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Predictive role of modified clinical diffusion mismatch in early neurological deterioration due to atherothrombotic ischemia in the anterior circulation

  • Clinical Article
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Abstract

Background

Atherothrombotic ischemia is the most frequent cause of cerebral ischemia; however, few reports have addressed the prognostic factors predicting early neurological deterioration (END) when the occlusive lesion is limited to the anterior main trunk, middle cerebral artery (MCA) or internal cerebral artery (ICA).

Method

Between 2006 and 2008, 122 atherothrombotic ischemia patients were diagnosed with MCA or ICA occlusive disease on magnetic resonance angiography. The National Institutes of Health Stroke Scale (NIHSS) score and the modified Alberta Stroke Program Early CT Score on diffusion-weighted imaging [ASPECTS-DW (modified)] were calculated. Clinical-DWI mismatch (CDM) was evaluated using NIHSS and the ASPECTS-DW (modified) to examine the predictive efficacy for early neurological deterioration.

Results

Eighteen of 122 (14.8%) patients fulfilled the definition of CDM. END was observed in 24 patients (19.7%) within 15 days after admission. CDM was observed in 14 cases in the END (+) group (14 of 24 cases, 58.3%) and 4 cases in the END (−) group (4 of 98 cases, 4.1%) (p = 0.001). Multivariate logistic regression analysis demonstrated that CDM was a significant predictive factor of END (odds ratio 26.68, p = 0.0001).

Conclusions

CDM based on NIHSS and ASPECTS-DW (modified) could be a significant predictive factor for END of atherothrombotic ischemia in MCA/ICA.

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Acknowledgments

The authors thank the radiological technicians at Kohnan Hospital for the preparation of image analysis.

Disclosure

Our present study was approved by the ethics committee of Kohnan Hospital and was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki.

Conflicts of interest

None.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Kohnan Hospital, 4-20-1 Nagamachiminami, Taihaku, Sendai, Miyagi, 982-8523, Japan

    Atsushi Saito, Miki Fujimura & Takashi Inoue

  2. Department of Neuroendovascular Therapy, Tohoku University Graduate School of Medicine, Sendai, Japan

    Hiroaki Shimizu

  3. Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan

    Teiji Tominaga

Authors
  1. Atsushi Saito
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  2. Hiroaki Shimizu
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  3. Miki Fujimura
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  4. Takashi Inoue
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  5. Teiji Tominaga
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Corresponding author

Correspondence to Atsushi Saito.

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Comment

The prognosis and management of stroke patients who could potentially undergo aggressive interventions remain complicated in this difficult to classify subpopulation. In this study, Dr. Saito et al. attempt to correlate the modified Clinical Diffusion Mismatch (CDM) with Early Neurological Deterioration (END) in atherothrombotic disease in patients with anterior circulation lesions. They evaluated 122 patients during a 2-year period using NIHSS and the modified ASPECTS-DW. According to their results, CDM was a significant predictive factor for END.

This group attempted to select a homogenous patient population to determine the efficacy of CDM on a specific population. They were successful in this goal; however, by selecting patients in this manner, the sample size was affected. Logical guidelines in terms of inclusion and exclusion criteria were included.

An interesting post-hoc evaluation would be if the excluded factors for END, such as brain edema, hemorrhagic infarction, etc., were in fact included. This may provide information as to what effect natural history or interventions had on the data.

The current literature suggests the utility of CDM as it accounts for both the clinical status of the patient and the radiological data of tissue perfusion. Utilizing these two separate but essential tools may show promise in determining indications for intervention as well as prognosis for these patients as shown by the multivariate analysis in this study.

Pulak Ray

Christopher M. Loftus

Philadelphia, PA

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Saito, A., Shimizu, H., Fujimura, M. et al. Predictive role of modified clinical diffusion mismatch in early neurological deterioration due to atherothrombotic ischemia in the anterior circulation. Acta Neurochir 153, 2205–2210 (2011). https://doi.org/10.1007/s00701-011-1084-4

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  • DOI: https://doi.org/10.1007/s00701-011-1084-4

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