Dhar Rajat, Yuan Kristy, Kulik Tobias, Chen Yasheng, Heitsch Laura, An Hongyu, Ford Andria, Lee Jin-Moo
Department of Neurology, Washington University School of Medicine, 660 S. Euclid Ave, Box 8111, St. Louis, MO, USA.
Department of Radiology, University of North Carolina, Chapel Hill, NC, USA.
Neurocrit Care. 2016 Jun;24(3):420-7. doi: 10.1007/s12028-015-0204-z.
Malignant cerebral edema (CED) complicates at least 20 % of large hemispheric infarcts (LHI) and may result in neurological deterioration or death. Midline shift (MLS) is a standard but crude measure of edema severity. We propose that volumetric analysis of shifts in cerebrospinal fluid (CSF) over time provides a reliable means of quantifying the spectrum of edema severity after LHI.
We identified 38 patients from 2008 to 2014 with NIHSS ≥8, baseline CT <6 h after stroke onset, at least 1 follow-up (FU) CT, and no parenchymal hematoma. The volumes of CSF (sulci, ventricles, and cisterns) ipsilateral (IL) and contralateral (CL) to infarct on baseline and FU CTs were quantified by manually assisted outlining with MIPAV image analysis software, as was infarct volume and MLS on FU CTs. Percentage change in CSF volumes (∆CSF) from baseline to FU scans was correlated with MLS and compared in those with vs. without malignant edema (defined as hemicraniectomy, osmotic therapy, or death/neurological deterioration with MLS ≥5 mm).
11 of 38 subjects (29 %) developed malignant edema. Neither baseline NIHSS nor CSF volume differed between those with and without edema (median NIHSS 18 vs. 13, p = 0.12, CSF volume 102 vs. 124 ml, p = 0.16). Inter-rater reliability for CSF measurements was excellent (intraclass correlation coefficient 0.97). ∆CSF correlated strongly with MLS at peak edema (r = -0.75), even adjusting for infarct volume (p = 0.009). ∆CSF was also greater in those with malignant edema [-55 % (IQR -49 to -62) vs. -36 % (-27 to -45), p = 0.004]. ∆CSF was the greatest within IL sulci [-97 % (-86 to -99) vs. -71 % (-41 to -79), p = 0.002] but also significantly greater within CL sulci in those with malignant edema [-50 % (-29 to -65) vs. -25 % (0 to -31), p = 0.014]. More than half this CSF volume reduction occurred by the time of first FU CT around 24 h after stroke, while MLS rose later.
Volumetric CSF analysis reliably quantifies CED and distinguishes those with malignant edema and MLS from those with a more benign course after LHI. ∆CSF may provide an earlier and more sensitive indicator of edema severity across a broader dynamic range than MLS.
恶性脑水肿（CED）使至少20%的大脑半球大面积梗死（LHI）病情复杂化，并可能导致神经功能恶化或死亡。中线移位（MLS）是衡量水肿严重程度的一种标准但粗略的方法。我们提出，随着时间推移对脑脊液（CSF）移位进行容积分析，可为量化LHI后水肿严重程度的范围提供一种可靠方法。
我们确定了2008年至2014年间38例美国国立卫生研究院卒中量表（NIHSS）评分≥8分、卒中发作后基线CT检查<6小时、至少有1次随访（FU）CT检查且无实质内血肿的患者。通过使用MIPAV图像分析软件进行手动辅助勾勒，对基线和FU CT上梗死灶同侧（IL）和对侧（CL）的脑脊液（脑沟、脑室和脑池）容积进行量化，同时对FU CT上的梗死灶容积和MLS进行量化。从基线扫描到FU扫描脑脊液容积的百分比变化（∆CSF）与MLS进行相关性分析，并在有和没有恶性水肿（定义为去骨瓣减压术、渗透性治疗或MLS≥5mm时死亡/神经功能恶化）的患者中进行比较。
38名受试者中有11名（29%）发生了恶性水肿。有水肿和无水肿患者的基线NIHSS评分和脑脊液容积均无差异（NIHSS评分中位数分别为18分和13分，p = 0.12；脑脊液容积分别为102ml和124ml，p = 0.16）。脑脊液测量的评分者间可靠性极佳（组内相关系数为0.97）。在水肿高峰期，∆CSF与MLS密切相关（r = -0.75），即使对梗死灶容积进行校正后也是如此（p = 0.009）。有恶性水肿患者的∆CSF也更大[-55%（四分位间距-49至-62）对-36%（-27至-45），p = 0.004]。IL脑沟内的∆CSF最大[-97%（-86至-99）对-71%（-41至-79），p = 0.002]，但有恶性水肿患者的CL脑沟内的∆CSF也显著更大[-50%（-29至-65）对-25%（0至-31），p = 0.014]。超过一半的脑脊液容积减少发生在卒中后约24小时首次FU CT检查时，而MLS稍后上升。
脑脊液容积分析可可靠地量化CED，并区分LHI后有恶性水肿和MLS的患者与病程较良性的患者。与MLS相比，∆CSF可能在更广泛的动态范围内提供一个更早且更敏感的水肿严重程度指标。
