Computed tomographic parameters predicting fatal outcome in large middle cerebral artery infarction

Philip A. Barber, Andrew M. Demchuk, Jinjin Zhang, Scott E. Kasner, Michael D. Hill, Jorg Berrouschot, Erich Schmutzhard, Lutz Harms, Piero Verro, Derk Krieger

Research output: Contribution to journalArticle

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Abstract

Background: Large middle cerebral artery (MCA) ischaemic stroke when associated with extensive mass effect can result in brain herniation and neurological death. As yet there are few guidelines to aid the selection of patients for aggressive interventional therapies, such as decompression hemicraniectomy and/or hypothermia. Methods: We studied a cohort of patients from seven centres with large MCA infarction requiring neurocritical care. The purpose of this analysis was to assess the use of early radiological signs on follow-up computed tomographic (CT) signs performed within 48 h of stroke onset for predicting mortality at 30 days. The CT parameters assessed included horizontal displacement of the septum pellucidum, pineal shift, complete or partial infarction of the temporal lobe, involvement of additional vascular territories, and the presence of hydrocephalus. The primary outcome measure was in-hospital death within 30 days. Results: One hundred and thirty-five patients who had follow-up CT scans within 48 h were identified from a total of 201 patients with large MCA infarction that received conventional medical therapy alone. The median age was 68 (range 29-99), 56% were female, and the median NIHSS category was 26-30 at 48 h. Among CT variables in univariable analysis, anteroseptal shift ≥5 mm, pineal shift ≥2 mm, complete temporal lobe infarction, involvement beyond the MCA territory, and moderate or severe hydrocephalus were equally predictive of death. Multivariable analysis adjusting for time to CT scan revealed the following predictors of fatal outcome: anteroseptal shift ≥5 mm (OR 10.9; 95% CI 3.2-37.6), NIHSS within 48 h >20 (OR 6.6; 95% CI 2.3-19.3), and infarction beyond the MCA territory (OR 4.9; 95% CI 1.6-15.0). Conclusions: We identified the role of early CT signs in predicting death following massive MCA infarction. The CT parameters anteroseptal shift (>5 versus ≤5 mm), pineal shift ≥2 mm, hydrocephalus, temporal lobe infarction, and other vascular territory infarction if present were predictive of fatal outcome. These CT parameters require prospective validation before they should be considered reliable markers for decision-making.

Original languageEnglish (US)
Pages (from-to)230-235
Number of pages6
JournalCerebrovascular Diseases
Volume16
Issue number3
DOIs
StatePublished - 2003

Fingerprint

Fatal Outcome
Middle Cerebral Artery Infarction
Infarction
Temporal Lobe
Hydrocephalus
Blood Vessels
Septum Pellucidum
Middle Cerebral Artery
Decompression
Hypothermia
Patient Selection
Decision Making
Stroke
Outcome Assessment (Health Care)
Guidelines
Mortality
Brain
Therapeutics

Keywords

  • Computed tomography
  • Hemicraniectomy, mortality
  • Middle cerebral artery infarction

ASJC Scopus subject areas

  • Clinical Neurology

Cite this

Barber, P. A., Demchuk, A. M., Zhang, J., Kasner, S. E., Hill, M. D., Berrouschot, J., ... Krieger, D. (2003). Computed tomographic parameters predicting fatal outcome in large middle cerebral artery infarction. Cerebrovascular Diseases, 16(3), 230-235. https://doi.org/10.1159/000071121

Computed tomographic parameters predicting fatal outcome in large middle cerebral artery infarction. / Barber, Philip A.; Demchuk, Andrew M.; Zhang, Jinjin; Kasner, Scott E.; Hill, Michael D.; Berrouschot, Jorg; Schmutzhard, Erich; Harms, Lutz; Verro, Piero; Krieger, Derk.

In: Cerebrovascular Diseases, Vol. 16, No. 3, 2003, p. 230-235.

Research output: Contribution to journalArticle

Barber, PA, Demchuk, AM, Zhang, J, Kasner, SE, Hill, MD, Berrouschot, J, Schmutzhard, E, Harms, L, Verro, P & Krieger, D 2003, 'Computed tomographic parameters predicting fatal outcome in large middle cerebral artery infarction', Cerebrovascular Diseases, vol. 16, no. 3, pp. 230-235. https://doi.org/10.1159/000071121
Barber, Philip A. ; Demchuk, Andrew M. ; Zhang, Jinjin ; Kasner, Scott E. ; Hill, Michael D. ; Berrouschot, Jorg ; Schmutzhard, Erich ; Harms, Lutz ; Verro, Piero ; Krieger, Derk. / Computed tomographic parameters predicting fatal outcome in large middle cerebral artery infarction. In: Cerebrovascular Diseases. 2003 ; Vol. 16, No. 3. pp. 230-235.
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abstract = "Background: Large middle cerebral artery (MCA) ischaemic stroke when associated with extensive mass effect can result in brain herniation and neurological death. As yet there are few guidelines to aid the selection of patients for aggressive interventional therapies, such as decompression hemicraniectomy and/or hypothermia. Methods: We studied a cohort of patients from seven centres with large MCA infarction requiring neurocritical care. The purpose of this analysis was to assess the use of early radiological signs on follow-up computed tomographic (CT) signs performed within 48 h of stroke onset for predicting mortality at 30 days. The CT parameters assessed included horizontal displacement of the septum pellucidum, pineal shift, complete or partial infarction of the temporal lobe, involvement of additional vascular territories, and the presence of hydrocephalus. The primary outcome measure was in-hospital death within 30 days. Results: One hundred and thirty-five patients who had follow-up CT scans within 48 h were identified from a total of 201 patients with large MCA infarction that received conventional medical therapy alone. The median age was 68 (range 29-99), 56{\%} were female, and the median NIHSS category was 26-30 at 48 h. Among CT variables in univariable analysis, anteroseptal shift ≥5 mm, pineal shift ≥2 mm, complete temporal lobe infarction, involvement beyond the MCA territory, and moderate or severe hydrocephalus were equally predictive of death. Multivariable analysis adjusting for time to CT scan revealed the following predictors of fatal outcome: anteroseptal shift ≥5 mm (OR 10.9; 95{\%} CI 3.2-37.6), NIHSS within 48 h >20 (OR 6.6; 95{\%} CI 2.3-19.3), and infarction beyond the MCA territory (OR 4.9; 95{\%} CI 1.6-15.0). Conclusions: We identified the role of early CT signs in predicting death following massive MCA infarction. The CT parameters anteroseptal shift (>5 versus ≤5 mm), pineal shift ≥2 mm, hydrocephalus, temporal lobe infarction, and other vascular territory infarction if present were predictive of fatal outcome. These CT parameters require prospective validation before they should be considered reliable markers for decision-making.",
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T1 - Computed tomographic parameters predicting fatal outcome in large middle cerebral artery infarction

AU - Barber, Philip A.

AU - Demchuk, Andrew M.

AU - Zhang, Jinjin

AU - Kasner, Scott E.

AU - Hill, Michael D.

AU - Berrouschot, Jorg

AU - Schmutzhard, Erich

AU - Harms, Lutz

AU - Verro, Piero

AU - Krieger, Derk

PY - 2003

Y1 - 2003

N2 - Background: Large middle cerebral artery (MCA) ischaemic stroke when associated with extensive mass effect can result in brain herniation and neurological death. As yet there are few guidelines to aid the selection of patients for aggressive interventional therapies, such as decompression hemicraniectomy and/or hypothermia. Methods: We studied a cohort of patients from seven centres with large MCA infarction requiring neurocritical care. The purpose of this analysis was to assess the use of early radiological signs on follow-up computed tomographic (CT) signs performed within 48 h of stroke onset for predicting mortality at 30 days. The CT parameters assessed included horizontal displacement of the septum pellucidum, pineal shift, complete or partial infarction of the temporal lobe, involvement of additional vascular territories, and the presence of hydrocephalus. The primary outcome measure was in-hospital death within 30 days. Results: One hundred and thirty-five patients who had follow-up CT scans within 48 h were identified from a total of 201 patients with large MCA infarction that received conventional medical therapy alone. The median age was 68 (range 29-99), 56% were female, and the median NIHSS category was 26-30 at 48 h. Among CT variables in univariable analysis, anteroseptal shift ≥5 mm, pineal shift ≥2 mm, complete temporal lobe infarction, involvement beyond the MCA territory, and moderate or severe hydrocephalus were equally predictive of death. Multivariable analysis adjusting for time to CT scan revealed the following predictors of fatal outcome: anteroseptal shift ≥5 mm (OR 10.9; 95% CI 3.2-37.6), NIHSS within 48 h >20 (OR 6.6; 95% CI 2.3-19.3), and infarction beyond the MCA territory (OR 4.9; 95% CI 1.6-15.0). Conclusions: We identified the role of early CT signs in predicting death following massive MCA infarction. The CT parameters anteroseptal shift (>5 versus ≤5 mm), pineal shift ≥2 mm, hydrocephalus, temporal lobe infarction, and other vascular territory infarction if present were predictive of fatal outcome. These CT parameters require prospective validation before they should be considered reliable markers for decision-making.

AB - Background: Large middle cerebral artery (MCA) ischaemic stroke when associated with extensive mass effect can result in brain herniation and neurological death. As yet there are few guidelines to aid the selection of patients for aggressive interventional therapies, such as decompression hemicraniectomy and/or hypothermia. Methods: We studied a cohort of patients from seven centres with large MCA infarction requiring neurocritical care. The purpose of this analysis was to assess the use of early radiological signs on follow-up computed tomographic (CT) signs performed within 48 h of stroke onset for predicting mortality at 30 days. The CT parameters assessed included horizontal displacement of the septum pellucidum, pineal shift, complete or partial infarction of the temporal lobe, involvement of additional vascular territories, and the presence of hydrocephalus. The primary outcome measure was in-hospital death within 30 days. Results: One hundred and thirty-five patients who had follow-up CT scans within 48 h were identified from a total of 201 patients with large MCA infarction that received conventional medical therapy alone. The median age was 68 (range 29-99), 56% were female, and the median NIHSS category was 26-30 at 48 h. Among CT variables in univariable analysis, anteroseptal shift ≥5 mm, pineal shift ≥2 mm, complete temporal lobe infarction, involvement beyond the MCA territory, and moderate or severe hydrocephalus were equally predictive of death. Multivariable analysis adjusting for time to CT scan revealed the following predictors of fatal outcome: anteroseptal shift ≥5 mm (OR 10.9; 95% CI 3.2-37.6), NIHSS within 48 h >20 (OR 6.6; 95% CI 2.3-19.3), and infarction beyond the MCA territory (OR 4.9; 95% CI 1.6-15.0). Conclusions: We identified the role of early CT signs in predicting death following massive MCA infarction. The CT parameters anteroseptal shift (>5 versus ≤5 mm), pineal shift ≥2 mm, hydrocephalus, temporal lobe infarction, and other vascular territory infarction if present were predictive of fatal outcome. These CT parameters require prospective validation before they should be considered reliable markers for decision-making.

KW - Computed tomography

KW - Hemicraniectomy, mortality

KW - Middle cerebral artery infarction

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