Cardiovascular complications in patients with massive middle cerebral artery infarction
Background: Patients with cerebral infarction have a high frequency of underlying cardiac diseases. Acute cardiac events may be observed in patients with massive middle cerebral artery (MCA) infarction due to the severity of neurological insult. We performed this study to determine the frequency of acute cardiac events in this patient population and their impact on outcome and management. Methods: Patients with massive MCA infarction were identified at five university affiliated medical centers using ICD-9 codes or local stroke registries. The medical and neuroimaging records were reviewed at each center by a neurointensivist or stroke neurologist. Only patients who underwent neurological deterioration, defined as a decline in Glasgow Coma Scale (GCS) score of ≥2, attributable to cerebral edema were included. All cardiac events and treatment required during hospitalization were recorded. Outcome was determined at 1 month using Glasgow outcome scores and modified Rankin scale. Results: A total of 54 patients (mean age 62.5±18.0 years; 26 were men) were studied. Underlying cardiac diseases included myocardial infarction (24%), congestive heart failure (20%), and dysrythmias (24%). A total of 16 patients had new cardiac events during hospitalization. These included atrial fibrillation (n=8), atrial flutter (n=1), ventricular fibrillation (n=1), ventricular tachycardia (n=2), myocardial infarction (n=2), and pulmonary edema (n=5); 3 patients had more than one event. Treatment was required for 10 of 16 (62%) events; 3 (19%) were fatal. Overall mortality was higher in patients who developed acute cardiac events during hospitalization (69%) compared to those who did not (40%, p<0.05). The mean Glasgow outcome score was 4.4±1.1 and 3.7±1.1 in patients with or without cardiac events. Conclusions: Our study demonstrates the relatively high frequency of acute cardiac events in patients with massive MCA infarction and their impact on outcome. Patients with massive MCA infarctions should be managed in settings suited for effective monitoring and management of cardiovascular emergencies.