J Neurocrit Care.  2019 Jun;12(1):30-36. 10.18700/jnc.190076.

Primary neurocritical care involving therapeutic hypothermia for acute ischemic stroke patients with malignant infarct cores

• Lee SJ
• Lee KS
• Lee JS
• Choi MH
• Lee SE
• Hong JM

• KMID: 2452824
• DOI: http://doi.org/10.18700/jnc.190076

Abstract

BACKGROUND
Acute ischemic stroke patients with malignant infarct cores were primarily treated with neurocritical care based on reperfusion and hypothermia. We evaluated the predictors for malignant progression and functional outcomes.
METHODS
From January 2010 to March 2015 ischemic stroke patients with large vessel occlusion of the anterior circulation with infarct volume >82 mL on baseline diffusion weighted image (DWI) within 6 hours from onset, with National Institutes of Health Stroke Scale ≥15 were included. All patients were managed with intent for reperfusion and neurocritical care. Malignant progression was defined as clinical signs of progressive herniation. Predictive factors for malignant progression and outcomes of decompressive hemicraniectomy (DHC) were evaluated.
RESULTS
In total, 49 patients were included in the study. Among them, 33 (67.3%) could be managed with neurocritical care and malignant progression was observed in the remainder. Decompressive surgery was performed in nine patients (18.4%). Factors predictive of malignant progression were initial DWI volumes (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.00 to 1.02; P=0.046) and parenchymal hematoma (OR, 6.77; 95% CI, 1.50 to 30.53; P=0.013) on computed tomography taken at Day 1. Infarct volume of >210 mL predicted malignant progression with 56.3% sensitivity and 90.9% specificity. Among the malignant progressors, 77.7% resulted in grave outcomes even with DHC, while all patients who declined surgery died.
CONCLUSION
Acute ischemic stroke patients with malignant cores between 82 to 209 mL can be primarily treated with neurocritical care based on reperfusion and hypothermia with feasible results. In patients undergoing surgical decompression due to malignant progression, the functional outcomes were not satisfactory.

Keyword

Infarction, middle cerebral artery; Brain edema; Thrombectomy; Hypothermia, induced; Critical care; Decompressive craniectomy

MeSH Terms

Brain Edema
Critical Care
Decompression, Surgical
Decompressive Craniectomy
Diffusion
Hematoma
Humans
Hypothermia
Hypothermia, Induced*
Infarction, Middle Cerebral Artery
National Institutes of Health (U.S.)
Reperfusion
Sensitivity and Specificity
Stroke*
Thrombectomy

Figure

• 

  Fig. 1. Distribution of initial diffusion weighted imaging (DWI) volumes and receiver operating characteristic (ROC) curve in prediction of malignant change. (A) The percentage of patients with malignant progression sharply increases with initial DWI volumes of >210 mL. (B) For prediction of malignant progression with initial infarct volume, the area under the ROC curve is 0.735, and an infarct volume threshold of >210 mL predicted malignant progression with 56.3% sensitivity and 90.9% specificity. AUC, area under the curve.

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  Fig. 2. Functional outcomes of nonprogressors and malignant progressors. DHC, decompressive hemicraniectomy; mRS, modified Rankin Scale.

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