(Stroke. 1999;30:287-292.)
© 1999 American Heart Association, Inc.
Original Contributions |
Early Clinical and Radiological Predictors of Fatal Brain Swelling in Ischemic Stroke
From the Department of Neurology, Stroke Program, University of Texas at Houston (D.W.K., A.M.D.); Department of Neurology, University of Pennsylvania, Philadelphia (S.E.K); Medical University of Luebeck, Luebeck, Germany (M.J.); and Janssen Research Foundation, Washington Crossing, NJ (L.H.).
Correspondence to Derk W. Krieger, MD, Cerebrovascular Center, Department of Neurology S91, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195-5001. E-mail KRIEGED{at}cesmtp.ccf.org
Background and Purpose—Early identification of acute stroke patients at risk of fatal brain swelling is necessary to facilitate implementation of aggressive therapies. Initial clinical, laboratory, and CT characteristics that may be used as selection criteria were analyzed to determine predictors of herniation and neurological death.
Methods—Data from the placebo arm of the Lubeluzole-International-9 trial were reviewed to identify patients with fatal brain edema. Early clinical, laboratory, and radiographic parameters were evaluated in a case-control design. Initial CT scans were analyzed for early ischemic abnormalities by 2 blinded investigators.
Results—Twenty-three patients died from brain swelling, with
minimum baseline National Institutes of Health Stroke Scale (NIHSS)
scores of 20 (n=12; mean, 23.2±1.8) with left and 15 (n=11; mean,
17.6±2.2) with right hemispheric infarctions
(P=0.0001). A sample of 112 subjects with comparably
severe strokes, but who did not die from brain swelling, was selected
from the remaining population according to the same NIHSS scores. Among
clinical and laboratory characteristics, nausea/vomiting within 24
hours after onset (odds ratio [OR], 5.1; 95% CI, 1.7 to 15.3;
P=0.003) and 12-hour systolic blood pressure
180 mm Hg (OR, 4.2; 95% CI, 1.4 to 12.9;
P=0.01) were independently associated with fatal brain
swelling. Among radiographic factors, only hypodensity of
>50% of the middle cerebral artery territory on initial CT scan was
an independent predictor (OR, 6.1; 95% CI, 2.3 to 16.6;
P=0.0004).
Conclusions—Patients with baseline NIHSS score 20 with left or
15 with right hemispheric infarctions within 6 hours of symptom onset
who also have nausea/vomiting or >50% middle cerebral artery
territory hypodensity are at high risk for developing fatal brain
swelling.
Key Words: brain edema • risk assessment • stroke, acute • stroke mortality
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