Massive Cerebral Infarction with Severe Brain Swelling: A CLINICOPATHOLOGICAL STUDY
TL;DR: Clinical and anatomic findings suggested that increased intracranial pressure probably did not develop until later in the course of the illness and should not be overlooked in the management of patients with severe strokes.
Abstract: All cases of acute supratentorial cerebral infarction which came to postmortem examination over the past 10 years at the Philadelphia General Hospital were reviewed. Of a total of 353 such cases, 45 showed severe brain swelling. Seventy-eight percent of these 45 patients died within seven days of the acute infarction. The rapidly fatal outcome appeared to be directly related to the acute brain swelling with transtentorial herniation and brain-stem edema or hemorrhage. In those patients who survived longer than one week following onset of the ictus (22%), clinical and anatomic findings suggested that increased intracranial pressure probably did not develop until later in the course of the illness. A second massive infarct was probably superimposed upon an earlier one and produced the acute brain swelling noted at the time of postmortem examination. Complicating visceral diseases were more common in this group and seemed to contribute to death in the majority of these patients. Although it has been establis...
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TL;DR: The prognosis of complete middle cerebral artery territory stroke is very poor and can be estimated by early clinical and neuroradiological data within the first few hours after the onset of symptoms.
Abstract: Background: Although the clinical features of space-occupying ischemic stroke are well known, there are limited prospective data on the clinical course of complete middle cerebral artery territory infarction and on the predisposing factors leading to subsequent herniation and brain death. Methods: The clinical course of patients with complete middle cerebral artery territory infarction, defined by computed tomography and vascular imaging, was evaluated. Initial clinical presentation was assessed by the Scandinavian Stroke Scale and the Glasgow Coma Scale. Serial computed tomography with measurement of midline and septum pellucidum shift and data on the presence and location of vascular occlusion by angiography or Doppler ultrasound were obtained directly after admission. Time course and outcome were analyzed with regard to the clinical findings on admission and at follow-up. The functional status of surviving patients was assessed using the Barthel Index. Results: Fifty-five patients with complete middle cerebral artery territory infarction caused by occlusion of either the distal intracranial carotid artery or the proximal middle cerebral artery trunk were studied. In all patients, embolic infarction was presumed. The mean Scandinavian Stroke Scale score on admission was 20, and the time course of deterioration varied between 2 and 5 days. Forty-nine patients required ventilator assistance during the acute stage of disease. Only 12 patients (22%) survived the infarct. The cause of death was transtentorial herniation with subsequent brain death in 43 patients. Survivors had a mean Barthel Index score of 60 (range, 45 to 70). Conclusions: The prognosis of complete middle cerebral artery territory stroke is very poor and can be estimated by early clinical and neuroradiological data within the first few hours after the onset of symptoms. A space-occupying mass effect develops rapidly and predictably over the initial 5 days after presentation. Herniation occurred as an end point in 43 (78%) of these patients.
1,236 citations
TL;DR: The outcome of patients treated with craniectomy in severe ischemic hemispheric infarction was surprisingly good, and early decompressive surgery may further improve outcome in these patients.
Abstract: Background and Purpose—Malignant, space-occupying supratentorial ischemic stroke is characterized by a mortality rate of up to 80%. Several reports indicate a beneficial effect of hemicraniectomy in this situation. However, whether and when decompressive surgery is indicated in these patients is still a matter of debate. Methods—In an open, prospective trial we performed hemicraniectomy in 63 patients with acute complete middle cerebral artery infarction. Initial clinical presentation was assessed by the Scandinavian Stroke Scale (SSS) and the Glasgow Coma Scale (GCS). All survivors were reexamined 3 months after surgical decompression, with the clinical evaluation graded according to the Rankin Scale (RS) and Barthel Index (BI). We analyzed the influence of early decompressive surgery ( 24 hours after first reversible signs of herniation) on mortality, functional outcome, and the length of t...
684 citations
TL;DR: Moderate hypothermia can help to control critically elevated ICP values in severe space-occupying edema after MCA stroke and may improve clinical outcome in these patients.
Abstract: Background and Purpose—Animal research and clinical studies in head trauma patients suggest that moderate hypothermia may improve outcome by attenuating the deleterious metabolic processes in neuronal injury. Clinical studies on moderate hypothermia in the treatment of acute ischemic stroke patients are still lacking. Methods—Moderate hypothermia was induced in 25 patients with severe ischemic stroke in the middle cerebral artery (MCA) territory for therapy of postischemic brain edema. Hypothermia was induced within 14±7 hours after stroke onset and achieved by external cooling with cooling blankets, cold infusions, and cold washing. Patients were kept at 33°C body-core temperature for 48 to 72 hours, and intracranial pressure (ICP), cerebral perfusion pressure, and brain temperature were monitored continuously. Outcome at 4 weeks and 3 months after the stroke was analyzed with the Scandinavian Stroke Scale (SSS) and Barthel index. The side effects of induced moderate hypothermia were analyzed. Results—Fo...
652 citations
TL;DR: This special report provides information about the current management of acute ischemic stroke and provides recommendations for initial care based on currently available data from clinical trials and predicts that in the future, many therapies for stroke will be linked to very early intervention.
Abstract: In 1991, about 500 000 Americans had a stroke (400 000 had an ischemic stroke) and more than 143 000 died. More than 3 000 000 people in the .Ignited States have survived a stroke. In 1994 the annual economic costs of stroke due to health care expenses and lost productivity are estimated to be nearly $20 billion. In spite of these human and financial costs, stroke unfortunately has not received a great deal of attention, and its management has been marred by an element of nihilism. Caplan concludes that past failures to establish effective therapies for stroke are due to problems in clinical trial design, lack of interest in care of stroke, and lack of available technologies to evaluate patients. However, with advances in diagnosis and treatment, stroke can now be managed as the life-threatening emergency that it is. In 1993 the American Heart Association included emergent stroke care as part of its special resuscitation situations for basic and advanced life support. This report builds on that statement. The goal of this special report is to provide information about the current management of acute ischemic stroke. It also provides recommendations for initial care (within 24 hours of stroke) based on currently available data from clinical trials. In the future, many therapies for stroke will be linked to very early (within 6 hours) intervention. No recommendations about rehabilitation or chronic medical or surgical measures to prevent recurrent stroke are made. To prepare this report, the members of the Stroke Council used the rules of evidence for specific treatments that have been used by other panels (Table I). These rules give greater credence to the results of well-designed clinical trials than to anecdotal case reports or case series. The current recommendations will eventually be altered
518 citations
TL;DR: The present study is based on 1073 consecutive stroke patients admitted to an intensive care stroke unit from a well-defined population, yielding a mortality rate of 20%.
Abstract: Analysis of early deaths after stroke is important, since some deaths may be preventable. Previous studies have relied on retrospective and often incomplete clinical data, for comparison with pathological findings. The present study is based on 1073 consecutive stroke patients admitted to an intensive care stroke unit from a well-defined population. There were 212 deaths within the first 30 days, yielding a mortality rate of 20%. Clinical, radiological, and laboratory data were collected prospectively according to a standardized protocol. Autopsies were performed on 90 of the 212 patients, and CT scanning on a further 27. Early mortality after stroke exhibits a bimodal distribution. One peak occurs during the first week, and a second during the second and third weeks. The majority of deaths in the first week are due to transtentorial herniation. Of these, deaths due to hemorrhage usually occur within the first three days, whilst deaths due to infarction peak between the third and sixth day post ictus. After the first week, deaths due to relative immobility (pneumonia, pulmonary embolism and sepsis) predominate, peaking towards the end of the second week. Cardiac deaths occur throughout the first month, and unfortunately account for many deaths in patients with small functional deficits.
470 citations
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TL;DR: Clinical and autopsy studies have reported that 4–35% of cancer patients have metastatic disease in the CNS and approximately 75% of these patients have significant neurological dysfunction as result of CNS metastases.
Abstract: Cancer involving the central nervous system is not an uncommon event. Gliomas, the primary CNS malignant tumors, occur in approximately 10/100,000 persons per year (28, 65, 72, 76). CNS metastases from systemic tumors are almost as common as primary brain tumors. Clinical and autopsy studies have reported that 4–35% of cancer patients have metastatic disease in the CNS (2, 9, 22, 23, 35, 52, 57, 59, 60, 73, 75, 77) and approximately 75% of these patients have significant neurological dysfunction as result of CNS metastases (59, 60).
255 citations
TL;DR: Whether swelling of the brain following massive infarction, often with thrombosis of the internal carotid artery, prompted the following study to determine whether such swelling was a regular occurrence following acuteinfarction of thebrain and, if so, to determine the degree and duration of the swelling.
Abstract: The common concept of encephalomalacia as an atrophic or a nonexpanding lesion stems from the appearance of the lesion which has been present for a considerable time and in which a sharply delimited destructive lesion has produced decreased bulk of the brain, and perhaps even enlargement of the ventricular system toward the lesion. The appearance of the corresponding lesion of short duration has received relatively little comment, although references to its edematous appearance can be found in the old, as well as in the recent, literature. Recent reports concerning swelling of the brain following massive infarction, often with thrombosis of the internal carotid artery, prompted the following study to determine whether such swelling was a regular occurrence following acute infarction of the brain and, if so, to determine the degree and duration of the swelling. Method In an attempt to limit the number of possible variable factors, only those cases
225 citations
TL;DR: An analysis of 245 cases of lesions of the cerebral vessels in which the diagnosis was proved at necropsy is presented in order to determine the significant findings in the history and examination that will aid in the differential diagnosis between cerebral hemorrhage and cerebral thrombosis.
Abstract: The purpose of this study is to present an analysis of 245 cases of lesions of the cerebral vessels in which the diagnosis was proved at necropsy in order to determine the significant findings in the history and examination that will aid in the differential diagnosis between cerebral hemorrhage and cerebral thrombosis. The average physician rarely attempts to differentiate between these types, and the majority of cases of cerebral vascular lesion are indiscriminately labelled "cerebral hemorrhage." This is true despite the difference in the symptoms, the signs and especially the prognosis of these conditions. Also, with the more recent application of surgical treatment 1 toward the relief of cerebral hemorrhage, it is evident that the treatment becomes even more divergent than that previously advocated. The academic exercise of localizing the lesion, which is so intriguing to the neurologist and internist, must be supplemented by an ability to differentiate the types
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TL;DR: The degree of danger of lumbar puncture to the patient with intracranial hypertension is a question that must be adequately answered beforehand and the danger of the alternative diagnostic procedure-such as ventriculography -must then be considered.
Abstract: THIS STUDY REEVALUATES lumbar puncture in diseases causing intracranial hypertension. Although many believe that lumbar puncture is contraindicated in patients with increased intracranial pressure and/or papilledema, the information obtained from the cerebrospinal fluid is often of great importance in diagnosis as well as in management of the patient. The immediate problem facing the physician presented with a patient who has signs and symptoms of intracranial hypertension is to perform specific diagnostic tests. Although diagnosis of intracranial tumor may be evident, many patients have other conditions which are nonneoplastic and cause intracranial hypertension and papilledema.'\" Lumbar puncture is a simple procedure and often aids in differentiation of these diseases. Whenever feasible, lumbar puncture should precede more involved surgical procedures, for instance, ventriculography. After lumbar puncture, the next diagnostic procedure to be performed is more clearly evaluated. However, the degree of danger of lumbar puncture to the patient with intracranial hypertension is a question that must be adequately answered beforehand. The danger of the alternative diagnostic procedure-such as ventriculography -must then be considered. Finally, the choice must depend on the relative dangers of the procedures under consideration and the diagnostic information obtainable from each. Cushing, Dandy, and others\"l0 have stated categorically that lumbar puncture should never be done in the presence of increased intracranial pressure and especially in the presence of papilledema. The major contention of many of these authors is that sudden death caused by herniation of the brain stem and the cerebellar tonsils into the foramen magnum
92 citations