Barber Philip A, Demchuk Andrew M, Zhang Jinjin, Kasner Scott E, Hill Michael D, Berrouschot Jorg, Schmutzhard Erich, Harms Lutz, Verro Piero, Krieger Derk
Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.
Cerebrovasc Dis. 2003;16(3):230-5. doi: 10.1159/000071121.
Large middle cerebral artery (MCA) ischaemic stroke when associated with extensive mass effect can result in brain herniation and neurological death. As yet there are few guidelines to aid the selection of patients for aggressive interventional therapies, such as decompression hemicraniectomy and/or hypothermia.
We studied a cohort of patients from seven centres with large MCA infarction requiring neurocritical care. The purpose of this analysis was to assess the use of early radiological signs on follow-up computed tomographic (CT) signs performed within 48 h of stroke onset for predicting mortality at 30 days. The CT parameters assessed included horizontal displacement of the septum pellucidum, pineal shift, complete or partial infarction of the temporal lobe, involvement of additional vascular territories, and the presence of hydrocephalus. The primary outcome measure was in-hospital death within 30 days.
One hundred and thirty-five patients who had follow-up CT scans within 48 h were identified from a total of 201 patients with large MCA infarction that received conventional medical therapy alone. The median age was 68 (range 29-99), 56% were female, and the median NIHSS category was 26-30 at 48 h. Among CT variables in univariable analysis, anteroseptal shift >/=5 mm, pineal shift >/=2 mm, complete temporal lobe infarction, involvement beyond the MCA territory, and moderate or severe hydrocephalus were equally predictive of death. Multivariable analysis adjusting for time to CT scan revealed the following predictors of fatal outcome: anteroseptal shift >/=5 mm (OR 10.9; 95% CI 3.2-37.6), NIHSS within 48 h >20 (OR 6.6; 95% CI 2.3-19.3), and infarction beyond the MCA territory (OR 4.9; 95% CI 1.6-15.0).
We identified the role of early CT signs in predicting death following massive MCA infarction. The CT parameters anteroseptal shift (>5 versus </=5 mm), pineal shift >/=2 mm, hydrocephalus, temporal lobe infarction, and other vascular territory infarction if present were predictive of fatal outcome. These CT parameters require prospective validation before they should be considered reliable markers for decision-making.
大脑中动脉（MCA）大面积缺血性卒中若伴有广泛的占位效应，可导致脑疝形成及神经功能死亡。目前，几乎没有指南可用于指导选择适合进行积极介入治疗（如减压性颅骨切除术和/或低温治疗）的患者。
我们研究了来自七个中心的一组患有大面积MCA梗死且需要神经重症监护的患者。本分析的目的是评估在卒中发作后48小时内进行的随访计算机断层扫描（CT）上的早期影像学征象，以预测30天的死亡率。评估的CT参数包括透明隔的水平移位、松果体移位、颞叶的完全或部分梗死、其他血管区域的累及以及脑积水的存在。主要结局指标是30天内的院内死亡。
在总共201例仅接受传统药物治疗的大面积MCA梗死患者中，确定了135例在48小时内进行了随访CT扫描的患者。中位年龄为68岁（范围29 - 99岁），56%为女性，48小时时美国国立卫生研究院卒中量表（NIHSS）中位数为26 - 30分。在单变量分析的CT变量中，前中隔移位≥5 mm、松果体移位≥2 mm、颞叶完全梗死、超出MCA区域的累及以及中度或重度脑积水对死亡的预测作用相同。对CT扫描时间进行校正的多变量分析显示，以下因素是致命结局的预测因素：前中隔移位≥5 mm（比值比[OR] 10.9；95%置信区间[CI] 3.2 - 37.6）、48小时内NIHSS＞20（OR 6.6；95% CI 2.3 - 19.3）以及梗死超出MCA区域（OR 4.9；95% CI 1.6 - 15.0）。
我们确定了早期CT征象在预测大面积MCA梗死患者死亡中的作用。CT参数前中隔移位（＞5 mm与≤5 mm）、松果体移位≥2 mm、脑积水、颞叶梗死以及其他血管区域梗死（若存在）可预测致命结局。在这些CT参数被视为可靠的决策标志物之前，需要进行前瞻性验证。
