Predictors of fatal brain edema in massive hemispheric ischemic stroke

Neurocritical Care for Patients With Ischemic Stroke

OBJECTIVE

Management of stroke due to large vessel occlusion (LVO) has undergone unprecedented change in the past decade. Effective treatment with thrombectomy has galvanized the field and led to advancements in all aspects of care. This article provides a comprehensive examination of neurologic intensive care unit (ICU) management of patients with stroke due to LVO. The role of the neurocritical care team in stroke systems of care and the importance of prompt diagnosis, initiation of treatment, and continued monitoring of patients with stroke due to LVO is highlighted.

LATEST DEVELOPMENTS

The management of complications commonly associated with stroke due to LVO, including malignant cerebral edema and respiratory failure, are addressed, stressing the importance of early identification and aggressive treatment in mitigating negative effects on patients' prognoses. In the realm of medical management, this article discusses various medical therapies, including antithrombotic therapy, blood pressure management, and glucose control, outlining evidence-based strategies for optimizing patient outcomes. It further emphasizes the importance of a multidisciplinary approach to provide a comprehensive care model. Lastly, the critical aspect of family communication and prognostication in the neurologic ICU is addressed.

ESSENTIAL POINTS

This article emphasizes the multidimensional aspects of neurocritical care in treating patients with stroke due to LVO.

Updates in Management of Large Hemispheric Infarct

This review delves into updates in management of large hemispheric infarction (LHI), a condition affecting up to 10% of patients with supratentorial strokes. While traditional management paradigms have endured, recent strides in research have revolutionized the approach to acute therapies, monitoring, and treatment. Notably, advancements in triage methodologies and the application of both pharmacological and mechanical abortive procedures have reshaped the acute care trajectory for patients with LHI. Moreover, ongoing endeavors have sought to refine strategies for the optimal surveillance and mitigation of complications, notably space-occupying mass effect, which can ensue in the aftermath of LHI. By amalgamating contemporary guidelines with cutting-edge clinical trial findings, this review offers a comprehensive exploration of the current landscape of acute and ongoing patient care for LHI, illuminating the evolving strategies that underpin effective management in this critical clinical domain.

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

BACKGROUND

Decompressive 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.

METHODS

We 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.

RESULTS

Of 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).

CONCLUSIONS

DC 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 REGISTRATION

The DEVT trial: http://www.chictr.org. Identifier, ChiCTR-IOR-17013568. The RESCUE BT trial: URL: http://www.chictr.org. Identifier, ChiCTR-INR-17014167.

Development and validation of a prognostic computed tomography scoring model for functional outcomes in patients with large hemispheric infarction following decompressive craniectomy

Background

There is no established prognostic scoring system developed for patients with large hemispheric infarction (LHI) following decompressive craniectomy (DC) based on imaging characteristics. The present study aimed to develop and validate a new computed tomography scoring model to assess the 6-month risk of poor functional outcomes (modified-Rankin scale [mRS] score of 4-6) in patients with LHI receiving DC.

Methods

This retrospective cohort study included patients at two tertiary stroke centers. A prediction model was developed based on a multivariable logistic regression. The final risk factors included the ASPECTS (Alberta Stroke Program Early Computed Tomography Score), longitudinal fissure cistern, Sylvian fissure cistern, and additional vascular territory involvement. 1,000 bootstrap resamples and temporal validation were implemented as validations for the scoring system.

Results

Of the 100 individuals included in the development cohort, 71 had poor functional outcomes. The scoring model presented excellent discrimination and calibration with C-index = 0.87 for the development cohort, and C-index = 0.83 for the temporal validation cohort with non-significant Hosmer-Lemeshow goodness-of-fit test. The scoring model also showed an improved AUC compared to the ASPECTS. For each point in the score model, the adjusted risk of poor functional outcomes increase by 47.8% (OR = 1.48, p < 0.001). The scores were inversely correlated with MAP (mean arterial pressure, paired t-test, p = 0.0015) and CPP (cerebral perfusion pressure, rho = -0.17, p = 0.04).

Conclusion

In patients with LHI following DC, the score system is an excellent predictor of poor functional outcomes and is associated with CPP and MAP, which might be worth considering in clinical settings after further external validation.

The predictive value of EEG reactivity by electrical stimulation and quantitative analysis in critically ill patients with large hemispheric infarction

PURPOSE

The intensive care of critically ill patients with large hemispheric infarction improves the survival rate. However, established prognostic markers for neurological outcome show variable accuracy. We aimed to assess the value of electrical stimulation and quantitative analysis of EEG reactivity for early prognostication in this critically ill population.

MATERIALS AND METHODS

We prospectively enrolled consecutive patients between January 2018 and December 2021. EEG reactivity was randomly performed by pain or electrical stimulation via visual and quantitative analysis. Neurological outcome within 6-month was dichotomized as good (modified Rankin Scale, mRS 0-3) or poor (mRS 4-6).

RESULTS

Ninety-four patients were admitted, and 56 were included in the final analysis. EEG reactivity using electrical stimulation was superior to pain stimulation for good outcome prediction (visual analysis: AUC 0.825 vs. 0.763, P = 0.143; quantitative analysis: AUC 0.931 vs. 0.844, P = 0.058). The AUC of EEG reactivity by pain stimulation with visual analysis was 0.763, which increased to 0.931 by electrical stimulation with quantitative analysis (P = 0.006). When using quantitative analysis, the AUC of EEG reactivity increased (pain stimulation 0.763 vs. 0.844, P = 0.118; electrical stimulation 0.825 vs. 0.931, P = 0.041).

CONCLUSION

EEG reactivity by electrical stimulation and quantitative analysis seems a promising prognostic factor in these critical patients.

The ACORNS grading scale: a novel tool for the prediction of malignant brain edema after endovascular thrombectomy

BACKGROUND

To develop and validate a novel tool for predicting the development of malignant brain edema (MBE) in large vessel occlusion stroke patients after endovascular thrombectomy (EVT).

METHODS

We used a prospectively registered population of EVT patients from three comprehensive stroke centers. The population was randomly divided into two subsets (7:3): a training cohort and an internal validation cohort. External validation was performed using the Endovascular Treatment for Acute Anterior Circulation Ischemic Stroke Registry in China (ACTUAL) database. MBE was defined as (1) hypodense parenchyma in at least 50% of the middle cerebral artery and signs of local brain swelling, and (2) a midline shift of ≥5 mm at the septum pellucidum or pineal gland with obliteration of the basal cisterns. The model was constructed using logistic regression analysis. The performance of the model was examined in terms of discrimination and calibration.

RESULTS

After adjusting for other confounders, baseline National Institutes of Health Stroke Scale (NIHSS) and Alberta Stroke Program Early CT (ASPECT) scores, a clinical history of hypertension, collateral status, intravenous thrombolysis before thrombectomy, fasting blood glucose, reperfusion status, and occlusion site were found to be independent predictors of MBE. These variables were combined to create the ACORNS grading scale. The areas under the curve in receiver operating curve analysis were 0.850 (95% CI 0.816 to 0.884), 0.874 (95% CI 0.821 to 0.926), and 0.785 (95% CI 0.740 to 0.829) for the training, internal validation, and external validation cohorts, respectively, indicating good discriminative performance in the validation cohorts.

CONCLUSIONS

The ACORNS grading scale is an accurate and easily applicable model for the prediction of the development of MBE after EVT.

Use of biomarkers for predicting a malignant course in acute ischemic stroke: an observational case-control study

Acute ischemic stroke is a sudden neurological event caused by brain ischemia. Patients with large vessel occlusion are at high risk of developing significant cerebral edema, which can lead to rapid neurological decline. The optimal timing for decompressive hemicraniectomy to prevent further brain damage is still uncertain. This study aimed to identify potential predictors of severe brain edema. The data indicate that specific cytokines may help identify patients with a higher risk of developing life-threatening brain swelling in the early phase post-stroke. The association between a positive biomarker and the outcome was calculated, and three biomarkers-S100B protein, MMP-9, and IL-10-were found to be significantly associated with malignant edema. A model was derived for early predicting malignant cerebral edema, including S100B protein and IL-1 beta. These findings suggest that molecular biomarkers related to the ischemic cascade may be a helpful way of predicting the development of malignant cerebral edema in ischemic stroke patients, potentially widening the time window for intervention and assisting in decision-making. In conclusion, this study provides insights into the molecular mechanisms of severe brain edema and highlights the potential use of biomarkers in predicting the course of ischemic stroke.

Development and validation of a nomogram for the risk prediction of malignant cerebral edema after acute large hemispheric infarction involving the anterior circulation

Background

Malignant cerebral edema (MCE) is a life-threatening complication of large hemisphere infarction (LHI). Therefore, a fast, accurate, and convenient tool for predicting MCE can guide triage services and facilitate shared decision-making. In this study, we aimed to develop and validate a nomogram for the early prediction of MCE risk in acute LHI involving the anterior circulation and to understand the potential mechanism of MCE.

Methods

This retrospective study included 312 consecutive patients with LHI from 1 January 2019 to 28 February 2023. The patients were divided into MCE and non-MCE groups. MCE was defined as an obvious mass effect with ≥5 mm midline shift or basal cistern effacement. Least absolute shrinkage and selection operator (LASSO) and logistic regression were performed to explore the MCE-associated factors, including medical records, laboratory data, computed tomography (CT) scans, and independent clinic risk factors. The independent factors were further incorporated to construct a nomogram for MCE prediction.

Results

Among the 312 patients with LHI, 120 developed MCE. The following eight factors were independently associated with MCE: Glasgow Coma Scale score (p = 0.007), baseline National Institutes of Health Stroke Scale score (p = 0.006), Alberta Stroke Program Early CT Score (p < 0.001), admission monocyte count (p = 0.004), white blood cell count (p = 0.002), HbA1c level (p < 0.001), history of hypertension (p = 0.027), and history of atrial fibrillation (p = 0.114). These characteristics were further used to establish a nomogram for predicting prognosis. The nomogram achieved an AUC-ROC of 0.89 (95% CI, 0.82-0.96).

Conclusion

Our nomogram based on LASSO-logistic regression is accurate and useful for the early prediction of MCE after LHI. This model can serve as a precise and practical tool for clinical decision-making in patients with LHI who may require aggressive therapeutic approaches.

Anatomical predictors of need for decompressive craniectomy after stroke using voxel-based lesion symptom mapping

BACKGROUND AND PURPOSE

Malignant cerebral edema (MCE) secondary to ischemic stroke is a highly morbid condition. Decompressive craniectomy (DC) is the only treatment for MCE that has been shown to reduce mortality. We examined whether early infarction and/or hypoperfusion in specific topographic regions was predictive of the need for later DC.

METHODS

A retrospective database of patients evaluated for large vessel occlusion (LVO) stroke at Stanford between 2010 and 2019 was used. Thirty patients with LVO and baseline perfusion MRI who underwent DC were evaluated. Propensity matching based on age, lesion size, and recanalization status was performed on the remaining cohort. Baseline masks of apparent diffusion coefficient (ADC) + Tmax  >6 seconds lesions were generated using automated perfusion software. Voxel-based lesion symptom maping was used to perform logistic regression at each voxel to generate statistical maps of lesion location associated with DC. Hemispheres were combined to increase statistical power.

RESULTS

Sixty patients were analyzed. After adjusting for age, lesion size, and recanalization status as covariates, scattered cortical regions, predominately within the temporal and frontal lobe, were mildly to moderately predictive of the need for DC (z-scores: 2.4-6.74, p < .01).

CONCLUSIONS

Scattered temporal and frontal lobe regions on baseline diffusion and perfusion MRI were found to be mildly to moderately predictive of the need for subsequent DC in patients with LVO stroke.

Prominent veins sign is associated with malignant cerebral edema after acute ischemic stroke

Malignant cerebral edema (MCE) is often associated with severe physical disability and a high mortality rate. The current prediction of MCE is focused on infarct volume, and tools are relatively lacking. The prominent veins sign (PVS-SWI) is considered a marker of severely impaired tissue perfusion. This study aimed to determine whether PVS-SWI is associated with early-onset MCE. Patients with acute ischemic stroke (AIS) due to severe large arterial stenosis or occlusion (SLASO) from June 2018 to June 2020 were included. The ASPECTS score assessed the extent of PVS-SWI, and 4-10 was defined as a positive group. The primary outcome was MCE, defined as the deterioration of neurological function and midline structural excursions of >5 mm during hospitalization. The secondary outcomes included worsening of the NIHSS by ≥ 2 points, in-hospital death, and death within 1 year after stroke. Logistic regression was used to assess the correlation between PVS-SWI and outcomes. The study included 157 patients， 40 (25.5%) of whom developed MCE. PVS-SWI was more prevalent in patients who developed MCE (75.0% vs 45.3%; P = 0.001). In multivariate regression analysis, PVS-SWI was an independent predictor of MCE development in patients with larger infarct sizes (OR: 4.00， 95%CI: 1.54-10.35，p = 0.004). In patients with small infarct sizes, PVS-SWI was an independent predictor of a worsening NIHSS of ≥2(OR: 11.13， 95%CI: 2.26-54.89， p = 0.003）. However, PVS-SWI was not associated with death. The main finding of our study was that in patients with larger infarct sizes, a positive PVS-SWI increased the risk of developing MCE. In these patients, more interventions may be needed.

Surgery for Malignant Acute Ischemic Stroke: A Narrative Review of the Knowns and Unknowns

Malignant acute ischemic stroke (AIS) is characterized by acute neurological deterioration caused by progressive space-occupying brain edema, often occurring in the first hours to days after symptom onset. Without any treatment, the result is often fatal. Despite advances in treatment for AIS, up to 80% of patients with a large hemispheric stroke or cerebellar stroke are at risk of poor outcome. Decompressive surgery can be life-saving in a subgroup of patients with malignant AIS, but uncertainties exist on patient selection, predictors of malignant infarction, perioperative management, and timing of intervention. Although survivors are left disabled, most agree with the original decision to undergo surgery and would make the same decision again. In this narrative review, we focus on the clinical and radiological predictors of malignant infarction in AIS and outline the technical aspects of decompressive surgery as well as duraplasty and cranioplasty. We discuss the current evidence and recommendations for surgery in AIS, highlighting gaps in knowledge, and suggest directions for future studies. KEY POINTS: · Acute ischemic stroke from occlusion of a proximal intracranial artery can progress quickly to malignant edema, which can be fatal in 80% of patients despite medical management.. · Decompression surgery is life-saving within 48 hours of stroke onset, but the benefits beyond this time and in the elderly are unknown.. · Decompressive surgery is associated with high morbidity, particularly in the elderly. The decision to operate must be made after considering the individual's preference and expectations of quality of life in the context of the clinical condition.. · Further studies are needed to refine surgical technique including value of duraplasty and understand the role monitoring intracranial pressure during and after decompressive surgery.. · More studies are needed on the pathophysiology of malignant cerebral edema, prediction models including imaging and biomarkers to identify which subgroup of patients will benefit from decompressive surgery.. · More research is needed on factors associated with morbidity and mortality after cranioplasty, safety and efficacy of implants, and comparisons between them.. · Further studies are needed to assess the long-term effects of physical disability and quality of life of survivors after surgery, particularly those with severe neurological deficits..

Predicting the emergence of malignant brain oedema in acute ischaemic stroke: a prospective multicentre study with development and validation of predictive modelling

Background

We aimed to develop and validate a prognostic model for predicting malignant brain oedema in patients with acute ischaemic stroke in a real-world setting of practice.

Methods

A prospective multicentre study enrolled adult patients with acute ischaemic stroke with brain CT < 24 h of onset of symptoms admitted to nine tertiary-level hospitals in China between September 2017 and December 2019. Malignant brain oedema was defined as any patient who had decompressive craniectomy, discharge in coma, or in-hospital death attributed to symptomatic brain swelling. The derivation cohort was a consecutive cohort of patients from one centre and the validation cohort was non-consecutive patients from the other centres. Multivariable logistic regression was used to define independent predictors from baseline clinical characteristics, imaging features, complications, and management. A web-based nomogram and a risk score were developed based on the final model. Model performance was assessed for discrimination and calibration in both derivation and validation cohorts. The study is registered, NCT03222024.

Findings

Based on the derivation cohort (n = 1627), the model was developed with seven variables including large infarct (adjusted odds ratio [OR] 40.90, 95% CI 20.20-82.80), National Institutes of Health Stroke Scale (NIHSS) score (OR 1.09, 1.06-1.12), thrombolysis (OR 2.11, 1.18-3.78), endovascular treatment (OR 2.87, 1.47-5.59), pneumonia (OR 2.47, 1.53-3.97), brain atrophy (OR 0.57, 0.37-0.86), and recanalisation (OR 0.36, 0.17-0.75). The classification threshold of a predicted probability ≥0.14 showed good discrimination and calibration in both derivation cohort (area under the receiver-operating curve [AUC] 0.90, 0.87-0.92; sensitivity 0.95, 0.92-0.98) and validation cohort (n = 556, AUC 0.88, 0.82-0.95; sensitivity 0.84, 0.73-0.95). The risk score based on this model had a total point that ranged from -1 to 20, with an optimal score of ≥10 showing good discrimination and calibration in both derivation (AUC 0.89, 0.87-0.92; sensitivity 0.95, 0.92-0.98) and validation (AUC 0.88, 0.82-0.95; sensitivity 0.84, 0.73-0.95) cohorts.

Interpretation

The INTEP-AR model (i.e. large Infarct, NIHSS score, Thrombolysis, Endovascular treatment, Pneumonia, brain Atrophy, and Recanalisation) incorporating multiple clinical and radiological characteristics has shown good prognostic value for predicting malignant brain oedema after acute ischaemic stroke.

Funding

National Natural Science Foundation of China; Science and Technology Department of Sichuan Province; West China Hospital.

Association between proteinuria and the development of malignant middle cerebral artery infarction: A retrospective cohort study

A disrupted blood-brain barrier (BBB) with extravasation of macromolecules plays a critical role in the development of malignant middle cerebral artery infarction (MMI). Proteinuria is considered a marker of generalized endothelial dysfunction, including BBB disruption. This study aimed to clarify whether proteinuria identified in the acute stage of stroke is associated with MMI development. Patients with infarctions involving the middle cerebral artery territory were reviewed. Urine samples collected within 8 hours after stroke were analyzed using urine dipsticks. Patients were divided into proteinuria (urine dipstick reading of 1 + to 4+) and nonproteinuria groups. MMI was present if either signs of uncal herniation or a progressive conscious disturbance were recorded along with a midline shift > 5 mm identified on follow-up computed tomography (CT). Among the 1261 patients identified between January 2010 and June 2019, 138 were eligible for final analyses. Patients in the MMI group had lower Alberta Stroke Program Early CT Scores (ASPECTS), higher National Institutes of Health Stroke Scale scores, and a greater proportion of proteinuria than those in the non-MMI group. Four multivariate logistic regression models were used to clarify the role of proteinuria in MMI development. In model 1, proteinuria was significantly associated with MMI after adjusting for age, sex, dyslipidemia and ASPECTS (OR = 2.987, 95% CI = 1.329-6.716, P = .0081). The risk of developing MMI in patients with proteinuria remained significant in model 2 (OR = 3.066, 95% CI = 1.349-6.968, P = .0075) after adjusting for estimated glomerular filtrate rate (eGFR) < 60ml/min/1.73 m2 in addition to variables in model 1. In model 3, proteinuria was still significantly associated with MMI after adjusting for age, sex, dyslipidemia, ASPECTS, hypertension, diabetes, and atrial fibrillation (OR = 2.521, 95% CI = 1.075-5.912, P = .0335). In model 4, the risk of developing MMI in patients with proteinuria remained significant (OR = 2.579, 95% CI = 1.094-6.079, P = .0304) after adjusting for eGFR < 60ml/min/1.73 m2 in addition to variables in model 3. Proteinuria is independently associated with MMI development. Proteinuria may be a clinically accessible predictor of MMI development.

Decompressive Hemicraniectomy and Favorable Outcome in a Pediatric Patient with Malignant Middle Cerebral Artery Infarction

We report a rare case of middle cerebral artery (MCA) stroke in a teenage girl with initial improvement, followed by progression to malignant MCA infarction, requiring an urgent decompressive hemicraniectomy (DHC). Additionally, we report improvement in all areas, including language, comprehension, and motor skills at discharge and the 4-month follow-up. This rare presentation highlights the importance of monitoring the neurological status of a patient with an MCA infarct for progression to a life-threatening malignant MCA infarct. This case report also highlights the importance of consideration of DHC for a favorable outcome of the MMCA infarction.

Prediction model of early biomarkers of massive cerebral infarction caused by anterior circulation occlusion: Establishment and evaluation

Objective

The purpose of this study is to establish and evaluate an early biomarker prediction model of massive cerebral infarction caused by anterior circulation occlusion.

Methods

One hundred thirty-four patients with acute cerebral infarction from January 2018 to October 2020 were selected to establish the development cohort for the internal test of the nomogram. Ninety-one patients with acute cerebral infarction hospitalized in our hospital from December 2020 to December 2021 were constituted the validation cohort for the external validation. All patients underwent baseline computed tomography (CT) scans within 12 h of onset and early imaging signs (hyperdense middle cerebral artery sign, obscuration of the lentiform nucleus, insular ribbon sign) of acute cerebral infarction were identified on CT by two neurologists. Based on follow-up CT images, patients were then divided into a massive cerebral infarction group and a non-massive cerebral infarction group. The nomogram model was constructed based on logistic regression analysis with R language. The nomogram was subsequently validated in an independent external validation cohort. Accuracy and discrimination of the prediction model were evaluated by a calibration chart, receiver operating characteristic (ROC) curve, and decision curve.

Results

The indicators, including insular ribbon sign, reperfusion therapy, National Institutes of Health Stroke Scale (NHISS) score, previous cerebral infarction, and atrial fibrillation, were entered into the prediction model through binary logistic regression analysis. The prediction model showed good predictive ability. The area under the ROC curve of the prediction model was 0.848. The specificity, sensitivity, and Youden index were 0.864, 0.733, and 0.597, respectively. This nomogram to the validation cohort also showed good discrimination (AUC = 0.940, 95% CI 0.894–0.985) and calibration.

Conclusion

Demonstrating favorable predictive efficacy and reproducibility, this study successfully established a prediction model of CT imaging signs and clinical data as early biomarkers of massive cerebral infarction caused by anterior circulation occlusion.

Filling Defect of Ipsilateral Transverse Sinus in Acute Large Artery Occlusion

Background and Purpose

Cerebral venous systems play a key role in regulating stroke outcomes. We aimed to elucidate the effect of the transverse sinus (TS) filling patterns on edema expansion and neurological outcomes in patients with acute large artery occlusion (LAO).

Materials and Methods

We recruited consecutive patients with acute M1 middle cerebral artery and/or internal carotid artery occlusion who underwent pretreatment computed tomographic perfusion (CTP). On the reconstructed 4-dimensional computed tomographic angiography derived from CTP, the filling defect of the ipsilateral transverse sinus (FDITS) was defined as the length of contrast filling defect occupying at least half of the ipsilateral TS. An unfavorable outcome was defined as having a modified Rankin Scale (mRS) score of 3–6 at 3 months.

Results

A total of 318 patients were enrolled in the final analysis and 70 (22.0%) patients had baseline FDITS. The presence of FDITS was associated with the baseline NIHSS (odds ratio [OR] 1.119; 95% CI, 1.051–1.192; p < 0.001) and poor arterial collaterals (OR 3.665; 95% CI 1.730–7.766; p = 0.001). In addition, FDITS was associated with 24-h brain edema expansion (OR 7.188; 95% CI, 3.095–16.696; p < 0.001) and 3-month unfavorable outcome (OR 8.143; 95% CI 2.547–26.041; p < 0.001) independent of arterial collateral status. In the subgroup analysis of patients with FDITS who received reperfusion therapy, no significant difference was found in the rate of edema expansion and unfavorable outcome between non-reperfusion and reperfusion subgroups (both p > 0.05).

Conclusion

Filling defect of the ipsilateral transverse sinus was associated with edema expansion and an unfavorable outcome irrespective of the baseline arterial collateral status in patients with acute LAO, indicating that FDITS may be an important stroke-related prognostic imaging marker.

Predictors and Dynamic Nomogram to Determine the Individual Risk of Malignant Brain Edema After Endovascular Thrombectomy in Acute Ischemic Stroke

Background and Purpose

This study aimed to construct an optimal dynamic nomogram for predicting malignant brain edema (MBE) in acute ischemic stroke (AIS) patients after endovascular thrombectomy (ET).

Methods

We enrolled AIS patients after ET from May 2017 to April 2021. MBE was defined as a midline shift of >5 mm at the septum pellucidum or pineal gland based on follow-up computed tomography within 5 days after ET. Multivariate logistic regression and LASSO (least absolute shrinkage and selection operator) regression were used to construct the nomogram. The area under the receiver operating characteristic curve (AUC) and decision-curve analysis were used to compare our nomogram with two previous risk models for predicting brain edema after ET.

Results

MBE developed in 72 (21.9%) of the 329 eligible patients. Our dynamic web-based nomogram (https://successful.shinyapps.io/DynNomapp/) consisted of five parameters: basal cistern effacement, postoperative National Institutes of Health Stroke Scale (NIHSS) score, brain atrophy, hypoattenuation area, and stroke etiology. The nomogram showed good discrimination ability, with a C-index (Harrell’s concordance index) of 0.925 (95% confidence interval=0.890–0.961), and good calibration (Hosmer-Lemeshow test, p=0.386). All variables had variance inflation factors of <1.5 and tolerances of >0.7, suggesting no significant collinearity among them. The AUC of our nomogram (0.925) was superior to those of Xiang-liang Chen and colleagues (0.843) and Ming-yang Du and colleagues (0.728).

Conclusions

Our web-based dynamic nomogram reliably predicted the risk of MBE in AIS patients after ET, and hence is worthy of further evaluation.

A Real-World Assessment of Outcomes, Health Resource Utilization, and Costs Associated with Cerebral Edema in US Patients with Large Hemispheric Infarction

BACKGROUND

Patients with large hemispheric infarction (LHI) are at risk of cerebral edema (CED). This study analyzed health resource use, costs, and outcomes during and after acute hospitalization for LHI in US patients with and without CED.

METHODS

Using IBM^® MarketScan^® Commercial, Medicaid, and Medicare databases, patients with incident hospitalization for LHI (International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes of I63.03x, I63.13x, I63.23x, I63.31x, I63.41x, I63.51x) from 31 March 2016 through 31 December 2018 were identified and further categorized by the presence or absence of CED based on related diagnosis codes or a procedure code of craniectomy. Health resource use, costs, and outcomes were compared in patients with and without CED during hospitalization and after discharge.

RESULTS

Of 7336 Commercial, 1946 Medicaid, and 5015 Medicare patients with LHI, 7.8%, 6.9%, and 4.3% had CED, respectively. After adjusting for age, sex, and baseline comorbidities, differences (95% confidence intervals) in mean total costs of the index hospitalization in patients with CED versus without CED were $65,572 ($56,506-$76,335), $44,395 ($26,442-$63,495), and $31,417 ($18,982-$48,543) in the Commercial, Medicaid, and Medicare groups, respectively. Similarly, the adjusted differences (95% confidence intervals) in mean lengths of stay between patients with CED and without CED were 11.75 (10.17-13.48), 10.84 (7.59-14.17), and 3.69 (2.40-5.19) days, respectively. Mortality during index hospitalization was 10-20 times greater in patients with CED versus without CED (p < 0.0001). In those patients who survived and had at least 30-days of follow-up after discharge, CED was also associated with higher post-discharge resource utilization and costs in the commercially insured population who were younger than Medicare patients, and had fewer comorbidities than Medicare and Medicaid patients. This indicates the effect of CED after discharge was particularly burdensome for younger individuals.

CONCLUSIONS

In this large cohort study, inpatient mortality, health resource utilization and costs were consistently higher in patients with LHI who developed CED than in those without CED. These findings underscore the need for greater awareness of CED among policymakers and healthcare practitioners.

Ultrasound of Optic Nerve Sheath Diameter and Stroke Outcomes

Supplemental Digital Content is available in the text.

We aimed at utilizing ocular ultrasound to determine its utility in predicting outcomes among stroke patients.

20-hydroxyeiscosatetraenoic acid may be as a predictor of malignant middle cerebral artery infarction in patients with massive middle cerebral artery infarction

Background

Early identification of massive middle cerebral artery infarction (MCAI) at risk for malignant MCAI (m-MCAI) may be useful in selecting patients for aggressive therapies. The aim of this study was to determine whether CYP metabolites may help to predict impending m-MCAI.

Methods

This is a prospective, two-center observational study in 256 patients with acute massive MCAI. Plasma levels of 20-hydroxyeicosatetraenoic acid (20-HETE), epoxyeicosatrienoic acids, and dihydroxyeicosatrienoic acids were measured at admission. Brain computed tomography (CT) was performed at admission and repeated between day 3 and 7, or earlier if there was neurological deterioration. The primary outcome was m-MCAI. The m-MCAI was diagnosed when follow-up brain CT detected a more than two-thirds space-occupying MCAI with midline shift, compression of the basal cisterns, and neurological worsening.

Results

In total of 256 enrolled patients, 77 (30.1%) patients developed m-MCAI. Among the 77 patients with m-MCAI, 60 (77.9%) patients died during 3 months of stroke onset. 20-HETE level on admission was significantly higher in patients with m-MCAI than those without m-MCAI. There was an increase in the risk of m-MCAI with increase of 20-HETE levels. The third and fourth quartiles of 20-HETE levels were independent predictors of m-MCAI (OR: 2.86; 95% CI: 1.16 – 6.68; P = 0.025, and OR: 4.23; 95% CI: 1.35 – 8.26; P = 0.002, respectively).

Conclusions

Incidence of m-MCAI was high in patients with massive MCAI and the prognosis of m-MCAI is very poor. Elevated plasma 20-HETE may be as a predictor for m-MCAI in acute massive MCAI, and it might useful in clinical practice in therapeutic decision making.

Association between pre-treatment perfusion profile and cerebral edema after reperfusion therapies in ischemic stroke

The relationship between reperfusion and edema is unclear, with experimental and clinical data yielding conflicting results. We investigated whether the extent of salvageable and irreversibly-injured tissue at baseline influenced the effect of therapeutic reperfusion on cerebral edema. In a pooled analysis of 415 patients with anterior circulation large vessel occlusion from the Tenecteplase-versus-Alteplase-before-Endovascular-Therapy-for-Ischemic-Stroke (EXTEND-IA TNK) part 1 and 2 trials, associations between core and mismatch volume on pre-treatment CT-Perfusion with cerebral edema at 24-hours, and their interactions with reperfusion were tested. Core volume was associated with increased edema (p < 0.001) with no significant interaction with reperfusion (p = 0.82). In comparison, a significant interaction between reperfusion and mismatch volume (p = 0.03) was observed: Mismatch volume was associated with increased edema in the absence of reperfusion (p = 0.009) but not with reperfusion (p = 0.27). When mismatch volume was dichotomized at the median (102 ml), reperfusion was associated with reduced edema in patients with large mismatch volume (p < 0.001) but not with smaller mismatch volume (p = 0.35). The effect of reperfusion on edema may be variable and dependent on the physiological state of the cerebral tissue. In patients with small to moderate ischemic core volume, the benefit of reperfusion in reducing edema is related to penumbral salvage.

Computed Tomography Based Score of Early Ischemic Changes Predicts Malignant Infarction

Background and Purpose: Identification of ischemic stroke patients at high risk of developing life-threatening malignant infarction at an early stage is critical to consider more rigorous monitoring and further therapeutic measures. We hypothesized that a score consisting of simple measurements of visually evident ischemic changes in non-enhanced CT (NEMMI score) predicts malignant middle cerebral artery (MCA) infarctions (MMI) with similar diagnostic power compared to other baseline clinical and imaging parameters. Methods: One hundred and nine patients with acute proximal MCA occlusion were included. Fifteen (13.8%) patients developed MMI. NEMMI score was defined using the sum of the maximum diameter (anterior-posterior plus medio-lateral) of the hypoattenuated lesion in baseline-CT multiplied by a hypoattenuation factor (3-point visual grading in non-enhanced CT, no/subtle/clear hypoattenuation = 1/2/3). Receiver operating characteristic (ROC) curve analysis and multivariable logistic regression analysis were used to calculate the predictive values of the NEMMI score, baseline clinical and other imaging parameters. Results: The median NEMMI score at baseline was 13.6 (IQR: 11.6-31.1) for MMI patients, and 7.7 (IQR: 3.9-11.2) for patients with non-malignant infarctions (p < 0.0001). Based on ROC curve analysis, a NEMMI score >10.5 identified MMI with good discriminative power (AUC: 0.84, sensitivity/specificity: 93.3/70.7%), which was higher compared to age (AUC: 0.76), NIHSS (AUC: 0.61), or ischemic core volume (AUC: 0.80). In multivariable logistic regression analysis, NEMMI score was significantly and independently associated with MMI (OR: 1.33, 95%CI: 1.13-1.56, p < 0.001), adjusted for recanalization status. Conclusion: The NEMMI score is a quick and simple rating tool of early ischemic changes on CT and could serve as an important surrogate marker for developing malignant edema. Its diagnostic accuracy was similar to CTP and clinical parameters.

Absent Cortical Venous Filling Is Associated with Aggravated Brain Edema in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Predicting malignant cerebral edema can help identify patients who may benefit from appropriate evidence-based interventions. We investigated whether absent cortical venous filling is associated with more pronounced early brain edema, which leads to malignant cerebral edema.

MATERIALS AND METHODS

Patients with acute ischemic stroke caused by large-vessel occlusion in the MCA territory who presented between July 2017 and September 2019 to our hospital were included. Collateral filling was rated using the modified Tan scale on CTA, and good collaterals were defined as a score of 2-3. The Cortical Vein Opacification Score (COVES) was calculated, and absent cortical venous filling was defined as a score of 0. Early brain edema was determined using net water uptake on baseline CT images. Malignant cerebral edema was defined as a midline shift of ≥5 mm on follow-up imaging or a massive cerebral swelling leading to decompressive hemicraniectomy or death. Multivariate linear and logistic regression models were performed to analyze data.

RESULTS

A total of 163 patients were included. Net water uptake was significantly higher in patients with absent than in those with favorable cortical venous filling (8.1% versus 4.2%; P < .001). In the multivariable regression analysis, absent cortical venous filling (β = 2.04; 95% CI, 0.75-3.32; P = .002) was significantly and independently associated with higher net water uptake. Absent cortical venous filling (OR, 14.68; 95% CI, 4.03-53.45; P < .001) and higher net water uptake (OR, 1.29; 95% CI, 1.05-1.58; P = .016) were significantly associated with increased likelihood of malignant cerebral edema.

CONCLUSIONS

Patients with absent cortical venous filling were associated with an increased early brain edema and a higher risk of malignant cerebral edema. These patients may be targeted for optimized adjuvant antiedematous treatment.

Limiting Brain Shift in Malignant Hemispheric Infarction by Decompressive Craniectomy

OBJECTIVE

Decompressive craniectomy (DC) improves functional outcomes in selected patients with malignant hemispheric infarction (MHI), but variability in the surgical technique and occasional complications may be limiting the effectiveness of this procedure. Our aim was to evaluate predefined perioperative CT measurements for association with post-DC midline brain shift in patients with MHI.

METHODS

At two medical centers we identified 87 consecutive patients with MHI and DC between January 2007 and December 2019. We used our previously tested methods to measure the craniectomy surface area, extent of transcalvarial brain herniation, thickness of tissues overlying the craniectomy, diameter of the cerebral ventricle atrium contralateral to the stroke, extension of infarction beyond the craniectomy edges, and the pre and post-DC midline brain shifts. To avoid potential confounding from medical treatments and additional surgical procedures, we excluded patients with the first CT delayed >30 hours post-DC, resection of infarcted brain, or insertion of an external ventricular drain during DC. The primary outcome in multiple linear regression analysis was the postoperative midline brain shift.

RESULTS

We analyzed 72 qualified patients. The average midline brain shift decreased from 8.7 mm pre-DC to 5.4 post-DC. The only factors significantly associated with post-DC midline brain shift at the p<0.01 level were preoperative midline shift (coefficient 0.32, standard error 0.10, p=0.002) and extent of transcalvarial brain herniation (coefficient -0.20, standard error 0.05, p <0.001).

CONCLUSIONS

In patients with MHI and DC, smaller post-DC midline shift is associated with smaller pre-DC midline brain shift and greater transcalvarial brain herniation. This knowledge may prove helpful in assessing DC candidacy and surgical success. Additional studies to enhance the surgical success of DC are warranted.

Outcomes and resource use of patients with large hemispheric infarction and cerebral edema: analysis of real-world data

OBJECTIVE

Large hemispheric infarction (LHI) is associated with a high likelihood of the evolution of life-threatening edema. Few studies have assessed real-world clinical outcomes and management strategies among patients with LHI. The objective of this study was to describe the management, in-hospital outcomes, and direct healthcare resource burden of patients with LHI, as well as those of patients with subsequent cerebral edema.

METHODS

This observational, retrospective cohort study analyzed de-identified data from US adult patients using the IBM MarketScan Hospital Drug Database (Q4-2015 to Q4-2017). Patients were included in the "Possible LHI" or the "Other Ischemic Strokes" cohorts using ICD-10 diagnosis codes. Patients with possible LHI were further categorized into "LHI with Edema" and "LHI without Edema" subgroups using diagnosis and procedure codes. Select clinical and economic outcomes were compared between cohorts and subgroups using multivariable regressions.

RESULTS

Of 79,201 eligible encounters with ischemic strokes, 11,772 unique patients were assigned to the Possible LHI cohort while 67,429 were assigned to the Other Ischemic Strokes cohort. Among patients with possible LHI, 869 (7%) were assigned to the LHI with Edema subgroup and 10,903 (93%) were assigned to the LHI without Edema subgroup. Patients in the Possible LHI cohort had longer hospital stays (mean difference [MD] [95%CI] = 2.6 [2.4;2.8] days), higher total facility charges (MD [95%CI] = $28,656 [26,794;30,524]), and higher odds of death (odds ratio [95%CI] = 2.2 [2.0;2.4]) than the Other Ischemic Strokes cohort. Among patients with possible LHI, the incremental clinical and resource burden was further exacerbated in the subgroup of patients with edema (hospital days: MD [95%CI] = 5.0 [3.9;6.2] days; total facility charges: MD [95%CI] = $59,585 [50,816;67,583]; mortality: odds ratio [95%CI] = 10.3 [8.5;12.4]).

CONCLUSIONS

Among patients with ischemic strokes, LHI was associated with increased clinical management and direct healthcare resource burden in real-world hospital settings. The burden was substantially increased among patients who developed cerebral edema.

The association between white matter changes and development of malignant middle cerebral artery infarction: A case-control study

ABSTRACT

Disrupted blood-brain barrier (BBB) in patients with ischemic stroke plays a critical role in malignant middle cerebral artery infarction (MMI) development.Cerebral white matter changes (WMC), particularly in the deep subcortical area or in severe one, may be also underlain by disrupted BBB. It is unclear whether the presence of WMC with potential premorbid disruption of BBB makes patients susceptible to MMI. Therefore, this study aimed to clarify any putative relationship between the MMI and WMC in terms of their severity and locations.In this case-control study, patients with infarction in the middle cerebral artery territory were retrospectively reviewed. Brain magnetic resonance images were analyzed according to Fazekas scale, and identified WMC were divided into periventricular WMC (PV-WMC) and deep subcortical WMC (deep-WMC). Patients were scored as having WMC, PV-WMC, deep-WMC, severe PV-WMC, and severe deep-WMC according to the severity and locations. Patients were defined as having MMI if either a progressive conscious disturbance or signs of uncal herniation was recorded in combination with a midline shift >5 mm identified on the follow-up computed tomography.Among 297 patients admitted between July 2009 and February 2015, 92 patients were eligible for final analysis. Compared to patients without MMI, patients with MMI had a higher score of National Institutes of Health Stroke Scale, a larger infarct volume, and an increasingly greater proportion of severe PV-WMC, deep-WMC, and severe deep-WMC, respectively. After adjustment for sex, age, infarct volume, and history of hypertension, severe deep-WMC (odds ratio [OR] = 6.362, 95% confidence interval [CI] = 1.444-28.023, P = .0144) and severe PV-WMC (odds ratio = 5.608, 95% confidence interval = 1.107-28.399, P = .0372) were significantly associated with MMI development.MMI and WMC are significantly associated such that MMI development is more likely when PV-WMC or deep-WMC is more severe. We hypothesize that Fazekas scale-defined severe deep-WMC and PV-WMC may be considered as clinically approachable predictors of MMI development. These findings support that the WMC with potential premorbid disrupted BBB may make patients susceptible to MMI, and further prospective study should be conducted to clarify this hypothesis.

External Validation and Modification of the EDEMA Score for Predicting Malignant Brain Edema After Acute Ischemic Stroke

BACKGROUND

Accurate prediction of malignant brain edema (MBE) after stroke is paramount to facilitate close monitoring and timely surgical intervention. The Enhanced Detection of Edema in Malignant Anterior Circulation Stroke (EDEMA) score was useful to predict potentially lethal malignant edema in Western populations. We aimed to validate and modify it to achieve a better predictive value for MBE in Chinese patients.

METHODS

Of ischemic stroke patients consecutively admitted in the Department of Neurology, West China Hospital between January 2010 and December 2017, we included patients with anterior circulation stroke, early signs of brain edema on computed tomography within 24 h of onset, and admission National Institutes of Health Stroke Scale (NIHSS) score ≥ 8. MBE was defined as the development of signs of herniation (including decrease in consciousness and/or anisocoria), accompanied by midline shift ≥ 5 mm on follow-up imaging. The EDEMA score consisted of five parameters: glucose, stroke history, reperfusion therapy, midline shift, and cistern effacement. We created a modified score by adding admission NIHSS score to the original EDEMA score. The discrimination of the score was assessed by the area under the receiver operating characteristics curve (AUC). Calibration was assessed by Hosmer-Lemeshow test and calibration plot. We compared the discrimination of the original and modified score by AUC, net reclassification improvement (NRI), and integrated discrimination improvement (IDI). Clinical usefulness of the two scores was compared by plotting net benefits at different threshold probabilities in the decision curve analysis.

RESULTS

Of the 478 eligible patients (mean age 67.3 years; median NIHSS score 16), 93 (19%) developed MBE. The EDEMA score showed moderate discrimination (AUC 0.72, 95% confidence interval [CI] 0.67-0.76) and good calibration (Hosmer-Lemeshow test, P = 0.77). The modified score showed an improved discriminative ability (AUC 0.80, 95% CI 0.76-0.84, P < 0.001; NRI 0.67, 95% CI 0.55-0.78, P < 0.001; IDI 0.07, 95% CI 0.06-0.09, P < 0.001). Decision curves showed that the modified score had a higher net benefit than the original score in a range of threshold probabilities lower than 60%.

CONCLUSIONS

The original EDEMA score showed an acceptable predictive value for MBE in Chinese patients. By adding the admission NIHSS score, the modified score allowed for a more accurate prediction and clinical usefulness. Further validation in large cohorts of different ethnicities is needed to confirm our findings.

Cortical Spreading Depression Phenomena Are Frequent in Ischemic and Traumatic Penumbra: A Prospective Study in Patients With Traumatic Brain Injury and Large Hemispheric Ischemic Stroke

PURPOSE

Spreading depolarization (SD) phenomena are waves of neuronal depolarization, which propagate slowly at a velocity of 1 to 5 mm/minute and can occur in patients with ischemic or hemorrhagic stroke, traumatic brain injury, and migraine with aura. They form part of secondary injury, occurring after spreading ischemia. The purposes of this study were to describe the frequency and characteristics of SD phenomena and to define whether a correlation existed between SD and outcome in a group of patients with TBI and large hemispheric ischemic stroke.

METHODS

This was a prospective observational study of 39 adult patients, 17 with malignant middle cerebral artery infarction and 22 with moderate or severe traumatic brain injury, who underwent decompressive craniectomy and multimodal neuromonitoring including electrocorticography. Identification, classification, and interpretation of SDs were performed using the published recommendations from the Cooperative Study on Brain Injury Depolarization group. The outcomes assessed were functional disability at 6 and 12 months after injury, according to the extended Glasgow outcome scale, Barthel index, and modified Rankin scale.

RESULTS

Four hundred eighty-three SDs were detected, in 58.9% of the patients. Spreading depolarizations were more common, particularly the isoelectric SD type, in patients with malignant middle cerebral artery infarction (P < 0.04). In 65.21% of patients with SDs on electrocorticography, the "peak" day of depolarization was day 0 (the first 24 hours of recording). Spreading depolarization convulsions were present in 26.08% of patients with SDs. Patients with more SDs and higher depolarization indices scored worse on extended Glasgow outcome scale (6 months) and Barthel index (6 and 12 months) (P < 0.05).

CONCLUSIONS

Evidence on SD phenomena is important to ensure continued progress in understanding their pathophysiology, in the search for therapeutic targets to avoid additional damage from these secondary injuries.

Hyperdense artery sign, symptomatic infarct swelling and effect of alteplase in acute ischaemic stroke

Background

Alteplase improves functional outcomes of patients with acute ischaemic stroke, but its effects on symptomatic infarct swelling, an adverse complication of stroke and the influence of CT hyperdense artery sign (HAS) are unclear. This substudy of the Third International Stroke Trial aimed to investigate the association between HAS and symptomatic infarct swelling and effect of intravenous alteplase on this association.

Methods

We included stroke patients whose prerandomisation scan was non-contrast CT. Raters, masked to clinical information, assessed baseline (prerandomisation) and follow-up (24–48 hours postrandomisation) CT scans for HAS, defined as an intracranial artery appearing denser than contralateral arteries. Symptomatic infarct swelling was defined as clinically significant neurological deterioration ≤7 days after stroke with radiological evidence of midline shift, effacement of basal cisterns or uncal herniation.

Results

Among 2961 patients, HAS presence at baseline was associated with higher risk of symptomatic infarct swelling (OR 2.21; 95% CI 1.42 to 3.44). Alteplase increased the risk of swelling (OR 1.69; 95% CI 1.11 to 2.57), with no difference between patients with and those without baseline HAS (p=0.49). In patients with baseline HAS, alteplase reduced the proportion with HAS at follow-up (OR 0.67; 95% CI 0.50 to 0.91), where HAS disappearance was associated with reduced risk of swelling (OR 0.25, 95% CI 0.14 to 0.47).

Conclusion

Although alteplase was associated with increased risk of symptomatic infarct swelling in patients with or without baseline HAS, it was also associated with accelerated clearance of HAS, which in return reduced swelling, providing further mechanistic insights to underpin the benefits of alteplase.

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

OBJECTIVE

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.

METHODS

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 12 months after injury were assessed using the Barthel, modified Rankin (mRS), and Extended Glasgow Outcome (GOS-E) scales.

RESULTS

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 6 months (R: - 0.3, p = 0.03) and 12 months (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 12 months) and Barthel (R: - 0.4 at 6 and 12 months) 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.

CONCLUSIONS

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.

A web based dynamic MANA Nomogram for predicting the malignant cerebral edema in patients with large hemispheric infarction

Background

For large hemispheric infarction (LHI), malignant cerebral edema (MCE) is a life-threatening complication with a mortality rate approaching 80%. Establishing a convenient prediction model of MCE after LHI is vital for the rapid identification of high-risk patients as well as for a better understanding of the potential mechanism underlying MCE.

Methods

One hundred forty-two consecutive patients with LHI within 24 h of onset between January 1, 2016 and August 31, 2019 were retrospectively reviewed. MCE was defined as patient death or received decompressive hemicraniectomy (DHC) with obvious mass effect (≥ 5 mm midline shift or Basal cistern effacement). Binary logistic regression was performed to identify independent predictors of MCE. Independent prognostic factors were incorporated to build a dynamic nomogram for MCE prediction.

Results

After adjusting for confounders, four independent factors were identified, including previously known atrial fibrillation (KAF), midline shift (MLS), National Institutes of Health Stroke Scale (NIHSS) and anterior cerebral artery (ACA) territory involvement. To facilitate the nomogram use for clinicians, we used the “Dynnom” package to build a dynamic MANA (acronym for MLS, ACA territory involvement, NIHSS and KAF) nomogram on web (http://www.MANA-nom.com) to calculate the exact probability of developing MCE. The MANA nomogram’s C-statistic was up to 0.887 ± 0.041 and the AUC-ROC value in this cohort was 0.887 (95%CI, 0.828 ~ 0.934).

Conclusions

Independent MCE predictors included KAF, MLS, NIHSS, and ACA territory involvement. The dynamic MANA nomogram is a convenient, practical and effective clinical decision-making tool for predicting MCE after LHI in Chinese patients.

Impaired consciousness at stroke onset in large hemisphere infarction: incidence, risk factors and outcome

Impaired consciousness (IC) at stroke onset in large hemispheric infarctions (LHI) patients is common in clinical practice. However, little is known about the incidence and risk factors of IC at stroke onset in LHI. Besides, stroke-related complications and clinical outcomes in relation to the development of IC has not been systematically examined. Data of 256 consecutive patients with LHI were collected. IC at stroke onset was retrospectively collected from the initial emergency department and/or admission records. Of the 256 LHI patients enrolled, 93 (36.3%) had IC at stroke onset. LHI patients with IC at stroke onset were older (median age 66 vs. 61, p = 0.041), had shorter prehospital delay (24 vs. 26 h, p < 0.001and higher baseline National Institutes of Health Stroke Scale (NIHSS) score (19 vs. 12, p < 0.001). Independent risk factors of IC at stroke onset were high NIHSS score (odds ratio, OR 1.17, 95% confidence interval [CI] 1.12 to 1.23) and atrial fibrillation (OR 1.93, 95% CI 1.07 to 3.47). Dyslipidemia appeared to protect against IC at stroke onset (adjusted OR 0.416, 95% CI 0.175 to 0.988). IC at stroke onset was associated with higher frequency of stroke-related complications (90.32% vs. 67.48%, p < 0.001), especially brain edema (45.16% vs. 23.31%, p < 0.001) and pneumonia (63.44% vs. 47.82%, p = 0.019). The IC group had higher rates of in-hospital death (23.66% vs. 11.66%, p = 0.012), 3-month mortality (49.46% vs. 24.87%, p = 0.002), and 3-month unfavorable outcome (64.51% vs. 49.07%, p = 0.017). However, after adjusting for age, baseline NIHSS score and other confounders, IC at stroke onset was not an independent predictor of in-hospital death (adjusted OR 0.56, 95% CI 0.22 to 1.47), 3-month mortality (adjusted OR 0.54, 95% CI 0.25 to 1.14) and 3-month unfavorable outcome (adjusted OR 0.64, 95% CI 0.31 to 1.33) in LHI patients (all p > 0.05). Our results suggested that IC occur in 1 out of every 3 LHI patients at stroke onset and was associated with initial stroke severity and atrial fibrillation. LHI patients with IC at stroke onset more frequently had stroke-related complications, 3-month mortality and unfavorable outcome, whereas IC was not an independent predictor of poor outcomes.

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.

Prognostic value of cerebral infarction coefficient in patients with massive cerebral infarction

OBJECTIVE

We proposed the concept of the cerebral infarction coefficient, which is cerebral infarction volume/brain volume. This study aimed to evaluate the prognostic value of the cerebral infarction coefficient in patients with massive cerebral infarction (MCI).

METHODS

According to the modified Rankin score, 71 patients with acute MCI were divided into good prognosis and poor prognosis groups. Clinical and imaging data of the two groups were collected and univariate analysis was carried out. If there were significant differences in the data between the two groups, binary logistic regression analysis was performed.

RESULTS

The poor prognosis group had a significantly higher cerebral infarction volume, cerebral infarction coefficient, and D-dimer levels, older age, the highest body temperature, a higher rate of a history of atrial fibrillation, and a lower rate of a history of hypertension compared with the good prognosis group (all P < 0.05). Binary logistic regression analysis showed that the cerebral infarction coefficient was an independent risk factor for a poor prognosis of patients with MCI (P < 0.05, 95 % confidence interval, 2.091, 42.562), and the odds ratio was 8.506. The area under the receiver operating characteristic curve for the cerebral infarction coefficient was 0.753. When the cut-off value was 7.8 %, the sensitivity of predicting a poor prognosis of patients with MCI was 92.5 %.

CONCLUSION

The cerebral infarction coefficient may have predictive value in determining the prognosis of patients with MCI.

Outcomes of Hypothermia in Addition to Decompressive Hemicraniectomy in Treatment of Malignant Middle Cerebral Artery Stroke: A Randomized Clinical Trial

Importance

Moderate hypothermia in addition to early decompressive hemicraniectomy has been suggested to further reduce mortality and improve functional outcome in patients with malignant middle cerebral artery (MCA) stroke.

Objective

To investigate whether moderate hypothermia vs standard treatment after early hemicraniectomy reduces mortality at day 14 in patients with malignant MCA stroke.

Design, Setting, and Participants

This randomized clinical trial recruited patients from August 2011 through September 2015 at 6 German university hospitals with dedicated neurointensive care units. Of the patients treated with hemicraniectomy and assessed for eligibility, patients were randomly assigned to either standard care or moderate hypothermia. Data analysis was completed from December 2016 to June 2018.

Interventions

Moderate hypothermia (temperature, 33.0 ± 1.0°C) was maintained for at least 72 hours immediately after hemicraniectomy.

Main Outcomes and Measures

The primary outcome was mortality rate at day 14 compared with the Fisher exact test and expressed as odds ratio (ORs) with 95% CIs. Rates of patients with serious adverse events were estimated for the period of the first 14 days after hemicraniectomy and 12 months of follow-up. Secondary outcome measures included functional outcome at 12 months.

Results

Of the 50 study participants, 24 were assigned to standard care and 26 to moderate hypothermia. Twenty-eight were male (56%); the mean (SD) patient age was 51.3 (6.6) years. Recruitment was suspended for safety concerns: 12 of 26 patients (46%) in the hypothermia group and 7 of 24 patients (29%) receiving standard care had at least 1 serious adverse event within 14 days (OR, 2.05 [95% CI, 0.56-8.00]; P = .26); after 12 months, rates of serious adverse events were 80% (n = 20 of 25) in the hypothermia group and 43% (n = 10 of 23) in the standard care group (hazard ratio, 2.54 [95% CI, 1.29-5.00]; P = .005). The mortality rate at day 14 was 19% (5 of 26 patients) in the hypothermia group and 13% (3 of 24 patients) in the group receiving standard care (OR, 1.65 [95% CI, 0.28-12.01]; P = .70). There was no significant difference regarding functional outcome after 12 months of follow-up.

Interpretation

In patients with malignant MCA stroke, moderate hypothermia early after hemicraniectomy did not improve mortality and functional outcome compared with standard care, but may cause serious harm in this specific setting.

Trial Registration

http://www.drks.de, identifier DRKS00000623.

Reduction in Cerebrospinal Fluid Volume as an Early Quantitative Biomarker of Cerebral Edema After Ischemic Stroke

Background and Purpose- Cerebral edema (CED) develops in the hours to days after stroke; the resulting increase in brain volume may lead to midline shift (MLS) and neurological deterioration. The time course and implications of edema formation are not well characterized across the spectrum of stroke. We analyzed displacement of cerebrospinal fluid (ΔCSF) as a dynamic quantitative imaging biomarker of edema formation. Methods- We selected subjects enrolled in a stroke cohort study who presented within 6 hours of onset and had baseline and ≥1 follow-up brain computed tomography scans available. We applied a neural network-based algorithm to quantify hemispheric CSF volume at each imaging time point and modeled CSF trajectory over time (using a piecewise linear mixed-effects model). We evaluated ΔCSF within the first 24 hours as an early biomarker of CED (defined as developing MLS on computed tomography beyond 24 hours) and poor outcome (modified Rankin Scale score, 3-6). Results- We had serial imaging in 738 subjects with stroke, of whom 91 (13%) developed CED with MLS. Age did not differ (69 versus 70 years), but baseline National Institutes of Health Stroke Scale was higher (16 versus 7) and baseline CSF volume lower (132 versus 161 mL, both P<0.001) in those with CED. ΔCSF was faster in those developing MLS, with the majority seen by 24 hours (36% versus 11% or 2.4 versus 0.8 mL/h; P<0.0001). Risk of CED almost doubled for every 10% ΔCSF within 24 hours (odds ratio, 1.76 [95% CI, 1.46-2.14]), adjusting for age, glucose, and National Institutes of Health Stroke Scale. Risk of neurological deterioration (1.6-point increase in National Institutes of Health Stroke Scale at 24 hours) and poor outcome (adjusted odds ratio, 1.34 [95% CI, 1.15-1.56]) was also greater for every 10% increase in ΔCSF. Conclusions- CSF volumetrics provides quantitative evaluation of early edema formation. ΔCSF from baseline to 24-hour computed tomography is a promising early biomarker for the development of MLS and worse neurological outcome.

Surgical Decompression versus Conservative Treatment in Patients with Malignant Infarction of the Middle Cerebral Artery: Direct Comparison of Death-Related Complications

BACKGROUND

Surgical decompression and conservative treatment are routinely used in the treatment of patients with malignant infarction of the middle cerebral artery (MIMCA). However, efficacy and safety are controversial. The purpose of this study is to systematically compare the clinical outcomes between surgical decompression and conservative treatment in patients with MIMCA.

METHODS

This study retrieved available academic randomized controlled trials (RCTs) comparing the clinical outcomes between surgical decompression and conservative treatment in patients with MIMCA from the databases of ScienceDirect, Cochrane Library, Embase, and PubMed. The references of previous reviews and related clinical studies were manually checked to retrieve potential literature that was not involved in our electronic search results.

RESULTS

A total of 7 RCTs were included in the study. The overall number of participants in the surgical decompression group was 165, whereas it was 173 in the conservative treatment group. The results revealed that the surgical decompression group was related to a lower incidence of 1-year death (odds ratio [OR], 0.192; 95% confidence interval [CI], 0.119-0.309; P < 0.001), 1-year death in patients >60 years of age (OR, 0.202; 95% CI, 0.097-0.421; P < 0.001), 1-year death in patients <60 years of age (OR, 0.145; 95% CI, 0.069-0.301; P < 0.001), 1-year death in patients treated within 48 hours of stroke onset (OR, 0.159; 95% CI, 0.090-0.282; P < 0.001), and modified Rankin Scale (mRS) score ≤3 (OR, 2.082; 95% CI, 1.185-3.658; P < 0.001).

CONCLUSIONS

Based on current evidence for patients with MIMCA, decompressive surgery not only is a life-saving therapy but also reduces the incidence of mortality without increasing the risk of severe disability.

CT pattern of Infarct location and not infarct volume determines outcome after decompressive hemicraniectomy for Malignant Middle Cerebral Artery Stroke

Malignant middle cerebral artery [MMCA] infarction has a different topographic distribution that might confound the relationship between lesion volume and outcome. Retrospective study to determine the multivariable relationship between computerized tomographic [CT] infarct location, volume and outcomes in decompressive hemicraniectomy [DHC] for MMCA infarction. The MCA infarctions were classified into four subgroups by CT, subtotal, complete MCA [co-MCA], Subtotal MCA with additional infarction [Subtotal MCAAI] and co-MCA with additional infarction [Co-MCAAI]. Maximum infarct volume [MIV] was measured on the pre-operative CT. Functional outcome was measured by the modified Rankin Scale [mRS] dichotomized as favourable 0–3 and unfavourable ≥4, at three months. In 137 patients, from least favourable to favourable outcome were co-MCAAI, subtotal MCAAI, co-MCA and subtotal MCA infarction. Co-MCAAI had the worst outcome, 56/57 patients with additional infarction had mRS ≥ 4. Multiple comparisons Scheffe test showed no significant difference in MIV of subtotal infarction, co-MCA, Subtotal MCAAI but the outcome was significantly different. Multivariate analysis confirmed MCAAI [7.027 (2.56–19.28), p = 0.000] as the most significant predictor of poor outcomes whereas MIV was not significant [OR, 0.99 (0.99–01.00), p = 0.594]. Other significant independent predictors were age ≥ 55 years 12.14 (2.60–56.02), p = 0.001 and uncal herniation 4.98(1.53–16.19), p = 0.007]. Our data shows the contribution of CT infarction location in determining the functional outcome after DHC. Subgroups of patients undergoing DHC had different outcomes despite comparable infarction volumes.

BIIB093 (IV glibenclamide): an investigational compound for the prevention and treatment of severe cerebral edema

Introduction: Brain swelling due to edema formation is a major cause of neurological deterioration and death in patients with large hemispheric infarction (LHI) and severe traumatic brain injury (TBI), especially contusion-TBI. Preclinical studies have shown that SUR1-TRPM4 channels play a critical role in edema formation and brain swelling in LHI and TBI. Glibenclamide, a sulfonylurea drug and potent inhibitor of SUR1-TRPM4, was reformulated for intravenous injection, known as BIIB093.Areas covered: We discuss the findings from Phase 2 clinical trials of BIIB093 in patients with LHI (GAMES-Pilot and GAMES-RP) and from a small Phase 2 clinical trial in patients with TBI. For the GAMES trials, we review data on objective biological variables, adjudicated edema-related endpoints, functional outcomes, and mortality which, despite missing the primary endpoint, supported the initiation of a Phase 3 trial in LHI (CHARM). For the TBI trial, we review data on MRI measures of edema and the initiation of a Phase 2 trial in contusion-TBI (ASTRAL).Expert opinion: Emerging clinical data show that BIIB093 has the potential to transform our management of patients with LHI, contusion-TBI and other conditions in which swelling leads to neurological deterioration and death.

Outcomes of therapeutic hypothermia in patients treated with decompressive craniectomy for malignant Middle cerebral artery infarction: A systematic review and meta-analysis

OBJECTIVES

The beneficial effects of therapeutic hypothermia (TH) after decompressive craniectomy (DC) for malignant middle cerebral artery (MCA) infarction are controversial. We conducted a systematic review and meta-analysis to assess the clinical efficacy of TH in aforementioned patients.

PATIENTS AND METHODS

A systematic literature search was conducted to find articles published up to April 2019 evaluating the effect of combining TH and DC on short-term (≤30 days) and long-term (>6 months) mortality and neurological outcomes in patients with malignant MCA infarction. Pooled relative risk (RRs) with 95% confidence interval (CI) were calculated using the Mantel-Haenszel fixed-effects model or the DerSimonian-Laird random-effects.

RESULTS

Patient data was analyzed for a total of 289 patients from four selected studies and two abstracts. Compared to DC alone, combining DC and TH had a tendency to reduce short-term mortality (RR = 0.52, 95% CI 0.26 to 1.05, P = 0.07, I² = 0%) but had no significant effects on long-term mortality (RR = 1.26, 95% CI 0.58 to 2.76, P = 0.56, I² = 68%) or neurological outcomes (RR = 0.81, 95% CI 0.53 to 1.24, P = 0.34, I² = 30%).

CONCLUSION

Using TH in tandem with DC did not show definite short- or long-term survival benefits in our study, but may tend to reduce the short-term mortality of patients with malignant MCA infarction.

Strokectomy and Extensive Cisternal CSF Drain for Acute Management of Malignant Middle Cerebral Artery Infarction: Technical Note and Case Series

Background and Purpose: Ischemic stroke is a major cause of death and disability worldwide. Large MCA stroke may evolve as malignant space occupying lesion and mortality rate reaches 80% despite maximal medical therapy. Early decompressive craniectomy is effective in reducing mortality and improving the functional outcome but is an extended and invasive surgical approach burdened with a significant complication rate. We report a surgical treatment based on partial strokectomy and basal cisterns opening with massive CSF drain.

Materials and Methods: We retrospectively collected 15 cases of massive middle cerebral artery stroke treated with strokectomy between 2010 and 2017: nine males and six females, mean age 61.73 ± 9.5 years. The right side was affected in 66.7%. All patients show clinical deterioration despite standard medical therapy and indication for surgery was placed after collegiate evaluation by neurologists and neurosurgeons based on clinical and radiological data.

Results: Surgical procedure was performed 24–96 h after the stroke onset. All the 15 patients survived the intervention, one patient died 20 days after the admission for massive lung embolism. Mean GCS and NIHSS at admission were 12.6 ± 1.18 (range 9–15) and 19.7 ± 2.3 (range 18–23), respectively. Mean mRS at 12 months was 3.6 ± 1.1 (range 2–6). Mean follow-up was 18.1 months (range 12–34). The outcome was evaluated as satisfactory (mRs ≤ 3) in 8 patients (53.3%). Mortality at 1 year was 6.7%. No patients developed hydrocephalus and 1 presented seizures. According to mRs outcome evaluation (mRs ≤ 3 vs. mRs ≥ 4) no quantitative variable resulted significantly different between the two groups, whereas the concomitant use of iv rTPA significantly differed (P < 0.05).

Conclusion: Supratentorial strokectomy seems to be safe and could be a potential alternative to decompressive craniectomy for the acute management of malignant MCA stroke. Advantages of this approach could be low complication rate, avoidance of bone reconstruction procedure, and reduced occurrence of hydrocephalus or seizures. A co-operative multicentric, prospective pilot study will be necessary to validate this technical approach.

Imaging After Thrombolysis and Thrombectomy: Rationale, Modalities and Management Implications

PURPOSE OF REVIEW

Urgent reperfusion treatment with intravenous thrombolysis or mechanical thrombectomy reduces disability after ischaemic stroke. Imaging plays an important role in identifying patients who benefit, particularly in extended time windows. However, the role of post-treatment neuroimaging is less well established. We review recent advances in neuroimaging after reperfusion treatment and provide a practical guide to the options and management implications.

RECENT FINDINGS

Post-treatment imaging is critical to identify patients with reperfusion-related haemorrhage and oedema requiring intervention. It also can guide the timing and intensity of antithrombotic medication. The degree of reperfusion on post-thrombectomy angiography and infarct volume and topography using CT or MRI carry important prognostic significance. Perfusion-weighted MRI and permeability analysis may help detect persistent perfusion abnormalities post-treatment and predict haemorrhagic complications. Post-treatment neuroimaging provides clinically relevant information to identify complications, assess prognosis and perform quality assurance after acute ischaemic stroke. Recent advances in neuroimaging represent a potential avenue to explore post-reperfusion pathophysiology and uncover therapeutic targets for secondary ischaemic and haemorrhagic injury.

Decompressive craniectomy for acute ischemic stroke

Malignant stroke occurs in a subgroup of patients suffering from ischemic cerebral infarction and is characterized by neurological deterioration due to progressive edema, raised intracranial pressure, and cerebral herniation. Decompressive craniectomy (DC) is a surgical technique aiming to open the “closed box” represented by the non-expandable skull in cases of refractory intracranial hypertension. It is a valuable modality in the armamentarium to treat patients with malignant stroke: the life-saving effect has been proven for both supratentorial and infratentorial DC in virtually all age groups. This leaves physicians with the difficult task to decide who will require early or preemptive surgery and who might benefit from postponing surgery until clear evidence of deterioration evolves. Together with the patient’s relatives, physicians also have to ascertain whether the patient will have acceptable disability and quality of life in his or her presumed perception, based on preoperative predictions. This complex decision-making process can only be managed with interdisciplinary efforts and should be supported by continued research in the age of personalized medicine.

Intracranial Cerebrospinal Fluid Volume as a Predictor of Malignant Middle Cerebral Artery Infarction

Background and Purpose- Predicting malignant middle cerebral artery (MCA) infarction can help to identify patients who may benefit from preventive decompressive surgery. We aimed to investigate the association between the ratio of intracranial cerebrospinal fluid (CSF) volume to intracranial volume (ICV) and malignant MCA infarction. Methods- Patients with an occlusion proximal to the M3 segment of the MCA were selected from the DUST (Dutch Acute Stroke Study). Admission imaging included noncontrast computed tomography (CT), CT perfusion, and CT angiography. Patient characteristics and CT findings were collected. The ratio of intracranial CSF volume to ICV (CSF/ICV) was quantified on admission thin-slice noncontrast CT. Malignant MCA infarction was defined as a midline shift of >5 mm on follow-up noncontrast CT, which was performed 3 days after the stroke or in case of clinical deterioration. To test the association between CSF/ICV and malignant MCA infarction, odds ratios and 95% CIs were calculated for 3 multivariable models by using binary logistic regression. Model performances were compared by using the likelihood ratio test. Results- Of the 286 included patients, 35 (12%) developed malignant MCA infarction. CSF/ICV was independently associated with malignant MCA infarction in 3 multivariable models: (1) with age and admission National Institutes of Health Stroke Scale (odds ratio, 3.3; 95% CI, 1.1-11.1), (2) with admission National Institutes of Health Stroke Scale and poor collateral score (odds ratio, 7.0; 95% CI, 2.6-21.3), and (3) with terminal internal carotid artery or proximal M1 occlusion and poor collateral score (odds ratio, 7.7; 95% CI, 2.8-23.9). The performance of model 1 (areas under the receiver operating characteristic curves, 0.795 versus 0.824; P=0.033), model 2 (areas under the receiver operating characteristic curves, 0.813 versus 0.850; P<0.001), and model 3 (areas under the receiver operating characteristic curves, 0.811 versus 0.856; P<0.001) improved significantly after adding CSF/ICV. Conclusions- The CSF/ICV ratio is associated with malignant MCA infarction and has added value to clinical and imaging prediction models in limited numbers of patients.