.38 cm2 (range, 74.75-132.32 cm2). Overall, 46% of patients had had a modified Rankin scale score of <3 (range, 0-6) from discharge to 12 months postoperatively. The median neurosurgical unit length of stay was 15 days (range, 6 hours to 365 days). The findings from the present update have confirmed that local practice has remained consistent with current evidence. However, patient selection might be optimized if diffusion-weighted magnetic resonance imaging and computed tomography perfusion were used at the original middle cerebral artery infarct admission.

Prediction of Malignant Acute Middle Cerebral Artery Infarction via Computed Tomography Radiomics.

Malignant middle cerebral artery infarction (mMCAi) is a serious complication of cerebral infarction usually associated with poor patient prognosis. In this retrospective study, we analyzed clinical information as well as non-contrast computed tomography (NCCT) and computed tomography angiography (CTA) data from patients with cerebral infarction in the middle cerebral artery (MCA) territory acquired within 24 h from symptoms onset. Then, we aimed to develop a model based on the radiomics signature to predict the development of mMCAi in cerebral infarction patients. Patients were divided randomly into training (n = 87) and validation (n = 39) sets. A total of 396 texture features were extracted from each NCCT image from the 126 patients. The least absolute shrinkage and selection operator regression analysis was used to reduce the feature dimension and construct an accurate radiomics signature based on the remaining texture features. Subsequently, we developed a model based on the radiomics signature and Alberta Stroke Program Early CT Score (ASPECTS) based on NCCT to predict mMCAi. Our prediction model showed a good predictive performance with an AUC of 0.917 [95% confidence interval (CI), 0.863–0.972] and 0.913 [95% CI, 0.795–1] in the training and validation sets, respectively. Additionally, the decision curve analysis (DCA) validated the clinical efficacy of the combined risk factors of radiomics signature and ASPECTS based on NCCT in the prediction of mMCAi development in patients with acute stroke across a wide range of threshold probabilities. Our research indicates that radiomics signature can be an instrumental tool to predict the risk of mMCAi.

Predictors of malignant middle cerebral artery infarction after mechanical thrombectomy

IntroductionSeveral predictors have been described to early diagnose malignant middle cerebral artery infarction (MMI) and select patient for hemicraniectomy. Nevertheless, few studies have assessed them among patients with acute ischemic stroke undergoing mechanical endovascular thrombectomy (MET). The overall objective in this study was to evaluate these predictors in patients undergoing MET in the purpose to guide the medical care in the acute phase. MethodsWe selected patients from a prospective local database which reference all patients eligible for treatment with Alteplase thrombolysis and/or mechanical endovascular thrombectomy in acute stroke. We investigated demographic, clinical, and radiological data. Multivariate regression analysis was used to identify clinical and imaging predictors of MMI. ResultsIn 32 months, 66 patients were included. Eighteen (27.3%) developed MMI. Malignant evolution was associated with: severity of neurological deficit and level of consciousness at admission, infarct size in DWI sequence and involvement of other vascular territories. Study groups didn’t differ in terms of successful reperfusion. Two variables were identified as independent predictors of MMI: DWI infarct volume (p<0.001) and time to thrombectomy (p=0.018). A decision tree based on these two factors was able to predict malignant evolution with high specificity (100%) and sensibility (73%). ConclusionOur study proposes a practical decision tree including DWI lesion volume and delay before thrombectomy to early and accurately predict MMI in a subgroup of patients with MCA infarction undergoing MET regardless to the status of reperfusion.

Early successful reperfusion after endovascular therapy reduces malignant middle cerebral artery infarction occurrence in young patients with large diffusion-weighted imaging lesions.

Malignant middle cerebral artery infarction (MMI) is a severe complication of acute ischaemic stroke (AIS). The aim of our study was to assess whether successful reperfusion after endovascular therapy (EVT) in AIS with clinical and imaging predictors of MMI decreased its occurrence. Data were collected between January 2014 and July 2018 in a monocentric prospective AIS registry of patients treated with EVT. Patients selected were <65years old with severe anterior circulation AIS with a National Institutes of Health Stroke Scale score >15, baseline Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Score≤6 and baseline diffusion-weighted imaging lesion volume >82mL within 6h of symptom onset. Successful reperfusion was defined as a Thrombolysis in Cerebral Ischemia score≥2b. Occurrence of MMI was the primary endpoint. A total of 66 EVT-treated patients were included in our study. MMI occurred in 27 patients (41%). In unadjusted analysis, successful reperfusion was associated with fewer MMIs (31.8% vs. 65.0%; P=0.015) and with more favorable outcome at 3months (50% vs. 20%; P=0.023). In multivariate analysis, successful reperfusion was associated with an adjusted odds ratio (95% confidence intervals) of 0.35 (0.10-1.12) for MMI and 2.77 (0.84-10.43) for 3-month favorable outcome occurrence. Early successful reperfusion performed in patients with AIS with clinical and imaging predictors of MMI was associated with decreased MMI occurrence. Reperfusion status might be considered in evaluating the need for craniectomy in patients with early predictors of MMI.

Sonography of optic nerve sheath diameter identifies patients with middle cerebral artery infarction at risk of a malignant course: a pilot prospective observational study.

To assess the value of optic nerve sheath diameter (ONSD) measurements at different time points to predict the malignant evolution in middle cerebral artery (MCA) infarction and to investigate the relationship between ONSD and infarct volume on follow-up computed tomography (CT). In a single-center prospective observational study, we recruited patients with MCA infarction and age- and sex-matched controls. Clinical characteristics including NationaI Institutes of Health Stroke Scale (NIHSS) and ONSD measurement were assessed during the first five days after symptom onset. Volumetric analysis of the infarction was performed by a neuroradiologist, who was blinded to results of ONSD measurement and clinical examinations, based on CT scans. We enrolled 29 patients with MCA infarction, including 10 with malignant MCA (mMCA) infarction and 14 controls. Mean ONSD on admission was already larger in patients who had developed an mMCA (5.99 ± 0.32mm) compared to patients with MCA infarction (4.98 ± 0.53mm; P = 0.003), and to control patients (4.57 ± 0.29mm; P < 0.001). Correlation was observed between the ONSD mean value bilateral measures per individual and volumetric evaluation of cerebral infarction in the CT scan after one day (r = 0.623; P = 0.002). An ONSD value of 5.6mm predicted an mMCA with a sensitivity of 100% and specificity of 90% yielding a positive predictive value of 83% and negative predictive value of 100%. ONSD measurement might be accurate for the noninvasive detection of increased ICP and for the recognition of patients being likely to develop mMCA.

Early Mortality of Brain Infarction Patients and Red Blood Cell Distribution Width.

Background: Meta-analysis has found that high baseline red blood cell distribution width (RDW) is associated with increased long-term mortality (mortality at one year or more) in ischemic stroke. The objectives of this study were to determine whether there is an association between RDW and 30-day mortality, and to explore whether RDW during the first week of ischemic stroke could be a 30-day mortality biomarker. Methods: We included patients with malignant middle cerebral artery infarction (MMCAI). RDW at days 1, 4, and 8 of MMCAI were determined. The end-point study was 30-day mortality. Results: We found that survivor (n = 37) in respect to non-survivor patients (n = 37) had lower RDW at days 1 (p < 0.001), 4 (p < 0.001), and 8 (p = 0.02). The area under curve (95% CI) for prediction of 30-day mortality by RDW at days 1, 4, and 8 of MMCAI were 0.80 (0.69–0.89; p < 0.001), 0.79 (0.66–0.89; p < 0.001), and 0.73 (0.58–0.84; p = 0.02). Regression analysis showed an association between RDW (odds ratio = 1.695; 95% CI = 1.230–2.335; p < 0.001) and 30-day mortality. Conclusions: The association between RDW and early mortality, and the potential role of RDW during the first week of MMCAI as a prognostic biomarker of early mortality were the main novelties of our study.

Value of computed tomography angiographic collateral status in prediction of malignant middle cerebral artery infarction

Background: Cerebral collateral circulation is necessary to maintain cerebral blood flow and penumbra when arterial insufficiency occurred. Only a few studies about collateral status on development of malignant middle cerebral artery infarction (mMCAi) have been documented.&#x0D; Objective: To determine whether collateral status evaluated by single phase computed tomographic angiography (CTA) help prediction of mMCAi in patients with large arterial occlusion whom not received endovascular treatment.&#x0D; Material and Methods: We retrospectively reviewed patients with acute ischemic stroke in anterior circulation in our institute during January 2015 to December 2015. We analyzed clinical data, baseline National Institutes of Health Stroke Scale (NIHSS), Alberta Stroke Program Early CT Score (ASPECTS) on baseline nonenhanced computed tomography of the brain (NECT brain), and CTA collateral status. Malignant MCA infarction was defined according to clinical criteria.&#x0D; Results: Thirty-five patients were included. Mean age was 68.8±15.56 years. Mean baseline NIHSS and baseline ASPECTS were 17(±5) and 6(±3), respectively. All patients received intravenous thrombolysis. CTA collateral status and baseline NECT ASPECTS significantly correlated with development of mMCAi (P-value = 0.007 and 0.001). Only baseline NECT ASPECTS was an independent predictive factor for mMCAi (OR 0.63, 95%CI 0.46-0.86, P-value =0.004). Patients with baseline NECT ASPECTS ? 7 were more likely develop mMCAi (OR 14.29 95%CI 1.57-129.94, P-value 0.018).&#x0D; Conclusion: In acute stroke patients with proximal MCA or ICA occlusion received intravenous thrombolysis alone, baseline NECT ASPECTS and CTA collateral status were significantly correlate with development of mMCAi. However, only baseline ASPECTS ? 7 was an independent predictor for mMCAi.

Value of computed tomography angiographic collateral status in prediction of malignant middle cerebral artery infarction

Background: Cerebral collateral circulation is necessary to maintain cerebral blood flow and penumbra when arterial insufficiency occurred. Only a few studies about collateral status on development of malignant middle cerebral artery infarction (mMCAi) have been documented. Objective: To determine whether collateral status evaluated by single phase computed tomographic angiography (CTA) help prediction of mMCAi in patients with large arterial occlusion whom not received endovascular treatment. Material and Methods: We retrospectively reviewed patients with acute ischemic stroke in anterior circulation in our institute during January 2015 to December 2015. We analyzed clinical data, baseline National Institutes of Health Stroke Scale (NIHSS), Alberta Stroke Program Early CT Score (ASPECTS) on baseline nonenhanced computed tomography of the brain (NECT brain), and CTA collateral status. Malignant MCA infarction was defined according to clinical criteria. Results: Thirty-five patients were included. Mean age was 68.8±15.56 years. Mean baseline NIHSS and baseline ASPECTS were 17(±5) and 6(±3), respectively. All patients received intravenous thrombolysis. CTA collateral status and baseline NECT ASPECTS significantly correlated with development of mMCAi (P-value = 0.007 and 0.001). Only baseline NECT ASPECTS was an independent predictive factor for mMCAi (OR 0.63, 95%CI 0.46-0.86, P-value =0.004). Patients with baseline NECT ASPECTS ≤ 7 were more likely develop mMCAi (OR 14.29 95%CI 1.57-129.94, P-value 0.018). Conclusion: In acute stroke patients with proximal MCA or ICA occlusion received intravenous thrombolysis alone, baseline NECT ASPECTS and CTA collateral status were significantly correlate with development of mMCAi. However, only baseline ASPECTS ≤ 7 was an independent predictor for mMCAi.

Can Computed Tomographic Angiography Be Used to Predict Who Will Not Benefit from Endovascular Treatment in Patients with Acute Ischemic Stroke? The CTA-ABC Score.

ObjectiveThe objective of this study was to develop a score to predict patients with acute ischemic stroke (AIS) who will not benefit from endovascular treatment (EVT) using computed tomographic angiography (CTA) parameters. MethodsThe CTA-ABC score was developed from 3 scales previously described in the literature: the Alberta Stroke Program Early CT Score (0–5 points, 3; 6–10 points, 0), the clot burden score (0–3 points, 1; 4–10 points, 0), and the leptomeningeal Collateral score (0–1 points, 2; 2–3 points, 0). We evaluated the predictive value of CTA parameters associated with symptomatic intracranial hemorrhage (sICH) or malignant middle cerebral artery infarction (MMCAI) after EVT and developed the score using logistic regression coefficients. The score was then validated. Performance of the score was tested with an area under the receiver operating characteristic curve (AUC-ROC). ResultsThe derivation cohort consisted of 115 and the validation cohort consisted of 40 AIS patients. The AUC-ROC was 0.97 (95% confidence interval [CI], 0.94–0.99; p<0.001) in the derivation cohort. The proportions of patients with sICH and/or MMCAI in the derivation cohort were 96%, 73%, 6%, and 0% for scores of 6, 5, 1, and 0 points, respectively. In the validation group, the proportions were similar (90%, 100%, 0%, and 0%, respectively) with an AUC-ROC of 0.96 (95% CI, 0.90–1.00; p<0.001). ConclusionOur CTA-ABC score reliably assessed risk for sICH and/or MMCAI in patients with AIS who underwent EVT. It can support clinical decision-making, especially when the need for EVT is uncertain.

Decompressive Hemicraniectomy in the Treatment of Malignant Middle Cerebral Artery Infarction

Abstract Background: Malignant middle cerebral artery infarctions affecting about 10% of stroke patients. Formed of huge space-occupying infarctions with extensive edema which lead to herniation, and usually death. Treatment includes medical treatment in addition to decompressive hemicraniectomy associated with duroplasty in many cases. Decompressive craniectomy has a great effect in reduction of mortality rates and improving the functional outcome of the patients. Aim of Study: We reviewed the outcome of decompressive hemicraniectomy in the treatment of Malignant Middle Cer-ebral Artery infarction. Patients and Methods: The study includes 14 patients of malignant middle cerebral artery infarctions operated upon by decompressive surgery (from January 2015 to August 2018). We evaluated the outcome by estimation of the mortality rate after one month, Glasgow Outcome Score (GOS) on leaving the hospital, at 3 months, and 6 months by modified Rankin scale (mRS). Results: Decompressive craniectomy leads to decrease in mortality rate at 30 days and acceptable GOS outcome at discharge. At 3 months and 6 months good functional outcome based on mRS occurred in cases of the infarction volume below than 250ml, midline shift below 10mm, good Glasgow Coma Scale (GCS) score before surgery and rapid surgical intervention (within 24 hours). Conclusion: Decompressive craniectomy gets great func-tional outcome in cases of young cases with acceptable GCS score before surgery, fair radiological pictures, and operated upon in less than 24 hours of onset.

Outcome After Decompressive Craniectomy for Middle Cerebral Artery Infarction: Timing of the Intervention.

BACKGROUNDBased on randomized controlled trials (RCTs), clinical guidelines for the treatment of space-occupying hemispheric infarct employ age (≤60 yr) and time elapsed since stroke onset (≤48 h) as decisive criteria whether to perform decompressive craniectomy (DC). However, only few patients in these RCTs underwent DC after 48 h.OBJECTIVETo study the association between the timing of DC and (un)favorable outcome in patients with space-occupying middle cerebral artery (MCA) infarct undergoing DC.METHODSWe performed a single-center cohort study from 2007 to 2017. Unfavorable outcome at 1 yr was defined as a Glasgow outcome scale 1 to 3. Additionally, we systematically reviewed the literature up to November 2018, including studies reporting on the timing of DC and other predictors of outcome. We performed Firth penalized likelihood and random-effects meta-analysis with odds ratio (OR) on unfavorable outcome.RESULTSA total of 66 patients were enrolled. A total of 26 (39%) patients achieved favorable and 40 (61%) unfavorable outcomes (13 [20%] died). DC after 48 h since stroke diagnosis did not significantly increase the risk of unfavorable outcome (OR 0.8, 95% CI 0.3-2.3). Also, in the meta-analysis, DC after 48 h of stroke onset was not associated with a higher risk of unfavorable outcome (OR 1.11; 95% CI 0.89-1.38).CONCLUSIONThe outcome of DC performed after 48 h in patients with malignant MCA infarct was not worse than the outcome of DC performed within 48 h. Contrary to current guidelines, we, therefore, advocate not to set a restriction of ≤48 h on the time elapsed since stroke onset in the decision whether to perform DC.

Non-Survivor Ischemic Stroke Patients Maintain High Serum Caspase-Cleaved Cytokeratin-18 Levels.

Objective: Caspase-cleaved cytokeratin (CCCK)-18 could appear in blood during apoptosis. In two different studies, on day 1 of cerebral infarction and at 72 h of cerebral infarction, respectively, higher circulating CCCK-18 levels were found in non-surviving than in surviving patients. The objective of this study was to analyze the ability of these levels to predict mortality at any time during the first week of cerebral infarction. Methods: Patients with malignant middle cerebral artery infarction (MMCAI) were included and the diagnosis criteria were the presence, observed in a computed tomography, of an acute cerebral infarction in at least 50% of this territory and midline shift, and an acute neurological deterioration with a Glasgow Coma Scale ≤ 8. Serum CCCK-18 levels at days 1, 4 and 8 of MMCAI were determined. Results: Serum concentrations of CCCK-18 at days 1, 4 and 8 of MMCAI were higher in non-surviving (n = 34) than in surviving patients (n = 34). Serum CCCK-18 concentrations at days 1, 4 and 8 of MMCAI had an area under curve (95% CI) used to predict a 30-day mortality of 0.83 (0.72 –0.91; p < 0.001), 0.78 (0.65–0.89; p < 0.001) and 0.82 (0.68–0.92; p < 0.001). Conclusions: The novel finding is that serum levels of CCCK-18 levels at any time after the first week of MMCAI could help predict 30-day mortality.

Decompressive hemicraniectomy without clot evacuation in spontaneous intracranial hemorrhage: A systematic review

ObjectiveDecompressive hemicraniectomy (DH) effectively alleviates increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI) and malignant middle cerebral artery (MCA) infarction. Its role in the management of spontaneous intracranial hemorrhage (SICH) however remains uncertain. This study aims to review the efficacy and safety of DH without clot evacuation in SICH. Patients and methodsA systematic literature search of PubMEd, EMBASE, Scopus and Cochrane Library Central Register of Control Trials was performed. Studies were reviewed independently for methodology, inclusion and exclusion criteria and end points. Primary endpoint was overall mortality. Secondary endpoint was functional outcome using modified Rankin scale (mRs) or Glasgow outcome scale (GOS). ResultsNine studies with a total of 146 patients who underwent DH without clot evacuation include: 1 RCT, 3 cohort, 2 case series, and 3 case-control studies. Age range was 40–60 years, with majority of patients presenting with a relatively depressed preoperative sensorium (GCS 6–8), large hematoma volumes (>50 mL), and deep locations (basal ganglia and thalamus). Pooled analysis showed a favorable outcome in 53 %, a mortality rate of 26 % and a complication rate of 35.8 %. ConclusionDH without clot evacuation may offer functional and mortality benefit in patients with spontaneous ICH, based on limited and heterogeneous studies.

Abstract WP202: Decompressive Hemicraniectomy After Malignant Middle Cerebral Artery Ischemic Stroke in a Developing Country is Associated With Poor Long Term Functional Outcome and High Mortality

Background: Decompressive hemicraniectomy (DH) is a level IA therapy for malignant middle cerebral artery (MCA) infarction. However, randomized trials were performed in high income countries with better access to post-stroke care and rehabilitation services. We aimed to assess long term functional outcome and the associated prognostic factors of patients undergoing DH in Brazil. Methods: From January 2013 and July 2018, all patients undergoing DH for malignant MCA infarction in a single comprehensive stroke center were retrospectively identified. Outcomes were the modified Rankin Scale (mRS) (dichotomized as ≤ 4 vs. &gt; 4) and mortality at follow-up. The mRS at follow-up was collected prospectively by telephone using a validated structured interview. Logistic regression analysis was performed to assess independent predictors of outcome. Results: Eighty patients who underwent DH for malignant MCA infarction were identified. Age ranged from 16 to 78 years (median 48 years, IQR 42 - 54,7 years), 46 (57.6%) were males and median time from stroke onset to hemicraniectomy was 30.75 hours (IQR 17.8-46.0). Hospital discharge mRS ≤ 3 and ≤ 4 was observed in 5 (6.2%) and 74 (92,5%) patients respectively. Follow-up information was available for 65 (81.2%) patients. At follow-up (raging from 1.1 to 5.6 years), mRS ≤ 4 was observed in 23 (35.3%) patients. In binary logistic regression analysis, age (OR 1.09, 95% CI 1.02 - 1.17, p=0.01), and right MCA infarction (OR 16.70, 95% CI 1.8-152.30, p=0.01) were independently associated with a worse functional outcome at follow-up. Admission NIHSS (OR 1.0 ,95% CI 0.8-1.3, p=0.45), IV rt-PA (OR 0.5, 95% CI 0.08-3.00, p=0.46) or time of hemicraniectomy (OR 1.00, 95% CI 1.00 - 1.00, p=0.94) were not associated with functional outcome at follow-up. Mortality was 26% (N=21) at hospital discharge and 46% (N=30) at follow-up. Conclusion: The large effect size of DH for malignant MCA infarction is significantly diminished in the population of patients treated under the less than ideal conditions typically found in the public healthcare system of a developing country. Poor access to post-stroke care and rehabilitation services might be possible reasons for the results observed.

Abstract 58: Prediction of Malignant Edema Formation After Endovascular Treatment for Middle Cerebral Artery Infarction: The Added Value of Intracranial Cerebrospinal Fluid Volume

Introduction: Prediction models may guide decisions in the management of patients at risk for malignant middle cerebral artery infarction. The ratio of intracranial cerebrospinal fluid (CSF) volume to intracranial volume (ICV) has been identified as a predictor of malignant edema in ischemic stroke patients treated with intravenous thrombolysis. The added predictive value in stroke patients who received endovascular treatment is unknown. Methods: Patients with available thin-slice non-contrast CT data on admission were selected from the MR CLEAN Registry, which is a prospective national multicenter registry of patients with large vessel occlusion who were treated with endovascular treatment between 2014 and 2017. Baseline characteristics and CT imaging data were collected. The CSF/ICV ratio was automatically measured on baseline thin-slice non-contrast CT. The primary outcome was the formation of malignant edema based on clinical and imaging features on follow-up. A previously built logistic regression model was fitted and included the following baseline predictors: age, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT score, poor collateral filling and reperfusion. An extended model with the CSF/ICV ratio was compared to the previous model by using the likelihood ratio test. Odds ratios (OR), areas under the receiver operating characteristic curve (AUROC) and 95% confidence intervals (CI) were reported. Results: Of the included 683 patients 40 (6%) developed malignant edema. The CSF/ICV ratio of the group with malignant edema (mean 9±5%) was lower than the group without malignant edema (mean 14±6%, P&lt;0.001). In the extended model, the CSF/ICV ratio was associated with the formation of malignant edema (per one percent decrease OR 1.2, 95% CI 1.1-1.3, P&lt;0.001). In addition, the discriminative performance of the model with the CSF/ICV ratio (AUROC 0.87, 95% CI 0.82-0.91) was higher than that of the model without the CSF/ICV ratio (AUROC 0.84, 0.78-0.89, P&lt;0.001). Conclusions: The CSF/ICV ratio improves the prediction of malignant edema formation in ischemic stroke patients who received endovascular treatment.

Outcome Following Decompressive Surgery for Malignant Middle Cerebral Artery Infarction

Background and purpose: When &gt;50% of the brain supplied by middle cerebral artery (MCA) gets infracted they are often termed as malignant MCA infarction. Decompressive hemicraniectomy has became the standard treatment option in carefully selected cases with higher survival benefit (78% Vs 29%) in a pooled analysis of one year follow up; however, there was no promising outcome noted in terms of disability rating. To see the outcome following decompressive hemicraniectomy and lax duroplasty for malignant middle cerebral artery (MCA) infarction this study was pserformed.&#x0D; Materials and Methods: This is a retrospective analytical study, with non-probability consecutive sampling of decompressive hemicraniectomy with lax duroplasty for malignant MCA territory infarction over the last 4 years were collected and Glasgow outcome scale (GOS) at one and six month were measured. The significance was analyzed using chi square or Fisher exact test wherever applicable using SPSS-20.&#x0D; Results: Total 31 cases, with male predominance (74.2%), and mean age of presentation was 51.9 years. Most commonly operated side was on the left (58.1%). Overall favorable outcome at 6 month was 35.5%. When operated for the preoperative GCS of &gt;8, favorable outcome was observed in 30.8% at one month and 76.9% at six months which was statistically significant.&#x0D; Conclusion: Decompressive hemicraniectomy with lax duroplasty has a significant survival benefit. The outcome is significantly better when the preoperative GCS is &gt;8.

High serum substance P levels and mortality after malignant middle cerebral artery infarction

PurposePreviously our team found higher serum substance P concentrations at day 1 of a malignant middle cerebral artery infarction (MMCAI) in non-surviving than in surviving patients. Thus, the objective of this study was to determine whether serum substance P levels during the first week of MMCAI could predict mortality. MethodsWe included patients with MMCAI defined as computed tomography findings of acute infarction in at least of 50% of the territory and Glasgow Coma Scale ≤8. We determined serum concentrations of substance P on days 1, 4 and 8 of MMCAI. Thirty-day mortality was the study end-point. ResultsSerum substance P concentrations at days 1 (p < .001), 4 (p < .001), and 8 (p = .001) of MMCAI in non-surviving (n = 34) were higher than in surviving patients (n = 34). Receiver operating characteristic analyses showed that serum substance P concentrations at days 1, 4, and 8 of MMCAI had an area under curve (95% confidence intervals) to predict 30-day mortality of 0.77 (0.66–0.87; p < .001), 0.82 (0.69–0.91; p < .001) and 0.85 (0.72–0.94; p < .001) respectively. ConclusionsThe two new findings of our study are that non-surviving MMCAI patients showed higher serum substance P levels at day 1, 4 and 8 than surviving, and that those levels could predict 30-day mortality.

Decompressive hemicraniectomy versus medical treatment of malignant middle cerebral artery infarction: a systematic review and meta-analysis.

Objectives: To estimate evidence for decompressive hemicraniectomy (DHC) versus medical treatment effects on survival rate and favorable functional recovery among patients of malignant middle cerebral artery infarction (MMCAI) in randomized controlled trials (RCTs).Design: The present study is a systematic review and meta-analysis of RCTs.Setting: The MEDLINE/PubMed, EMBASE, Springer, Cochrane Collaboration database, China National Knowledge Infrastructure (CNKI) database, and Wanfang database were comprehensively searched for RCTs regarding the effects of DHC versus medical treatment among patients of MMCAI in these English and Chinese electronic databases from inception to 1 June 2019. Two reviewers independently retrieved RCTs and extracted relevant information. The methodological quality of the included trials was estimated using the Cochrane risk of bias tool. Review Manager5.3.5 software was used for statistical analyses. The statistical power of meta-analysis was estimated by Power and Precision, version 4 software.Participants: Nine RCTs with a total of 425 patients with MMCAI, containing 210 cases in the DHC group and 215 cases in the medical treatment group, met the inclusion criteria were included. Primary outcomes were measured by survival rate, defined as modified Rankin scale (mRS) score 0–5 and favorable functional recovery as mRS score 0–3. The follow-up time of all studies was at 6–12months.Results: First, compared with the medical treatment group, DHC was associated with a statistically significant increase survival rate (RR: 1.96, 95%CI 1.61–2.38, P < 0.00001) and favorable functional recovery (RR: 1.62, 95%CI 1.11–2.37, P = 0.01). Second, subgroup analysis: (1) Compared with the medical treatment group among patients age ≤60 years, DHC was associated with a statistically significant increase survival rate (RR = 2.20, 95%CI 1.60–3.04, P < 0.00001); (2) Compared with the medical treatment group among patients of age >60 years, DHC was also associated with a statistically significant increase survival rate (RR: 1.93, 95%CI 1.45–2.59, P < 0.00001); (3) Compared with the medical treatment group, the time of DHC was preformed within 48 h from the onset of stroke that could statistically significant increase survival rate (RR: 2.16, 95%CI 1.69–2.75, P < 0.00001). Third, sensitivity analyses that measured the results were consistent, indicating that the results were stable. Fourth, the results of statistical power analysis were ≥80%. Finally, the funnel plot of the survival rate included nine RCTs showed no remarkable publication bias.Conclusions: Our study results indicated that DHC could increase survival rate and favorable functional recovery among patients age ≤60 or >60 years. The optimal time for DHC might be no more than 48 h from the onset of symptoms. However, due to the limitations of this research, it is necessary to design high quality, large-scale RCTs to further evaluate these findings.