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Early Prediction of Malignant Edema After Successful Recanalization in Patients with Acute Ischemic Stroke

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A Correction to this article was published on 11 January 2022

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Abstract

Background

Postinterventional cerebral hyperdensities are common on non-contrast-enhanced computed tomography (CT) after endovascular thrombectomy in patients with acute ischemic stroke, which may reflect blood–brain barrier damage. The disruption of the blood–brain barrier may lead to malignant brain edema. The relationship between the extent of postinterventional cerebral hyperdensities and malignant brain edema is unclear.

Methods

Patients with middle cerebral artery territory infarction and successful recanalization were consecutively enrolled. Postinterventional non-contrast-enhanced CT was performed to evaluate postinterventional cerebral hyperdensities within 24 h after endovascular thrombectomy. On the basis of the areas of the Alberta Stroke Program Early CT Score, we devised the Hyperdensity on CT Score to evaluate the extent of postinterventional cerebral hyperdensities. The primary outcome was malignant brain edema, defined as the development of clinical signs of herniation (including a decrease in consciousness and/or anisocoria), accompanied by imaging evidence of brain swelling. The component of postinterventional cerebral hyperdensities was divided into contrast staining and hemorrhage on the basis of persistency.

Results

Three hundred sixty patients were included (50.6% male, mean age 67.9 years), of whom 247 (68.6%) developed postinterventional cerebral hyperdensities and 66 (18.3%) developed malignant brain edema. After adjustment for confounders, including the component of postinterventional cerebral hyperdensities, the extent of postinterventional cerebral hyperdensities assessed by the Hyperdensity on CT Score was significantly associated with malignant brain edema (odds ratio 1.46, 95% confidence interval 1.20–1.77, p < 0.001). A Hyperdensity on CT Score greater than 3 had a sensitivity of 0.73 and a specificity of 0.87 for predicting malignant brain edema.

Conclusions

The extent of postinterventional cerebral hyperdensities on postinterventional non-contrast-enhanced CT was associated with malignant brain edema. The Hyperdensity on CT Score could be used to predict malignant brain edema regardless of the component of postinterventional cerebral hyperdensities.

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References

  1. Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723–31.

    Article  Google Scholar 

  2. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344-418.

    Article  Google Scholar 

  3. Kim JM, Bae JH, Park KY, et al. Incidence and mechanism of early neurological deterioration after endovascular thrombectomy. J Neurol. 2019;266(3):609–15.

    Article  Google Scholar 

  4. Huang X, Yang Q, Shi X, et al. Predictors of malignant brain edema after mechanical thrombectomy for acute ischemic stroke. J Neurointerv Surg. 2019;11(10):994–8.

    Article  Google Scholar 

  5. Thorén M, Dixit A, Escudero-Martínez I, et al. Effect of recanalization on cerebral edema in ischemic stroke treated with thrombolysis and/or endovascular therapy. Stroke. 2020;51(1):216–23.

    Article  Google Scholar 

  6. White OB, Norris JW, Hachinski VC, Lewis A. Death in early stroke, causes and mechanisms. Stroke. 1979;10(6):743.

    Article  CAS  Google Scholar 

  7. Huttner HB, Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol. 2009;8(10):949–58.

    Article  Google Scholar 

  8. Berrouschot J, Sterker M, Bettin S, Köster J, Schneider D. Mortality of space-occupying ('malignant’) middle cerebral artery infarction under conservative intensive care. Intensive Care Med. 1998;24(6):620–3.

    Article  CAS  Google Scholar 

  9. Wijdicks EF, Diringer MN. Middle cerebral artery territory infarction and early brain swelling: progression and effect of age on outcome. Mayo Clin Proc. 1998;73(9):829–36.

    Article  CAS  Google Scholar 

  10. Ropper AH. Lateral displacement of the brain and level of consciousness in patients with an acute hemispheral mass. N Engl J Med. 1986;314(15):953–8.

    Article  CAS  Google Scholar 

  11. Vahedi K, Hofmeijer J, Juettler E, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol. 2007;6(3):215–22.

    Article  Google Scholar 

  12. Dekeyzer S, Nikoubashman O, Lutin B, et al. Distinction between contrast staining and hemorrhage after endovascular stroke treatment: one CT is not enough. J Neurointerv Surg. 2017;9(4):394–8.

    Article  Google Scholar 

  13. Yoon W, Seo JJ, Kim JK, et al. Contrast enhancement and contrast extravasation on computed tomography after intra-arterial thrombolysis in patients with acute ischemic stroke. Stroke. 2004;35(4):876–81.

    Article  Google Scholar 

  14. Yedavalli V, Sammet S. Contrast extravasation versus hemorrhage after thrombectomy in patients with acute stroke. J Neuroimaging. 2017;27(6):570–6.

    Article  Google Scholar 

  15. Xu C, Zhou Y, Zhang R, et al. Metallic hyperdensity sign on noncontrast ct immediately after mechanical thrombectomy predicts parenchymal hemorrhage in patients with acute large-artery occlusion. AJNR Am J Neuroradiol. 2019;40(4):661–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  16. Nakano S, Iseda T, Kawano H, et al. Parenchymal hyperdensity on computed tomography after intra-arterial reperfusion therapy for acute middle cerebral artery occlusion: incidence and clinical significance. Stroke. 2001;32(9):2042–8.

    Article  CAS  Google Scholar 

  17. Parrilla G, García-Villalba B, Espinosa de Rueda M, et al. Hemorrhage/contrast staining areas after mechanical intra-arterial thrombectomy in acute ischemic stroke: imaging findings and clinical significance. AJNR Am J Neuroradiol. 2012;33(9):1791–6.

    Article  CAS  Google Scholar 

  18. Nikoubashman O, Reich A, Gindullis M, et al. Clinical significance of post-interventional cerebral hyperdensities after endovascular mechanical thrombectomy in acute ischaemic stroke. Neuroradiology. 2014;56(1):41–50.

    Article  Google Scholar 

  19. Kim JT, Heo SH, Cho BH, et al. Hyperdensity on non-contrast CT immediately after intra-arterial revascularization. J Neurol. 2012;259(5):936–43.

    Article  Google Scholar 

  20. Kim JM, Park KY, Lee WJ, et al. The cortical contrast accumulation from brain computed tomography after endovascular treatment predicts symptomatic hemorrhage. Eur J Neurol. 2015;22(11):1453–8.

    Article  CAS  Google Scholar 

  21. Puntonet J, Richard ME, Edjlali M, et al. Imaging findings after mechanical thrombectomy in acute ischemic stroke. Stroke. 2019;50(6):1618–25.

    Article  Google Scholar 

  22. Simard JM, Kent TA, Chen M, Tarasov KV, Gerzanich V. Brain oedema in focal ischaemia: molecular pathophysiology and theoretical implications. Lancet Neurol. 2007;6(3):258–68.

    Article  CAS  Google Scholar 

  23. Zaidat OO, Yoo AJ, Khatri P, et al. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke. 2013;44(9):2650–63.

    Article  Google Scholar 

  24. Adams HP Jr, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35–41.

    Article  Google Scholar 

  25. Higashida RT, Furlan AJ, Roberts H, et al. Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke. 2003;34(8):e109–37.

    Article  Google Scholar 

  26. Lummel N, Schulte-Altedorneburg G, Bernau C, et al. Hyperattenuated intracerebral lesions after mechanical recanalization in acute stroke. AJNR Am J Neuroradiol. 2014;35(2):345–51.

    Article  CAS  Google Scholar 

  27. Hacke W, Kaste M, Fieschi C, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet. 1998;352(9136):1245–51.

    Article  CAS  Google Scholar 

  28. Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet. 2000;355(9216):1670–4.

    Article  CAS  Google Scholar 

  29. Wu S, Yuan R, Wang Y, et al. Early prediction of malignant brain edema after ischemic stroke. Stroke. 2018;49(12):2918–27.

    Article  Google Scholar 

  30. Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46-110.

    Article  Google Scholar 

  31. DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics. 1988;44(3):837–45.

    Article  CAS  Google Scholar 

  32. Payabvash S, Qureshi MH, Khan SM, et al. Differentiating intraparenchymal hemorrhage from contrast extravasation on post-procedural noncontrast CT scan in acute ischemic stroke patients undergoing endovascular treatment. Neuroradiology. 2014;56(9):737–44.

    Article  Google Scholar 

  33. Jang YM, Lee DH, Kim HS, et al. The fate of high-density lesions on the non-contrast CT obtained immediately after intra-arterial thrombolysis in ischemic stroke patients. Korean J Radiol. 2006;7(4):221–8.

    Article  Google Scholar 

  34. Lun R, Walker GB, Guenego A, et al. Is this contrast? Is this blood? An agreement study on post-thrombectomy computed tomography scans. Front Neurol. 2020;11:593098.

    Article  Google Scholar 

  35. Tijssen MP, Hofman PA, Stadler AA, et al. The role of dual energy CT in differentiating between brain haemorrhage and contrast medium after mechanical revascularisation in acute ischaemic stroke. Eur Radiol. 2014;24(4):834–40.

    Article  CAS  Google Scholar 

  36. Liu K, Jiang L, Ruan J, et al. The role of dual energy ct in evaluating hemorrhagic complications at different stages after thrombectomy. Front Neurol. 2020;11:583411.

    Article  Google Scholar 

  37. Kimberly WT, Dutra BG, Boers AMM, et al. Association of reperfusion with brain edema in patients with acute ischemic stroke: a secondary analysis of the MR CLEAN Trial. JAMA Neurol. 2018;75(4):453–61.

    Article  Google Scholar 

  38. Song SY, Ahn SY, Rhee JJ, et al. Extent of contrast enhancement on non-enhanced computed tomography after intra-arterial thrombectomy for acute infarction on anterior circulation: as a predictive value for malignant brain edema. J Korean Neurosurg Soc. 2015;58(4):321–7.

    Article  CAS  Google Scholar 

  39. van der Worp HB, Hofmeijer J, Juttler E, et al. European Stroke Organisation (ESO) guidelines on the management of space-occupying brain infarction. Eur Stroke J. 2021;6(2):XC–CX.

    Article  Google Scholar 

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Funding

BW, FH, ZH, and SW obtained public funding. This work was supported by the National Key Development Plan for Precision Medicine Research (2017YFC0910004), the National Natural Science Foundation of China (81671146, 81870937, 82171285, 81371281), the Science and Technology Department of Sichuan Province (2021YJ0433, 2017SZ0007), and the 1.3.5 Project for Disciplines of Excellence, West China Hospital, Sichuan University (ZYGD18009).

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Authors and Affiliations

  1. Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, China

    Changyi Wang, Ting Cui, Tang Yang, Zilong Hao, Simiao Wu, Hongbo Zheng, Fayun Hu & Bo Wu

  2. Departement of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China

    Changyi Wang & Lu Wang

  3. The Second Department of Neurology, Shaanxi Provincial People’s Hospital, Xi’an, Shaanxi, China

    Qiange Zhu

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  1. Changyi Wang
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  2. Qiange Zhu
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  3. Ting Cui
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  4. Lu Wang
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  5. Tang Yang
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  6. Zilong Hao
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  7. Simiao Wu
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  8. Hongbo Zheng
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  9. Fayun Hu
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  10. Bo Wu
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Contributions

BW and FH conceived and designed the study. CW, QZ, TC and TY acquired the data, which CW, ZH and SW analyzed. CW, LW, ZH and SW aided in data interpretation and wrote the manuscript. All authors were involved in revising the article and approved the final version.

Corresponding authors

Correspondence to Fayun Hu or Bo Wu.

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The authors have no conflicts of interest to disclose.

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This study was approved by the Scientific Research Department of West China Hospital. Informed consent was obtained from patients or their next of kin.

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Wang, C., Zhu, Q., Cui, T. et al. Early Prediction of Malignant Edema After Successful Recanalization in Patients with Acute Ischemic Stroke. Neurocrit Care 36, 822–830 (2022). https://doi.org/10.1007/s12028-021-01380-4

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  • DOI: https://doi.org/10.1007/s12028-021-01380-4

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