Prediction of Malignant Middle Cerebral Artery Infarction by Diffusion-Weighted Imaging

Background and Purpose This study was designed to analyze whether early diffusion-weighted imaging (DWI) provides reliable quantitative information for the prediction of stroke patients at risk of malignant brain infarct. Methods We selected 28 patients with a middle cerebral artery (MCA) infarct and proven MCA or carotid T occlusion on DWI and MRI angiography performed within 14 hours after onset (mean 6.5±3.5 hours, median 5.2 hours). Of these, 10 patients developed malignant MCA infarct, whereas 18 did not. For the 2 groups, we compared the National Institutes of Health Stroke Scale (NIHSS) score at admission, site of arterial occlusion, standardized visual analysis of DWI abnormalities, quantitative volume measurement of DWI abnormalities (volumeDWI), and apparent diffusion coefficient values. Univariate and multivariate discriminant analysis was used to determine the most accurate predictors of malignant MCA infarct. Results Univariate analysis showed that an admission NIHSS score >20, total versus partial MCA infarct, and volumeDWI >145 cm3 were highly significant predictors of malignant infarct. The best predictor was volumeDWI >145 cm3, which achieved 100% sensitivity and 94% specificity. Prediction was further improved by bivariate models combining volumeDWI and apparent diffusion coefficient measurements, which reached 100% sensitivity and specificity in this series of patients. Conclusions Quantitative measurement of infarct volume on DWI is an accurate method for the prediction of malignant MCA infarct in patients with persistent arterial occlusion imaged within 14 hours of onset. This may be of importance for early management of severe stroke patients.

[1]  G. Schlaug,et al.  The ischemic penumbra: operationally defined by diffusion and perfusion MRI. , 1999, Neurology.

[2]  C. Beaulieu,et al.  Longitudinal magnetic resonance imaging study of perfusion and diffusion in stroke: Evolution of lesion volume and correlation with clinical outcome , 1999, Annals of neurology.

[3]  A. Awada,et al.  Posterior leukoencephalopathy without severe hypertension: utility of diffusion-weighted MRI. , 1999, Neurology.

[4]  W R Clarke,et al.  Baseline NIH Stroke Scale score strongly predicts outcome after stroke , 1999, Neurology.

[5]  G. Hessenberger,et al.  Attenuated corticomedullary contrast: An early cerebral computed tomography sign indicating malignant middle cerebral artery infarction. A case-control study. , 1999, Stroke.

[6]  P. Barber,et al.  Absent middle cerebral artery flow predicts the presence and evolution of the ischemic penumbra , 1999, Neurology.

[7]  Various patterns of perfusion-weighted MR imaging and MR angiographic findings in hyperacute ischemic stroke. , 1999, AJNR. American journal of neuroradiology.

[8]  A. Demchuk,et al.  Early clinical and radiological predictors of fatal brain swelling in ischemic stroke. , 1999, Stroke.

[9]  S. Schwab,et al.  Neurochemical monitoring of fatal middle cerebral artery infarction. , 1999, Stroke.

[10]  L H Schwamm,et al.  Diffusion-weighted MR imaging: diagnostic accuracy in patients imaged within 6 hours of stroke symptom onset. , 1999, Radiology.

[11]  J. Wales.  Hypergonadotropic Hypogonadism in a 3-Yea r-Old Girl with Blepharophimosis, Ptosis, and Epicanthus inversus Syndrome , 1998, Hormone Research in Paediatrics.

[12]  S. Hesse,et al.  99m technetium-ethyl-cysteinate-dimer single-photon emission CT can predict fatal ischemic brain edema. , 1998, Stroke.

[13]  F. Buonanno,et al.  Posterior leukoencephalopathy without severe hypertension , 1998, Neurology.

[14]  E. Wijdicks,et al.  Middle cerebral artery territory infarction and early brain swelling: progression and effect of age on outcome. , 1998, Mayo Clinic proceedings.

[15]  W Hacke,et al.  Early hemicraniectomy in patients with complete middle cerebral artery infarction. , 1998, Stroke.

[16]  H. Yonas,et al.  Relationship between cerebral blood flow and the development of swelling and life-threatening herniation in acute ischemic stroke. , 1998, Journal of neurosurgery.

[17]  R R Edelman,et al.  Clinical experience with diffusion-weighted MR in patients with acute stroke. , 1998, AJNR. American journal of neuroradiology.

[18]  U. Grzyska,et al.  The predictive value of early CT and angiography for fatal hemispheric swelling in acute stroke. , 1998, AJNR. American journal of neuroradiology.

[19]  L H Schwamm,et al.  Regional ischemia and ischemic injury in patients with acute middle cerebral artery stroke as defined by early diffusion-weighted and perfusion-weighted MRI. , 1998, Stroke.

[20]  J. Bogousslavsky,et al.  Large infarcts in the middle cerebral artery territory Etiology and outcome patterns , 1998, Neurology.

[21]  A. Alexandrov,et al.  Mass effect and death from severe acute stroke , 1997, Neurology.

[22]  F. Buonanno,et al.  One-year Outcome after Decompressive Surgery for Massive Nondominant Hemispheric Infarction , 1997 .

[23]  G. Schlaug,et al.  Enlargement of human cerebral ischemic lesion volumes measured by diffusion‐weighted magnetic resonance imaging , 1997, Annals of neurology.

[24]  F. Buonanno,et al.  One-year outcome after decompressive surgery for massive nondominant hemispheric infarction. , 1997, Neurosurgery.

[25]  G. Nesbit,et al.  Direct carotid cavernous fistula after trigeminal balloon microcompression gangliolysis: case report. , 1996, Neurosurgery.

[26]  Decompressive craniectomy in a rat model of "malignant" cerebral hemispheric stroke: experimental support for an aggressive therapeutic approach. , 1996, Journal of neurosurgery.

[27]  W. Hacke,et al.  'Malignant' middle cerebral artery territory infarction : Clinical course and prognostic signs , 1996 .

[28]  R R Edelman,et al.  Clinical Outcome in Ischemic Stroke Predicted by Early Diffusion-Weighted and Perfusion Magnetic Resonance Imaging: A Preliminary Analysis , 1996, Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral Blood Flow and Metabolism.

[29]  D. Saunders,et al.  Measurement of infarct size using MRI predicts prognosis in middle cerebral artery infarction. , 1995, Stroke.

[30]  M. Kaste,et al.  Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS) , 1995, JAMA.

[31]  D. Krieger,et al.  Decompressive surgery in space-occupying hemispheric infarction: results of an open, prospective trial. , 1995, Critical care medicine.

[32]  W. Hacke,et al.  Decompressive craniectomy for cerebral infarction. An experimental study in rats. , 1995, Stroke.

[33]  W Hacke,et al.  Sensitivity and prognostic value of early CT in occlusion of the middle cerebral artery trunk. , 1994, AJNR. American journal of neuroradiology.

[34]  G. Marchal,et al.  PET imaging of cerebral perfusion and oxygen consumption in acute ischaemic stroke: relation to outcome , 1993, The Lancet.

[35]  J. Marshall,et al.  The variable clinical and CT findings after carotid occlusion: the role of collateral blood supply. , 1988, Journal of neurology, neurosurgery, and psychiatry.

[36]  M. Cowan,et al.  American Heart Association. , 2018, P & T : a peer-reviewed journal for formulary management.

[37]  H. Barnett,et al.  Prognosis in middle cerebral artery occlusion. , 1985, Stroke.

[38]  V. Hachinski,et al.  Early Mortality Following Stroke: A Prospective Review , 1984, Stroke.