Timing of neurologic deterioration in massive middle cerebral artery infarction: A multicenter review

ObjectiveTo determine the time interval between symptom onset and neurologic deterioration related to cerebral edema in patients with massive middle cerebral artery infarction. The time period between onset and neurologic deterioration represents the window for surgical intervention. DesignMulticenter retrospective chart review. SettingsFive university-affiliated medical centers. PatientsFifty-three patients with massive middle cerebral artery infarction who experienced neurologic deterioration defined by a decrease in the Glasgow Coma Scale score of two or more points attributable to mass effect. Measurements and Main ResultsA total of 53 patients (mean age, 62 ± 18 yrs; 25 [47%] were men) with neurologic deterioration were identified by using International Classification of Diseases (9th revision) codes and local registries. Medical records and neuroimaging studies were reviewed by a stroke neurologist or neurointensivist to identify the time of neurologic deterioration. Thrombolytics were used at presentation in 19 (35%) patients. A total of 19 (36%) patients had neurologic deterioration within 24 hrs of symptom onset. By 48 hrs, 36 (68%) patients had manifested clinical deterioration. A few patients had later neurologic deterioration on day 3 (n = 10), day 4 (n = 2), day 5 (n = 2), and day 6 or after (n = 3). A total of 25 (47%) of the 53 patients died during hospitalization. The highest frequency of deaths occurred on day 3. ConclusionsNeurologic deteriorations related to cerebral edema after massive middle cerebral artery infarction occur in most patients within 48 hrs of symptom onset.

[1]  J. Hofmeijer,et al.  Decompressive surgery in space-occupying hemispheric infarction. A randomised controlled trial , 2003 .

[2]  E. Lesaffre,et al.  Neurological deterioration in acute ischemic stroke: potential predictors and associated factors in the European cooperative acute stroke study (ECASS) I. , 1999, Stroke.

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

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

[5]  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.

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

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

[8]  J. Broderick,et al.  Early hemorrhage growth in patients with intracerebral hemorrhage. , 1997, Stroke.

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

[10]  M. Frankel,et al.  Predictors of early deterioration and mortality in black Americans with spontaneous intracerebral hemorrhage. , 1995, Stroke.

[11]  D. Edwards,et al.  Unified Neurological Stroke Scale is valid in ischemic and hemorrhagic stroke. , 1995, Stroke.

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

[13]  J. Frank.  Large hemispheric infarction, deterioration, and intracranial pressure , 1995, Neurology.

[14]  J. Grotta,et al.  Elective intubation for neurologic deterioration after stroke , 1995, Neurology.

[15]  H. Cambon,et al.  Infarcts in the middle cerebral artery territory , 1993, Acta neurologica Scandinavica.

[16]  W C Broaddus,et al.  Treatment of right hemispheric cerebral infarction by hemicraniectomy. , 1990, Stroke.

[17]  James N. Davis,et al.  Interrater reliability of the NIH stroke scale. , 1989, Archives of neurology.

[18]  V Hachinski,et al.  The Canadian Neurological Scale , 1989, Neurology.

[19]  C. Martin,et al.  Comparison of four severity scores in patients with head trauma. , 1989, The Journal of trauma.

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

[21]  A. Ropper,et al.  Brain edema after stroke. Clinical syndrome and intracranial pressure. , 1984, Archives of neurology.

[22]  H. Schouten,et al.  Agreement between physicians on assessment of outcome following severe head injury. , 1983, Journal of neurosurgery.

[23]  D. Wiebers,et al.  Mechanisms and Timing of Deaths from Cerebral Infarction , 1981, Stroke.

[24]  B. Jennett,et al.  ASSESSMENT OF OUTCOME AFTER SEVERE BRAIN DAMAGE A Practical Scale , 1975, The Lancet.

[25]  B Jennett,et al.  Assessment of outcome after severe brain damage. , 1975, Lancet.

[26]  B. Jennett,et al.  Assessment of coma and impaired consciousness. A practical scale. , 1974, Lancet.

[27]  Foss Mv.  MANAGEMENT OF VIRUS HEPATITIS. , 1964 .