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Hypoperfusion Intensity Ratio Predicts Malignant Edema and Functional Outcome in Large-Vessel Occlusive Stroke with Poor Revascularization

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Abstract

Background and Objective

Malignant cerebral edema (MCE) is a well-known complication in patients with acute ischemic stroke with core infarcts ≥ 80 mL caused by large-vessel occlusions. MCE can also develop in patients with smaller infarcts with moderate -to-large volume of tissue at risk who do not achieve successful revascularization with endovascular thrombectomy (ET). Features that predict the development of MCE in this population are not well-described. We aim to identify predictors of MCE and 90-day functional outcome in stroke patients with an anterior circulation large vessel occlusion (LVO) and a < 80 mL ischemic core who do not achieve complete reperfusion.

Methods

We reviewed our institutional stroke registry and included patients who achieved unsuccessful revascularization, mTICI 0-2a, after ET and whose baseline imaging was notable for a core infarct < 80 mL, a Tmax > 6 s volume ≥ 80 mL, and a mismatch ratio ≥ 1.8. MCE was defined as ≥ 5 mm of midline shift on follow-up imaging, obtained 6–48 h after the pre-ET perfusion scan.

Results

Thirty-six patients met inclusion criteria. Unadjusted analysis demonstrated that younger age, higher systolic blood pressure, larger core volume, and higher hypoperfusion intensity ratio (HIR) were associated with MCE (all p < 0.02). In multivariate logistic regression analysis, age, HIR, and core infarct volume were independent predictors of MCE. The optimal HIR threshold to predict MCE was ≥ 0.54 (OR 14.7, 95% CI 2.4–78.0, p = 0.003). HIR was also associated with 3-month mRS (HIR ≥ 0.54 for mRS of 3–6: OR 10.8, 95% CI 1.9–44.0, p = 0.02).

Conclusions

Younger age, larger core infarct volume, and higher HIR are predictive of MCE in patients with anterior circulation LVO, moderate-to-large tissue at risk, and suboptimal revascularization. HIR is correlated with three-month functional outcomes.

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Funding

The study was not funded.

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Authors and Affiliations

  1. Department of Neurology, Division of Vascular Neurology, Stanford University School of Medicine, Palo Alto, CA, 94304, USA

    Nick M. Murray, Collin J. Culbertson, Michael Mlynash & Maarten G. Lansberg

  2. Department of Radiology, Division of Neuroradiology and Neurointervention, Stanford University School of Medicine, Palo Alto, CA, 94304, USA

    Dylan N. Wolman

  3. Department of Neurology, Division of Neurocritical Care, Stanford University School of Medicine, Palo Alto, CA, 94304, USA

    Nick M. Murray

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  1. Nick M. Murray
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  2. Collin J. Culbertson
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  4. Michael Mlynash
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  5. Maarten G. Lansberg
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This manuscript complies with all instructions to authors. The authorship requirements have been met and the final manuscript was approved by all authors.

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Correspondence to Nick M. Murray.

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This study complied with the Health Insurance Portability and Accountability Act and was approved by our Institutional Review Board, which waived the need for written informed consent.

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Murray, N.M., Culbertson, C.J., Wolman, D.N. et al. Hypoperfusion Intensity Ratio Predicts Malignant Edema and Functional Outcome in Large-Vessel Occlusive Stroke with Poor Revascularization. Neurocrit Care 35, 79–86 (2021). https://doi.org/10.1007/s12028-020-01152-6

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  • DOI: https://doi.org/10.1007/s12028-020-01152-6

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