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We report on a male patient who was investigated for frequent apneic episodes, feeding problems, hypotonia, and left-sided middle cerebral artery infarction in the magnetic resonance imaging at 2 weeks of age. Primary diagnosis of dihydropyrimidinase (DPYS) deficiency was suspected following the analysis of urine for organic acid; DPYS deficiency was strongly suggested by the presence of dihydrouracil, thymine, and uracil. Subsequent genetic evaluation by whole exome sequencing revealed 2 separate mutations, homozygous pathogenic variant c.1010T>C p.Leu337Pro of the DPYS gene, resulting in DPYS deficiency, and homozygous pathogenic variant c.535C>T p.Arg179* of TBX19 gene, which is associated with autosomal recessive congenital isolated adrenocorticotrophic hormone deficiency. Currently, the patient is 2 years old, and he has gross motor retardation and seizure disorder. We suggest that the clinical phenotype of the proband can be a result of mixed expression of both mutations. [ABSTRACT FROM AUTHOR]

Introduction: In malignant cerebral infarction decompressive hemicraniectomy has demonstrated beneficial effects, but the optimum size of hemicraniectomy is still a matter of debate. Some surgeons prefer a large-sized hemicraniectomy with a diameter of more than 14 cm (HC > 14). We investigated whether this approach is associated with reduced mortality and an improved long-term functional outcome compared to a standard hemicraniectomy with a diameter of less than 14 cm (HC ≤ 14). Methods: Patients from the DESTINY (DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY) registry who received hemicraniectomy were dichotomized according to the hemicraniectomy diameter (HC ≤ 14 cm vs. HC > 14 cm). The primary outcome was modified Rankin scale (mRS) score ≤ 4 after 12 months. Secondary outcomes were in-hospital mortality, mRS ≤ 3 and mortality after 12 months, and the rate of hemicraniectomy-related complications. The diameter of the hemicraniectomy was examined as an independent predictor of functional outcome in multivariable analyses. Results: Among 130 patients (32.3% female, mean (SD) age 55 (11) years), the mean hemicraniectomy diameter was 13.6 cm. 42 patients (32.3%) had HC > 14. There were no significant differences in the primary outcome and mortality by size of hemicraniectomy. Rate of complications did not differ (HC ≤ 14 27.6% vs. HC > 14 36.6%, p = 0.302). Age and infarct volume but not hemicraniectomy diameter were associated with outcome in multivariable analyses. Conclusion: In this post-hoc analysis, large hemicraniectomy was not associated with an improved outcome or lower mortality in unselected patients with malignant middle cerebral artery infarction. Randomized trials should further examine whether individual patients could benefit from a large-sized hemicraniectomy. Clinical trial registration information: German Clinical Trials Register (URL: https://www.drks.de; Unique Identifier: DRKS00000624). [ABSTRACT FROM AUTHOR]

Mesenchymal stromal cells (MSCs) are characterized by paracrine and immunomodulatory functions capable of changing the microenvironment of damaged brain tissue toward a more regenerative and less inflammatory milieu. The authors conducted a phase 2, single-center, assessor-blinded randomized controlled trial to investigate the safety and efficacy of intravenous autologous bone marrow-derived MSCs (BMMSCs) in patients with subacute middle cerebral artery (MCA) infarct. Patients aged 30–75 years who had severe ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] score of 10–35) involving the MCA territory were recruited within 2 months of stroke onset. Using permuted block randomization, patients were assigned to receive 2 million BMMSCs per kilogram of body weight (treatment group) or standard medical care (control group). The primary outcomes were the NIHSS, modified Rankin Scale (mRS), Barthel Index (BI) and total infarct volume on brain magnetic resonance imaging (MRI) at 12 months. All outcome assessments were performed by blinded assessors. Per protocol, analyses were performed for between-group comparisons. Seventeen patients were recruited. Nine were assigned to the treatment group, and eight were controls. All patients were severely disabled following their MCA infarct (median mRS = 4.0 [4.0–5.0], BI = 5.0 [5.0–25.0], NIHSS = 16.0 [11.5–21.0]). The baseline infarct volume on the MRI was larger in the treatment group (median, 71.7 [30.5–101.7] mL versus 26.7 [12.9–75.3] mL, P = 0.10). There were no between-group differences in median NIHSS score (7.0 versus 6.0, P = 0.96), mRS (2.0 versus 3.0, P = 0.38) or BI (95.0 versus 67.5, P = 0.33) at 12 months. At 12 months, there was significant improvement in absolute change in median infarct volume, but not in total infarct volume, from baseline in the treatment group (P = 0.027). No treatment-related adverse effects occurred in the BMMSC group. Intravenous infusion of BMMSCs in patients with subacute MCA infarct was safe and well tolerated. Although there was no neurological recovery or functional outcome improvement at 12 months, there was improvement in absolute change in median infarct volume in the treatment group. Larger, well-designed studies are warranted to confirm this and the efficacy of BMMSCs in ischemic stroke. [ABSTRACT FROM AUTHOR]

BACKGROUND: Posterior cerebral artery infarction simulates middle cerebral artery infarction in approximately 17% of patients. The distinction is difficult when the hemiplegia is not associated with symptoms indicating a midbrain lesion. Occlusion of the proximal posterior cerebral artery results in paramedian and anterolateral midbrain infarction. Paramedian infarction results in oculomotor and pupillary disturbances, while anterolateral midbrain infarction results in hemiplegia. Distinguishing between these two infarctions is important given the potential implications for treatment and outcome. CLINICAL CASE: A 67-year-old male patient with the clinical expression of Weber syndrome -which is a crossed or alternating clinical syndrome- as part of a proximal occlusion of the posterior cerebral artery. CONCLUSIONS: It is essential to consider the existence of a posterior cerebral artery infarction in patients with acute hemiparesis-hemiplegia associated with oculomotor abnormalities, drowsiness, and variations in the level of consciousness. [ABSTRACT FROM AUTHOR]

Objective: We aimed to measure the craniectomy area using three-dimensional (3D) anatomic area and volume calculations to demonstrate that it can be an effective criterion for evaluating survival and functional outcomes of patients with malignant middle cerebral artery (MCA) infarction. Material and Methods: The patients diagnosed with malignant ischemic stroke between 2013 and 2018, for which they underwent surgery due to deterioration in their neurological function, were retrospectively reviewed. Radiological images of all patients were evaluated; total brain tissue volume, ischemic brain tissue volume, total calvarial bone area, and decompression bone area were measured using 3D anatomical area and volume calculations. Results: In total, 45 patients (27 males and 18 females) had been treated with decompressive craniectomy (DC). The removed bone area was found to be significantly related to the outcome in patients with MCA infarction. The average decompression bone area and mean bone removal rate for patients who died after DC were 112 ± 27 ² and 20%, whereas these values for surviving patients were 149 ± 29 cm2 and 26% (P = 0.001), respectively. At the 6-month follow-up, the average decompression bone area and mean bone removal rate for patients with severe disability were 126 ± 30 ² and 22.2%, whereas these values for patients without severe disability were 159 cm² ± 26 and 28.4% (P = 0.001), respectively. Conclusion: In patients with malignant MCA infarction, the decompression area is associated with favorable functional outcomes, first, survival and second, 6-month modified Rankin scale score distribution after craniectomy. [ABSTRACT FROM AUTHOR]

Background: A hyper-intense vessel sign on fluid attenuated inversion recovery magnetic resonance imaging (FHV) represents slow blood flow in the cerebral arteries. Purpose: To investigate the relationship between the proximal FHV (pFHV) on initial magnetic resonance imaging (MRI) and the status of the culprit vessel (stenosis, obstruction) in hyper-acute strokes affecting the territory of the middle cerebral artery (MCA). Material and Methods: The study participants consisted of 105 patients presenting to the emergency department (ED) with acute MCA infarction within 4.5 h of onset of symptoms. Patients underwent brain MRI within 45 min of arrival at the ED and angiography within 2 h of arrival. Culprit vessel status and presence of a pFHV on initial MRI were investigated retrospectively. Results: The pFHV was observed in 71/105 (67.6%) patients who presented with a hyper-acute MCA infarction. All patients with hyper-acute MCA infarction caused by internal carotid artery (90.6% caused by M1 occlusion, 92.9% caused by M2 occlusion) showed a pFHV on initial MRI. After logistic regression analysis, the presence of a pFHV showed significant positive correlation with large vessel occlusion (adjusted odds ratio [OR] 34.533, 95% confidence interval [CI] 9.781–121.926; P < 0.001). A pFHV was not associated with severe large vessel stenosis. Conclusion: A pFHV is independently representative of the acute occlusion of intervention-eligible proximal arteries within the territory of the MCA. If a patient with a hyper-acute MCA infarction shows a pFHV, aggressive flow augmentation strategies and early activation of intervention team should be warranted for best patient outcome. [ABSTRACT FROM AUTHOR]

BACKGROUND AND PURPOSE: Iterative model reconstruction (IMR) has shown to improve computed tomography (CT) image quality compared to hybrid iterative reconstruction (HIR). Alberta Stroke Program Early CT Score (ASPECTS) assessment in early stroke is particularly dependent on high‐image quality. Purpose of this study was to investigate the reliability of ASPECTS assessed by humans and software based on HIR and IMR, respectively. METHODS: Forty‐seven consecutive patients with acute anterior circulation large vessel occlusions (LVOs) and successful endovascular thrombectomy were included. ASPECTS was assessed by three neuroradiologists (one attending, two residents) and by automated software in noncontrast axial CT with HIR (iDose4; 5 mm) and IMR (5 and 0.9 mm). Two expert neuroradiologists determined consensus ASPECTS reading using all available image data including MRI. Agreement between four raters (three humans, one software) and consensus were compared using square‐weighted kappa (κ). RESULTS: Human raters achieved moderate to almost perfect agreement (κ =.557‐.845) with consensus reading. The attending showed almost perfect agreement for 5 mm HIR (κHIR =.845), while residents had mostly substantial agreements without clear trends across reconstructions. Software had substantial to almost perfect agreement with consensus, increasing with IMR 5 and 0.9 mm slice thickness (κHIR =.751, κIMR =.777, and κIMR0.9 =.814). Agreements inversely declined for these reconstructions for the attending (κHIR =.845, κIMR =.763, and κIMR0.9 =.681). CONCLUSIONS: Human and software rating showed good reliability of ASPECTS across different CT reconstructions. Human raters performed best with the reconstruction algorithms they had most experience with (HIR for the attending). Automated software benefits from higher resolution with better contrasts in IMR with 0.9 mm slice thickness. [ABSTRACT FROM AUTHOR]

The application of decompressive craniectomy (DC) is thoroughly documented in the management of brain edema, particularly following traumatic brain injury. However, an increasing amount of concern is developing among the universal medical community as regards the application of DC in the treatment of other causes of brain edema, such as subarachnoid hemorrhage, cerebral hemorrhage, sinus thrombosis and encephalitis. Managing stroke continues to remain challenging, and demands the aggressive and intensive consulting of a number of medical specialties. Middle cerebral artery (MCA) infarcts, which consist of 1-10% of all supratentorial infarcts, are often associated with mass effects, and high mortality and morbidity rates. Over the past three decades, a number of neurosurgical medical centers have reported their experience with the application of DC in the treatment of malignant MCA infarction with varying results. In addition, over the past decade, major efforts have been dedicated to multicenter randomized clinical trials. The present study reviews the pertinent literature to outline the use of DC in the management of malignant MCA infarction. The PubMed database was systematically searched for the following terms: 'Malignant cerebral infarction', 'surgery for stroke', 'DC for cerebral infarction', and all their combinations. Case reports were excluded from the review. The articles were categorized into a number of groups; the majority of these were human clinical studies, with a few animal experimental clinical studies. The surgical technique involved was DC, or hemicraniectomy. Other aspects that were included in the selection of articles were methodological characteristics and the number of patients. The multicenter randomized trials were promising. The mortality rate has unanimously decreased. As for the functional outcome, different scales were employed; the Glasgow Outcome Scale Extended was not sufficient; the Modified Rankin Scale and Bathel index, as well as other scales, were applied. Other aspects considered were demographics, statistics and the very interesting radiological ones. There is no doubt that DC decreases mortality rates, as shown in all clinical trials. Functional outcome appears to be the goal standard in modern-era neurosurgery, and quality of life should be further discussed among the medical community and with patient consent. [ABSTRACT FROM AUTHOR]

Background: Pathological yawning is a compulsive, frequent, repetitive yawning triggered by a specific reason besides fatigue or boredom. It may be related to iatrogenic, neurologic, psychiatric, gastrointestinal, or metabolic disorders. Moreover, it could also be seen in the course of an ischemic stroke. Aims: To determine whether pathological yawning is a prognostic marker of middle cerebral artery stroke and evaluate its relationship with the infarct location. Study Design: Cross-sectional study. Methods: We examined 161 patients with acute middle cerebral artery stroke, consecutively admitted to emergency department. Demographic information, stroke risk factors, stroke type according to Trial of Org 10172 in Acute Stroke Treatment classification, blood oxygen saturation, body temperature, blood pressure, heart rate, glucose levels, daytime of stroke onset, National Institutes of Health Stroke Scale score (National Institutes of Health Stroke Scale score, at admission and 24 h), modified Rankin scale (at 3 months), and infarct locations were documented. Pathological yawning was defined as ≥3 yawns/15 min. All patients were observed for 6 hours to detect pathological yawning. National Institutes of Health Stroke Scale score >10 was determined as severe stroke. The correlation between the presence of pathological yawning and stroke severity, infarct location, and the short- and long-term outcomes of the patients were evaluated. Results: Sixty-nine (42.9%) patients had pathological yawning and 112 (69.6%) had cortical infarcts. Insular and opercular infarcts were detected in 65 (40.4%) and 54 (33.5%) patients, respectively. Pathological yawning was more frequently observed in patients with cortical, insular, and opercular infarcts (p<0.05). Pathological yawning was related to higher National Institutes of Health Stroke Scale scores. Patients with severe stroke (National Institutes of Health Stroke Scale score ≥10) presented with more pathological yawning than those with mild to moderate strokes (p<0.05). The clinical outcomes and mortality rates showed no significant relationship with the occurrence of pathological yawning. Conclusion: Pathological yawning in middle cerebral artery stroke was associated with stroke severity, presence of cortical involvement, and insular and opercular infarcts. However, no association was found with long-term outcome and mortality. [ABSTRACT FROM AUTHOR]

Aim: In the patients with malignant middle cerebral artery (MCA) infarctions, the mortality was as high as 70% with conservative treatment. Decompressive craniectomy (DC) was shown to decrease mortality especially in 48 hours. We aimed to investigate both the effect of decompression time and the size of craniectomy on the mortality in this patient group. Material and Methods: 45 adult patients underwent to DC due to malignant MCA infarction were evaluated in this study. The demographic and clinical features were recorded retrospectively. The patients were splitted into three groups: Group 1, DC in the first 24 hours; group 2, in 24-48th hours; group3, in 48-96th hours of the admission. The size of craniectomy was the same as the infarct (standard), or it was two centimeters larger than the size of infarct (larger). Results: Of all patients, 53.3% (n=24) was female; and mean age of the sample was 67.38±4.76. 66.7% (n=30) of the patients died due to malign MCA infarction. The size of craniectomy was larger in 26.7% (n=12), and was standard in the others. Mean time to surgery was 43.07±29.87 hours. Mortality rate was minimum in group 2 (p=0.01). The patients undergoing to larger craniectomy survived longer than the others, but the difference was non-significant (p=0.06). Conclusion: We suggested that not the approach of "surgery as soon as possible" but the surgery between 24-48th hours of the admission would be the optimal approach. This issue is especially important, because earlier or later interventions not only have a less benefit on the outcome but also may lead several unnecessary complications. [ABSTRACT FROM AUTHOR]

Background Malignant infarction of the middle cerebral artery (MCI) is life threatening. It is associated with a mortality as high as 80%, and survival often at the expense of serious disability. Limited success of medical therapies has resulted in decompressive craniectomy (DC) being increasingly used as a treatment for MCI, although evidence of its efficacy is inconclusive. In this study, the efficacy of DC in improving survival, or survival free of severe disability, was assessed. Methods A meta-analysis was performed to approximate the efficacy of DC for treating MCI, considering age and time to surgery. A systematic literature review was conducted on Medline, Embase, and Cochrane library databases to August 1, 2018. Death and severe disability at 3, 6, 12, and 36 months follow-up were assessed, comparing best medical therapy with DC. Results 18 studies were eligible for inclusion and represented 987 individuals who received DC. Nine of these were randomized controlled trials (RCTs) (n = 374 DC). Early DC (<48 hours from onset of stroke) reduced mortality (odds ratio [OR] = 0.18, 95% confidence interval [CI] = 0.11, 0.29; P < 0.00001) but not unfavourable outcome (modified Rankin Scale [mRS] >4) (OR = 1.38, 95% CI = 0.47, 4.11; P = 0.56) at 12 months follow-up. This survival benefit was maintained regardless of age. Conclusion Early DC reduces mortality but does not appear to improve favourable outcomes in patients younger or older than 60 years after MCI. RCTs incorporating quality of life assessments are warranted for MCI patients, in addition to defining the optimal timing and benefits of DC in older patients. Highlights • Decompressive craniectomy within 48 hours of stroke onset reduces mortality in patients with middle cerebral infarction. • Decompressive craniectomy may not reduce poor functional outcomes in survivors. • The survival benefit of decompressive craniectomy is maintained in patients under and over age 60 years. • Further studies are required to establish the role of age as a predictor of poor outcome. [ABSTRACT FROM AUTHOR]

Objective: To outline the association between the National Institutes of Health Stroke Scale (NIHSS) in the acute stage and the Functional Independence Measure (FIM) of motor items several months later. Methods: Seventy-nine infarct cases with middle-cerebral-artery region transferred to long-term rehabilitation facilities were analyzed. Patients were allocated to either the model-development group or the confirmatory group at a 2:1 ratio. Independent variables were based on the NIHSS during the acute care and on demographic factors such as age and modified Rankin Scale (mRS) before onset. Multivariate logistic analyses were performed to predict the independence of each FIM motor item. These models were evaluated in the confirmatory group. Results: Multivariate logistic analyses in the model-development group (n=53) indicated that at least one NIHSS item was statistically significantly associated with the functional independence of a single FIM motor item. Of the NIHSS items, the affected lower extremity item was the most widely associated with 11 of the FIM motor items, except for eating and shower transfer. The affected upper extremity function was the second widely involved factor associated with 7 of the FIM motor items including eating, grooming, bathing, toileting, bed transfer, toilet transfer, and shower transfer. Age and mRS were also statistically significant contributing factors. The obtained predictive models were assessed in the confirmatory group (n=26); these were successful except for the stairs climb item. Conclusion: In combination with age and pre-stroke status, the NIHSS items (especially the affected extremity items) may be useful for the prediction of long-term outcome in terms of activities in daily living. [ABSTRACT FROM AUTHOR]

Abstract: Stroke is a leading cause of death and disability worldwide. Although neuroimaging has been used to examine brain changes related to recovery from stroke, cerebral perfusion changes after rehabilitation have yet to be elucidated. The aim of this study was to evaluate the regional cerebral blood flow (rCBF) changes and their associations with gross motor functions after neurorehabilitation therapy in stroke patients. A total of 7 patients with middle cerebral artery (MCA) infarction received conventional neurorehabilitation therapy twice per day for 4‐6 weeks on admission. Brain perfusion images were acquired before and after the therapy using acetazolamide‐challenged single photon emission computed tomography. A whole‐brain voxel‐wise analysis found increased rCBF in the contralesional prefrontal, precentral, and postcentral cortical areas and decreased rCBF in the ipsilesional insula, posterior orbital gyrus, and central operculum. Moreover, a region of interest analysis revealed that rCBF of the ipsilesional basal ganglia was positively correlated with motor function at baseline and follow‐up, and perfusion changes in the ipsilesional basal ganglia was positively correlated with changes in motor function. These findings suggest that the contralesional prefrontal and sensorimotor cortex may play compensatory roles during the motor recovery and that perfusion in the ipsilesional basal ganglia is closely associated not only with current functional status but also with clinical improvement after neurorehabilitation therapy in patients with MCA infarction. Further studies with larger sample size are warranted to investigate whether assessment of cerebral perfusion may be clinically useful in rehabilitation of stroke patients. [ABSTRACT FROM AUTHOR]

Background: Swollen middle cerebral artery infarction is a life-threatening disease and decompressive craniectomy is improving survival significantly. Despite decompressive surgery, however, many patients are not discharged from the hospital alive. We therefore wanted to search for predictors of early in-hospital death after craniectomy in swollen middle cerebral artery infarction. Methods: All patients operated with decompressive craniectomy due to swollen middle cerebral artery infarction at the Department of Neurosurgery, Oslo University Hospital Rikshospitalet, Oslo, Norway, between May 1998 and October 2010, were included. Binary logistic regression analyses were performed and candidate variables were age, sex, time from stroke onset to decompressive craniectomy, NIHSS on admission, infarction territory, pineal gland displacement, reduction of pineal gland displacement after surgery, and craniectomy size. Results: Fourteen out of 45 patients (31%) died during the primary hospitalization (range, 3-44 days). In the multivariate logistic regression model, middle cerebral artery infarction with additional anterior and/or posterior cerebral artery territory involvement was found as the only significant predictor of early in-hospital death (OR, 12.7; 95% CI, 0.01-0.77; p = 0.029). Conclusions: The present study identified additional territory infarction as a significant predictor of early in-hospital death. The relatively small sample size precludes firm conclusions. [ABSTRACT FROM AUTHOR]

Introduction: Large hemispheric infarctions secondary to occlusion of middle cerebral artery (MCA) are termed "malignant MCA territory infarctions" due to high mortality and morbidity resulting from large infarction volume and herniation. Decompressive craniectomy has been found to improve the outcome in these patients. Objectives: To evaluate the outcome with surgical management in comparison with conservative management in the treatment of malignant MCA territory infarction. Materials and Methods: The patients with malignant MCA territory infarction admitted from August 2009 to January 2014 were included in the study. Clinical, laboratory, and radiological data were collected from hospital records. The outcome was measured at discharge and at last follow-up. Results: Out of 692 patients with MCA territory infarctions 66 had malignant MCA infarctions (9.53%). Among them 31 underwent surgical decompression (age 45.77 ± 15.33 years) and 35 were medically treated (age 56.11 ± 14.99 years). There was no significant difference in the sex ratio, comorbidities, blood sugars, incidence of hemorrhagic transformation, and herniation between the two groups. Admission Glasgow coma scale (GCS) was higher in surgically treated patients. In-hospital mortality among the patients in the surgical group was 19.35% and in the medical group was 17.34%. Thirteen patients were lost for follow-up. In the remaining 53 patients, there was statistically nonsignificant increase in the death and severe disability in medically treated patients (75% and 78.5%, respectively) in comparison with Surgically treated patients (52% and 68%, respectively). Conclusion: Decompressive craniectomy can improve long-term survival and functional outcome in the patients with malignant MCA territory infarctions. [ABSTRACT FROM AUTHOR]

We report a case of a 5-year-old girl who developed left hemiparesis and left facial palsy, 6 days after the initiation of fever and respiratory symptoms due to pneumonia. Chest radiography, conducted upon admission, showed pneumonic infiltration and pleural effusion in the left lung field. Brain magnetic resonance imaging showed acute ischemic infarction in the right middle cerebral artery territory. Brain magnetic resonance angiography and transfemoral cerebral angiography revealed complete occlusion of the right middle cerebral artery. Mycoplasma pneumoniae infection was identified by a 4-fold increase in IgG antibodies to M. pneumoniae between acute and convalescent sera by enzyme-linked immunosorbent assay. Fibrinogen and D-dimer levels were elevated, while laboratory exams in order to identify other predisposing factors of pediatric stroke were all negative. This is the first reported pediatric case in English literature of a M. pneumoniae-associated cerebral infarction involving complete occlusion of the right middle cerebral artery. [ABSTRACT FROM AUTHOR]

Introduction: Hemorrhagic transformation (HT) after acute ischemic stroke (AIS) can be seen at any time following ischemic stroke. Although HT usually occurs as a complication of antithrombotic, anticoagulant, or thrombolytic treatments, it can also occur spontaneously. We aimed to investigate the occurrence of early HT and its relevant risk factors in patients diagnosed with acute middle cerebral artery (MCA) infarction who were not treated with thrombolytic agents. Methods: We recruited 171 patients with acute MCA infarction between January 2011 and July 2012 who were not treated with thrombolytic agents and were suitable to our inclusion criteria. Controlled neuroimaging was performed immediately in patients with deterioration, otherwise on day 7 following stroke. All patients were investigated for AIS risk factors and biochemical analyses were performed. Patients with HT in controlled neuroimaging were grouped both clinically (i.e., symptomatic or asymptomatic) and radiologically, according to "European Cooperative Acute Stroke Radiological Study" (ECASS), and risk factors were examined. Results: We enrolled 171 patients [94 men (55%) and 77 women (45%)] in the study. HT developed in 37 patients (21.63%). In terms of risk factor analysis, the most frequent etiological factor was atherosclerosis in AIS patients (50.3%). National Institutes of Health Stroke Scale scores were significantly higher both in sHT patients according to asHT patients and in HT patients on day 7 compared with their initial scores. Serum lowdensity lipoprotein (LDL-C), triglycerides (TG), and total cholesterol (TC) levels were significantly lower in patients with HT (p<.001). Conclusion: HT is a major complication in AIS that considerably increases the morbidity and mortality. To reduce the occurrence of HT, risk factors for each patient population should be determined. Acute thrombolytic therapy should be used cautiously in high-risk patients, and appropriate alternative therapies should be revised in them. [ABSTRACT FROM AUTHOR]

Large hemispheric infarction (LHI), synonymously called malignant middle cerebral artery (MCA) infarction, is a severe neurological disease with a high mortality and morbidity. Treating physicians as well as relatives are often faced with few and low quality data when attempting to apply optimal treatment to these patients and make decisions. While current stroke treatment guidelines focus on risk factors, prevention and acute management, they include only limited recommendations concerning intensive care management of LHI. The Neurocritical Care Society (NCS) and the German Society for Neurocritical and Emergency Medicine (DGNI) organized an interdisciplinary consensus conference on intensive care management of LHI to meet this demand. European and American experts in neurology, neurocritical care, neurosurgery, neuroradiology and neuroanesthesiology were selected based on their expertise and research focus. Subgroups for several main topics elaborated a number of central clinical questions concerning this topic and evaluated the quality of the currently available data according to the grading of recommendation assessment, development and evaluation (GRADE) guideline system. Subsequently, evidence-based recommendations were compiled after weighing the advantages against the disadvantages of certain management options. This is a commented abridged version of the results of the consensus conference. [ABSTRACT FROM AUTHOR]

Background: Decompressive craniectomy in malignant middle cerebral artery infarction (MMCAI) reduces mortality. Whether speech-dominant side infarction results in less favorable outcome is unclear. This study compared functional outcome, quality of life, and mental health among patients with speech-dominant and non-dominant side infarction. Methods: All patients undergoing decompressive craniectomy for MMCAI were included. Demographics, side of infarction, and speech-dominant hemisphere were recorded. Outcome at follow-up was assessed by global functioning (modified Rankin Scale score), neurological impairment (National Institutes of Health Stroke Scale score), dependency (Barthel Index), anxiety and depression (Hospital Anxiety and Depression scale), and quality of life (Short Form-36). Results: Twenty-nine out of 45 patients (mean age ± SD, 48.1 ± 11.6 years; 58 % male) were alive at follow-up, and 26 were eligible for analysis [follow-up, median (interquartile range): 66 months (32-93)]. The speech-dominant hemisphere was affected in 13 patients. Outcome for patients with speech-dominant and non-dominant side MMCAI was similar regarding neurological impairment (National Institutes of Health Stroke Scale score, mean ± SD: 10.3 ± 7.0 vs. 8.9 ± 2.7, respectively; p = 0.51), global functioning [modified Rankin Scale score, median (IQR): 3.0 [2-4] vs. 4.0 [3-4]; p = 0.34], dependence (Barthel Index, mean ± SD: 16.2 ± 5.0 vs. 13.1 ± 4.8; p = 0.12), and anxiety and depression (Hospital Anxiety and Depression scale, mean ± SD: anxiety, 5.0 ± 4.5 vs. 7.3 ± 5.8; p = 0.30; depression, 5.0 ± 5.2 vs. 5.9 ± 3.9; p = 0.62). The mean quality of life scores (Short Form-36) were not significantly different between the groups. Conclusions: There was no statistical or clinical difference in functional outcome and quality of life in patients with speech-dominant compared to non-dominant side infarction. The side affected should not influence suitability for decompressive craniectomy. [ABSTRACT FROM AUTHOR]

Background: Space-occupying malignant stroke of the middle cerebral artery (MCA) is associated with a high mortality rate of up to 80% under conservative treatment. Although there is convincing evidence that decompression craniectomy can significantly reduce mortality rate and improve neurological outcome in young patients (<60 years), many surgeons are still hesitant to recommend hemicraniectomy for stroke patients. Summary: This review addresses some major issues that appear to be an obstacle to decompression craniectomy, in particular, indicating surgery for patients >60 years or with infarcts of the dominant hemisphere. Furthermore, it emphasizes technical issues such as timing and size of the craniectomy, additional temporal lobectomy, and resection of the temporal muscle, as well as duraplasty and cranioplasty. According to the current literature, decompression craniectomy in older patients can increase survival without most severe disabilities, although, most survivors need assistance in most bodily needs. Involvement of the dominant hemisphere results in aphasia that might partly recover in younger patients, although, considering the neuropsychological deficits caused by infarctions of the nondominant hemisphere, involvement of the dominant hemisphere does not pose as a contraindication for decompression craniectomy. Furthermore, there is convincing evidence that surgery should be performed within 48 h after the onset of symptoms and the size of the craniectomy should be at least 12 cm as a minimum. An additional lobectomy or the resection of the temporal muscle, however, can only be part of individual treatment options. Conceding the weak evidence, it is recommended to close the dura by some form of a duraplasty avoiding cerebrospinal fluid leakages or scarring between the cortex and the scalp leading to injuries during reimplantation of the bone-flap. Complications associated with decompression surgery (hemorrhages, infections, 'sinking skin-flap syndrome', cerebrospinal fluid leakages, hydrocephalus, seizures), with the infarction itself, or with those that occur during the ICU course (cardiac and pulmonary complications) appear acceptable and are mostly treatable, especially considering the fatal course of conservative treatment. Key Message: This review summarizes the current state of the literature about decompression craniectomy of patients with malignant stroke addressing, in particular, critical surgical issues, and thus, help surgeons to make decisions confidently for/or against performing surgery. © 2014 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Malignant middle cerebral artery infarction is a life-threatening sub-type of ischemic stroke that may only be survived at the expense of permanent disability. Decompressive hemicraniectomy is an effective surgical therapy to reduce mortality and improve functional outcome without promoting most severe disability. Evidence derives from three European randomized controlled trials in patients up to 60 years. The recently finished DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arter Y - II trial gives now high-level evidence for the effectiveness of decompressive hemicraniectomy in patients older than 60 years. Nevertheless, pressing issues persist that need to be answered in future clinical trials, e.g. the acceptable degree of disability in survivors of malignant middle cerebral artery infarction, the importance of aphasia, and the best timing for decompressive hemicraniectomy. This review provides an overview of the current diagnosis and treatment of malignant middle cerebral artery infarction with a focus on decompressive hemicraniectomy and outlines future perspectives. [ABSTRACT FROM AUTHOR]

Background: Autologous bone flap reinsertion follows as a second surgical intervention after decompressive craniectomy in patients with malignant middle cerebral artery (MCA) infarction. In addition to surgery-related short-term complications, aseptic resorption of the reimplanted bone flap is a possible long-term problem which has not yet been sufficiently elucidated in these patients. Methods: A total of 109 patients who had undergone decompressive hemicraniectomy for malignant MCA infarction in our institution between September 1994 and December 2011 were included in the study. Clinical and radiological findings were retrieved retrospectively. Aseptic bone necrosis was classified into two categories based on computer tomographic features. Results: A total of 76 patients received their own cryoconserved bone flap (mean age 54.34 ± 10.73 years; 49 males). The overall short-term complication rate was 9.2 %. Bone flap necrosis occurred in 26 patients (22.8 %) with 7 flaps showing signs of surgically relevant type II necrosis after a median time of 14 months (interquartile range [IQR] 4-22). Conclusions: There is a noticeable complication rate in patients undergoing bone flap reinsertion after hemicraniectomy due to malignant MCA infarction. Aseptic bone necrosis represents a significant complication during long-term follow-up. The pathophysiological mechanisms remain unclear and more efforts should be undertaken to understand and possibly prevent this complication in these patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: Prolonged dysphagia after middle cerebral artery (MCA) territory strokes may require percutaneous endoscopic gastrostomy (PEG) tube feeding. OBJECTIVE: We examined the predictors of PEG placement among patients with MCA stroke. It was hypothesized that stroke laterality was a predictor. METHODS: A retrospective cohort study of existing data from Hartford Hospital Stroke Database was done. A total of 157 patients with acute ischemic MCA stroke were included. Patients were divided into the 'PEG' group (n = 24) and 'no PEG' group (n = 133). Existing demographic, clinical and swallowing data were compared between the 2 groups. RESULTS: Demographic data were similar between the groups. The 'PEG' group had a higher admission National Institute of Health Stroke Scale (NIHSS) score, higher proportion of patients who had thrombolytic administration, in- hospital aspiration pneumonia and inability to be assessed on first swallow evaluation. Multivariate analysis revealed that all, except thrombolytic administration may predict PEG placement. CONCLUSION: Admission NIHSS score, in-hospital aspiration pneumonia and inability to undergo first swallow evaluation may predict PEG placement in patients with acute MCA stroke. Stroke laterality was not associated. This knowledge facilitates early identification of patients that may require PEG tube placement for early nutrition provision and discharge to rehabilitation. [ABSTRACT FROM AUTHOR]

Background. Malignant infarction of the middle cerebral artery (MCA) is characterised by a severe course and extremely high mortality rate. Randomised controlled trials (DECIMAL, DESTINY, HAMLET) proved mortality reduction and increase of favourable functional outcome in early decompressive surgery. However, factors predicting functional outcome are not well defined. Objective. To identify prognostic factors on outcome of decompressive surgery in malignant MCA infarction. Methods. It was the retrospective hospital based study, including 18 patients treated with decompressive surgery due to the malignant MCA infarction. There were 10 female and 8 male patients, mean age 62.2±8.2 years. Clinical and laboratory variables were collected from case histories. Information about patient's survival and functional state was collected from telephone conversation with patient's relatives. Functional outcome, assessed by modified Rankin Scale (mRS) on discharge, half-year and 1 year after operation, was divided between favourable (scores 0-4) and unfavourable (5 and death). Results. 1 year survival after decompressive surgery in patients with malignant infarction of the MCA is 50%. According to 1 year mRS evaluation the mean time from stroke onset to malignant manifestation was 63.6 h in favourable and 24.9 h in unfavourable group (p=0.001); post-operative (24 h) Glasgow Coma Scale (GCS) score was higher in favourable group (p=0.041). Patients with malignant manifestation after 48 hours from stroke onset had statistically longer 1 year survival and better functional outcome (p<0.003). A significant correlation was noted between preoperative fibrinogen concentration and mRS on discharge (r=-0.522,p=0.031). Conclusions. Slower malignant manifestation (>48 hours), higher post-operative GCS score on 24th hour and higher fibrinogen concentration at malignant manifestation suggest the better outcome in patients after decompressive surgery for malignant infarction of MCA. [ABSTRACT FROM AUTHOR]

Background: Decompressive hemicraniectomy reduces mortality in patients with space-occupying MCA infarction. Quality of life in surviving patients is discussed controversially. We assessed attitudes of neurologists and nurses providing care to this patient group towards decompressive hemicraniectomy. Methods: A postal questionnaire on attitudes and opinions on prognosis and quality of life after decompressive hemicraniectomy was returned by 280 neurologists and 166 nurses from tertiary care centers throughout Germany. Results: In both groups of professionals, estimates of the probability of survival after decompressive hemicraniectomy and the resulting degree of disability were consistent with results of clinical outcomes studies. Only 9% of the nurses and 33% of the physicians assumed that the majority of survivors achieve an acceptable quality of life; 58% of physicians and 32% of nurses would suggest decompressive hemicraniectomy to their nearest relative. Under the assumption of an uncertain outcome, 61% of physicians and 22% of nurses would agree to decompressive hemicraniectomy. In both professional groups, agreement for surgery increases when scenarios with a more favorable outcome were proposed [modified Rankin Scale (mRS) 2-5)]. If an outcome of 4 on the mRS is proposed, indicating moderately severe disability, only a minority favored decompressive hemicraniectomy (25% of doctors and 8% of nurses). Conclusions: Despite a realistic assessment of prognosis after decompressive hemicraniectomy, a majority of respondents estimated the quality of life of survivors as unsatisfactory. Nurses had a more pessimistic attitude towards decompressive hemicraniectomy. The majority of respondents consider an outcome of 4 on the mRS as unacceptable. [ABSTRACT FROM AUTHOR]

Terson syndrome is the occurrence of intraocular hemorrhage secondary to intracranial hemorrhage. Here we describe an infant with retinal hemorrhage attributed to a middle cerebral artery infarction and provide a review of previously reported cases of neonatal Terson syndrome in the literature. These cases highlight the need for early ophthalmologic evaluation in infants with significant intracranial hemorrhage to screen for Terson syndrome. [ABSTRACT FROM AUTHOR]

Background: A striatocapsular infarct (SCI) is a subcortical infarct in the territory of the lenticulostriate arteries, most likely due to transient occlusion of the main stem of the middle cerebral artery (MCA). Presence of the hyperdense middle cerebral artery sign (HMCAS) is a reliable marker of occlusion of the MCA. We hypothesized that SCIs are related to HMCAS at baseline, which subsequently disappears (HMCAS-D) on follow-up CT in stroke patients treated with intravenous rtPA. Methods: Baseline and 24-hour follow-up CTs were evaluated for HMCAS in acute ischemic stroke patients treated with intravenous rtPA and follow-up scans were also reviewed for the presence of isolated cortical (CIn), SCI, cortical and striatocapsular (CI-SCI) or lacunar infarct. We determined the incidence of SCI and the association between SCI and HMCAS on baseline and follow-up CT. Results: Of the 247 patients, 43 had an SCI (17.4%; 95% CI: 13.1–22.5). The presence of HMCAS at baseline was related to the occurrence of infarction with involvement of the striatocapsular region (SCI or CI-SCI) on follow-up CT (OR: 11.6; 95% CI: 5.9–22.8). HMCAS-D on follow-up scans was significantly related to SCI on follow-up CT compared to CI-SCI (OR: 4.9; 95% CI: 3.7–6.1). Conclusions: Occurrence of SCI and CI-SCI is associated with the presence of HMCAS on CT before thrombolysis, whereas HMCAS-D on follow-up CT is strongly related to the occurrence of SCI. Our findings support the causative role of transient occlusion of the MCA main stem in the pathogenesis of SCI. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Early prediction of outcome after decompressive surgery for space-occupying middle cerebral artery (MCA) infarction is needed to guide further therapy. Here we applied spectral EEG analysis to determine the prognosis early after hemicraniectomy, while the patient is still treated in the intensive care unit. Methods: Continuous EEG monitoring following hemicraniectomy was performed in 10 patients with space-occupying MCA infarction. All patients were analgosedated and mechanically ventilated. The first 6 h of monitoring after surgery were evaluated by spectral analysis. Outcome measures included Glasgow Outcome Scale (GOS), Level of Consciousness Scale (LOC) and National Institute of Health Stroke Scale (NIHSS) at discharge. Outcome after 3 months was assessed by modified Rankin Scale. Results: Six patients displayed a peak at 5–10 Hz in the EEG power spectrum. All these patients had a GOS score of 3 and an LOC score ≥7 at discharge. In contrast, the 4 patients without faster EEG activity had a GOS of 2 and LOC ≤6. GOS (r = 1, p < 0.001), LOC (r = 0.89, p = 0.001) and NIHSS (r = –0.8; p < 0.01) at discharge significantly correlated with the presence of 5- to 10-Hz activity, but not with age, time to hemicraniectomy, duration of hospital stay or baseline NIHSS scores. Outcome after 3 months significantly correlated with age (r = 0.67; p < 0.05) and the presence of faster EEG activity (r = –0.76; p < 0.01). Conclusions: Spectral analysis in the subacute phase following hemicraniectomy may represent a parameter to predict early regain of consciousness and thus the capability and potential for further rehabilitation and favorable outcome. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Abstract: Background: An acute perfusion–diffusion mismatch is known to be the strongest predictor of infarct growth. However, the differential patterns of clinical and radiological evolution according to stroke mechanism are unknown. Methods: The study retrospectively reviewed consecutive patients who had 1) acute middle cerebral artery (MCA) territory infarction, 2) diffusion- and perfusion-weighted imaging (DWI and PWI) and MR angiography within 24 h of onset, and follow-up DWI 5 days later, 3) stenosis (≥50%) or occlusion of MCA on baseline imaging, 4) a baseline PWI–DWI mismatch >20%, and 5) either atherosclerotic MCA disease (MCAD) or cardioembolism (CE). National Institutes of Health Stroke Scale (NIHSS) scores and infarct volume at baseline and 5 days were obtained. Results: Of 90 patients, 52 had MCAD and 38 had CE. At baseline, CE group had more severe stroke (median NIHSS, 9 vs. 5; p =0.001) and larger infarct volume (median 8.32 cc vs. 3.0 cc; p =0.034) than MCAD group. During the 1-week period, CE group had larger infarct volume growth (median 12.85 cc vs. 3.02 cc; p =0.004) than MCAD group, although clinical improvement based on NIHSS (baseline minus 5-day) tended to be higher for CE than MCAD group (median 3 vs. 1; p =0.08). The correlation between infarct volume and NIHSS score was stronger in CE (r =0.841) compared to MCAD (r =0.582) group at 5-day. Conclusions: Substantial differences in the clinico-radiological evolution of acute ischemic stroke exist according to stroke mechanism. These data emphasize the importance of the stroke mechanism in the design of MRI-based acute stroke trials. [Copyright &y& Elsevier]

Objectives – To study the long-term outcome in patients with malignant middle cerebral artery (MCA) infarction treated with decompressive craniectomy. The outcome is described in terms of survival, impairment, disabilities and life satisfaction. Materials and methods – Patients were examined at a minimum of 1 year (mean 2.9, range 1–6) after the surgery and classified according to the Glasgow Outcome Scale (GOS), the National Institutes of Health Stroke scale (NIHSS), the Barthel Index (BI), the short-form health survey (SF-36) and the life satisfaction checklist (LiSat-11). Results – Eighteen patients were included. The long-term survival was 78%. The mean NIHSS score was 13.8 (range 6–20). No patient was left in a vegetative state. The mean BI was 63.9 (5-100). The SF-36 scores showed that the patients’ view of their health was significantly lower in most items compared with that of a reference group. According to the LiSat checklist, 83% found their life satisfying/rather satisfying and 17% found their life rather dissatisfying/dissatisfying. Conclusion – We conclude that the patients remained in an impaired neurological condition, but had fairly good insight into their limitations. Although their life satisfaction was lower compared with that of the controls, the majority felt that life in general could still be satisfying. [ABSTRACT FROM AUTHOR]

Background: We performed a systematic review to identify predictors of the development of life-threatening brain edema in patients with middle cerebral artery infarction. Methods: We searched Medline from January 1966 and Embase from January 1974 to April 2007 for cohort and case-control studies on predictors of life-threatening edema in patients with middle cerebral artery infarction. Crude data were used to calculate risk ratios, odds ratios, or weighted mean differences. Results: Infarct size was the major determinant of the development of life-threatening edema. Other associated determinants were early mass effect, involvement of other vascular territories, higher body temperature, internal carotid artery occlusion, and need for mechanical ventilation. However, predictive values were only moderate. Conclusions: The size of the ischemic area is the major determinant. Single predictors lack sufficient predictive value to select candidates for surgical decompression before the onset of clinical signs of herniation. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Abstract: We report a complication of decompressive craniectomy in the treatment of aneurismal subarachnoid hemorrhage (SAH) and accompanying middle cerebral artery (MCA) infarction. A 56-year-old man presented with subarachnoid hemorrhage and right sylvian hematoma. He was diagnosed with high-grade SAH and medical therapy was employed. He showed rapid clinical deterioration on day 9 of his admission. Computed tomographic scans showed right MCA infarction and prominent midline shift. Because of the patient''s rapidly worsening condition, further evaluation to find origin of SAH could not be obtained, and decompressive right hemicraniectomy was performed. During sylvian dissection, right middle cerebral and posterior communicant artery aneurysms were detected and clipped. One week after operation, a contralateral frontoparietal subdural effusion and left to right midline shift was detected and drained through a burr-hole. Through successive percutaneous aspirations, effusion recurred and complete resolution was achieved after cranioplasty and subduroperitoneal shunt procedures. Decompressive craniectomy is generally accepted as a technically simple operation with a low incidence of complications. In the light of this current case, we hypothesize that a large craniectomy may facilitate the accumulation of recurrent effusion on contralateral side creating a resistance gradient between two hemispheres. This point may be especially true for subarachnoid hemorrhage cases requiring aneurysm surgery. We conclusively suggest that subdural effusions may be resistant to simple drainage techniques if a large contralateral craniectomy does exist, and early cranioplasty may be required for treatment in addition to drainage procedures. [Copyright &y& Elsevier]

Hyperglycemia aggravates brain injury induced by focal ischemia-reperfusion. The mitogen-activated protein kinase (MAPK) members extracellular-signal regulated kinase (Erk) and c-Jun N-terminal kinase (JNK) have been proposed as mediators of ischemic brain injury, and Erk is strongly activated by combined hyperglycemia and transient global ischemia. It is unclear whether similar MAPK activation appears in focal brain ischemia with concomitant hyperglycemia. Hyperglycemia was induced in rats by an intraperitoneal bolus of glucose (2 g kg−1). The rats were then subjected to 90 min of transient middle cerebral artery occlusion (MCAO). Erk and JNK activation were investigated with immunofluorescence and Western blot along with infarct size measurement based on tetrazolium staining and neurological score. The hyperglycemic rats showed increased tissue damage and impaired neurological performance after 1 day compared with controls. The hyperglycemia was generally moderate (< 15 mM). Erk activation was increased after 30 min of reperfusion in the ischemic cortex of the hyperglycemic rats, while JNK activation was present on the contralateral side. Phospho-Erk immunofluorescence revealed marked neuronal activation of Erk in the ischemic cortex of hyperglycemic rats compared with controls. Besides confirming the detrimental effects of hyperglycemia on focal ischemia-reperfusion, this study shows that hyperglycemia strongly activates the pathogenic mediator Erk in the ischemic brain in the early phase of reperfusion. JNK activation at this stage is present in the nonischemic hemisphere. The functional relevance of these findings needs further investigation. Eur J Clin Invest 2005; 35 (7): 457–463 [ABSTRACT FROM AUTHOR]

Background. Although surgical decompression of large hemispheric infarction is often a life-saving procedure, many patients remain functionally dependent. The aims of this study were to identify specific factors that can be used to predict functional outcome, thus establish predictive criteria to reduce poor surgical results. Method. In this non-randomized prospective study, we performed decompressive craniectomy in 32 patients (age range, 27 to 77 years) with large hemispheric infarctions. Based on their modified Rankin Score (RS), which was calculated 6 months postoperatively, patients were divided into two functional groups: good (RS 0–3, n = 7) and poor (RS 4–6, n = 25). The characteristics of the two groups were compared using statistical analysis. Findings. One-month mortality was 31%. However, most of the surviving patients were severely disabled (RS 4 or 5), and 6-month total mortality reached 50%. Increased age (≥60 years) (P = 0.010), preoperative midline shift greater than 10 mm (P = 0.008), low preoperative Glasgow Coma Score (GCS≤7) (P = 0.002), presence of preoperative anisocoria (P = 0.032), early (within the first three days of the stroke) clinical deterioration (P = 0.032), and an internal carotid artery infarct (P = 0.069) were the positive predictors of a poor outcome. Interpretation. We view decompressive craniectomy for space-occupying large hemispheric infarction as a life-sparing procedure that sometimes yields good functional outcomes. A dominant hemispheric infarction should not be an exclusion criterion when deciding to perform this operation. Early operation and careful patient selection based on the above-mentioned factors may improve the functional outcome of surgical management for large hemispheric infarction. [ABSTRACT FROM AUTHOR]

Background: 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. Methods: 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. Results: 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 120 (OR 6.6; 95% CI 2.3-19.3), and infarction beyond the MCA territory (OR 4.9; 95% CI 1.6-15.0). Conclusions: 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. [ABSTRACT FROM AUTHOR]

• More NETs were found in thrombus from patients suffering from stroke associated with hyperglycemia. • Hyperglycemia primes NETosis in peri-infarction brain tissue of pMCAO mice. • Neutrophil extracellular traps exacerbate ischemic brain damage in pMCAO mice. • Inhibition of NETosis could partly eliminate the harmful effect of hyperglycemia on ischemic brain injury. Hyperglycemia is common and associated with poor outcome in acute ischemic stroke patients. Neutrophil extracellular traps (NETs) are increased either in diabetes or ischemic stroke. We aimed to determine the role of NETs in acute ischemic stroke with hyperglycemia as it has not been clarified. NETs were observed in thrombi retrieved from ischemic stroke patients undergoing endovascular treatment. Citrullinated histone H3 was much more abundant in thrombi from hyperglycemic patients than in those from normoglycemic patients. BKS-db/db and wild-type mice injected with glucose were used to establish the permanent middle cerebral artery occlusion model with hyperglycemia. NETs induced by hyperglycemia were detected in the peri-ischemic brain tissue. Inhibition of NET formation decreased the infarction volume both in db/db and wild-type mice with hyperglycemia. Neurological function deficits were alleviated by blocking NET formation. These findings suggest that NETs increased by hyperglycemia play a role in exacerbation of ischemic brain damage. [ABSTRACT FROM AUTHOR]

Background and purpose: Data from randomly controlled trials have indicated that a decompressive hemicraniectomy is more clinically effective than medical treatment in the management of space‐occupying brain oedema post middle cerebral artery infarction. This economic evaluation compares the impact of the two options in the UK. No recent study has conducted an economic evaluation on this topic for the UK. Method: A cost–utility analysis over a time period of 1 year was used, measuring benefits in terms of quality adjusted life years (QALYs) and costs in pound sterling, discounted to 2015 prices. The evaluation was from the perspective of the National Health Service, the largest healthcare provider in the UK. Results: The cost–utility analysis found an incremental cost effectiveness of £116 595.10 for every QALY gained if patients were offered a decompressive hemicraniectomy compared to the best medical treatment. Discussion: This is above the National Institute for Health and Care Excellence (NICE) 'cost‐effective' threshold of £20 000–£30 000 per QALY, but lower mortality rates associated with the surgical alternative raises ethical considerations for healthcare providers in the UK. [ABSTRACT FROM AUTHOR]

Objective Decompressive craniectomy (DC) is an established part of the management of patients with increased intracranial pressure due to malignant middle cerebral artery (MCA) infarction or traumatic brain injury (TBI). The aim of this study was to determine prognostic radiologic parameters regarding the functional outcome of patients with increased intracranial pressure (ICP) undergoing DC. Special focus was put on the potential differences between malignant MCA infarction and TBI. Methods A total of 113 patients were analyzed for their clinical course where preoperative and postoperative radiologic features in computed tomography (CT) scans were correlated to the clinical outcome assessed by the Glasgow Outcome Scale. The difference between presurgical and postsurgical midline shift (ΔMLS) and the ratio between the diameter of the affected and contralateral hemisphere (HDratio) in presurgical and postsurgical CT scans were calculated . Results ΔMLS (MCA infarction group) and postsurgical HDratio (TBI group) were found to be highly correlating with the clinical outcome on Spearman-correlation testing and underwent further analysis using a binary logistic regression model to evaluate their prognostic value on the outcome, which showed the predictive power of ΔMLS in malignant MCA infarction patients (odds ratio [OR] 0.715; confidence interval [CI] 0.551–0.865). Postsurgical HDratio correlated significantly (OR 0.620; CI 0.384–0.901) with the outcome in the TBI group. Conclusion ΔMLS is an objectifiable parameter, predicting outcome in malignant MCA infarction. In contrast, ΔMLS was of no predictive value in TBI patients. Here postsurgical HDratio serves as a strong predictor of clinical outcome. We recommend applying postsurgical HDratio to TBI patients in order to estimate their clinical outcome and adjust treatment. [ABSTRACT FROM AUTHOR]