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Introduction: Prediction models may guide decisions in the management of patients at risk for malignant middle cerebral artery infarction. The ratio of intracranial cerebrospinal fluid (CSF) volume to intracranial volume (ICV) has been identified as a predictor of malignant edema in ischemic stroke patients treated with intravenous thrombolysis. The added predictive value in stroke patients who received endovascular treatment is unknown. Methods: Patients with available thin-slice non-contrast CT data on admission were selected from the MR CLEAN Registry, which is a prospective national multicenter registry of patients with large vessel occlusion who were treated with endovascular treatment between 2014 and 2017. Baseline characteristics and CT imaging data were collected. The CSF/ICV ratio was automatically measured on baseline thin-slice non-contrast CT. The primary outcome was the formation of malignant edema based on clinical and imaging features on follow-up. A previously built logistic regression model was fitted and included the following baseline predictors: age, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT score, poor collateral filling and reperfusion. An extended model with the CSF/ICV ratio was compared to the previous model by using the likelihood ratio test. Odds ratios (OR), areas under the receiver operating characteristic curve (AUROC) and 95% confidence intervals (CI) were reported. Results: Of the included 683 patients 40 (6%) developed malignant edema. The CSF/ICV ratio of the group with malignant edema (mean 9±5%) was lower than the group without malignant edema (mean 14±6%, P Conclusions: The CSF/ICV ratio improves the prediction of malignant edema formation in ischemic stroke patients who received endovascular treatment.

Background and Purpose— The presence of intracranial artery calcification is associated with an increased risk for stroke. However, calcified atherosclerotic plaques are also known to be less vulnerable to rupture. Given this discrepancy, we investigated whether the vulnerability of intracranial arterial atherosclerosis differed based on the presence or absence of calcification. Methods— We considered consecutive patients with acute stroke in the unilateral middle cerebral artery (MCA) territory. Patients with any stenotic MCAs were included in this study. Symptomatic MCA was defined as the occurrence of infarctions relevant to the stenotic MCA. The presence of calcification in the MCA was evaluated on noncontrast thin-section computed tomography images using a 3dimensional software package. Generalized estimating equations were used to compare the frequency of calcification between symptomatic and asymptomatic stenosis. Results— Of the 1066 MCAs examined in 533 patients, 645 MCAs were stenotic and were included in the study. Among the 645 stenotic MCAs, 406 MCAs (62.9%) were symptomatic. Calcification was observed in 36 MCAs (5.6%). Calcification in the MCA was more frequently observed in the asymptomatic group (7.9% versus 4.2%; P =0.032). On multivariable analysis, the presence of calcification in MCA atherosclerosis was less frequent in the symptomatic group (odds ratio, 0.46; 95% confidence interval, 0.23–0.92; P =0.027). Conclusions— This study showed that calcified atherosclerosis in the MCA was less frequently symptomatic.

Introduction: Malignant middle cerebral artery infarction (MMI) is a severe complication of ischaemic stroke (IS), with a mortality rate up to 80%. Diffusion-weighted imaging (DWI) lesion volume larger than 82 millilitres on cerebral MRI performed within the six first hours is known to be predictive of MMI. These patients, with “malignant profile”, were mostly excluded of endovascular therapy (EVT) randomised trials. The aim of our study was to evaluate whether successful reperfusion after EVT in patients presenting IS with large DWI lesion decreased occurrence of malignant stroke. Methods: We analysed data collected between 2014 and 2018, in a monocentric prospective IS patients registry treated with EVT. Patients were selected if they had a malignant profile and could be eligible to a craniectomy. Thus, selected patients were less than 65-years old, with a severe stroke defined by National Institutes of Health Stroke Scale (NIHSS) score > 15 and with DWI lesion larger than 82ml. We compared patients with successful recanalization (defined by Thrombolysis in Cerebral Ischemia (TICI) 2b or 3) and poor recanalization (TICI 0, 1 or 2A). Primary end point was malignant stroke rate. Secondary end points were craniectomy, haemorrhagic complications, 90-days all-cause mortality rates and 90-days favourable outcome (defined by modified Rankin Scale 0-2). Results: From 2014 to 2018, 66 patients were selected. MMI occurred in 27 patients (42%), and 22 (33%) had effectively craniectomy. Successful recanalization was observed for 46 patients (69.7%). MMI occurrence was significantly lower in the latter patients compared to the poor recanalization group (14/44(31.8%) vs 13/20(65.0%); OR=0.25 (0.08-0.77), p = 0.015). Less craniectomies were performed in the successful recanalization group (12/46 (26.1%) vs 10/20 (50.0%); OR=0.35 (011-1.06), p=0.063).There was no significant difference in symptomatic intracranial haemorrhage rate; in 90-days favourable outcome and all causes mortality rate between the two groups. Conclusion: Successful recanalization performed in IS patients with large DWI lesion decreases the occurrence of malignant strokes and the need for craniectomy procedure. Further data with a larger sample or from randomized studies are needed.

Complete or subtotal infarction in the territory of the middle cerebral artery (MCA) may be complicated by the formation of a space-occupying cerebral edema, which leads to fatal transtentorial herniation within a few days. Even maximum conservative treatment may not change the course of the disease substantially. These so-called malignant MCA infarctions (MMI) are, therefore, life-threatening events and survivors have permanent disability.1

Background and purpose: Decompression craniectomy in acute malignant middle cerebral artery (MCA) ischemic stroke (IS) reduces mortality. However, its role in reducing disability in this group of patients is often questioned in the stroke community since previous studies have employed variable time intervals for surgical decompression as well as criteria for defining severe disability. We evaluated our Asian cohort of acute IS patients for determining the factors associated with favorable functional outcome. Methods: Data for all acute IS patients hospitalized to our tertiary center were entered into a prospectively maintained registry. In this retrospective analysis, data for all malignant MCA IS patients who underwent decompressive hemicraniectomy were extracted. Various demographic, clinical and neuroimaging factors were analyzed for identifying independent predictors of favorable functional outcome at 6 months, which was defined as modified Rankin Scale of 0-3. Results: From January 2005 to December 2014, a total of 75 patients with anterior circulation IS underwent decompressive hemicraniectomy. Median age was 55 years (IQR 44-64) with male preponderance (66%) and median NIH Stroke Scale (NIHSS) score 21 points (IQR 18-24). Considerable proportion of them (60%) received intravenous thrombolysis with tissue plasminogen activator (IV-tPA). Majority (70%) of patients suffered from acute right MCA IS and median time from symptom-onset to surgery was 31 hours (range18-51). Decompressive surgery was performed within 48 hours of symptom-onset in 50 (67%) of the patients. Favorable functional outcome was achieved by 25 (33.3%) patients at 6 months. Right sided stroke (OR 5.333; 95% CI 1.359- 20.927, p=0.016 ) and early decompression surgery (performed within 48 hours from symptom-onset (OR 3.636; 95% CI 1.032- 12.809, p=0.045 ) were independent predictors of favorable functional outcome at 6 months. Conclusion: Early decompression craniectomy, especially in right MCA ischemic stroke is associated with better favorable functional outcome at 6 months.

Introduction and Hypothesis: We evaluated the ability of mixed grading system based on thrombus burden and collateral status assessed by multiphase computed tomography (MPCT) as a predictor of outcome after recanalization therapy. Methods: Eighty-six consecutive patients who underwent MPCT for acute M1 middle cerebral artery occlusion within 6 hours of symptom onset were included. Collateral status to the occluded MCA territory was classified as follows: grade 1, no collaterals; grade 2, slow collaterals with persistence of defect; Grade 3, slow but complete collateral; grade 4, rapid complete collateral. A grade of 1-2 was designated as poor, 3-4 as good collateral flow. Short clot segment was defined as contrast filling defect length on MPCT < 1 centimeter. We divided patients into 3 groups based on collateral status and clot segment length: good collateral with short clot segment (N=29), good collateral with long clot segment (N=34), poor collateral (N=23). Results: Clinical characteristics were not different between 3 groups. Good functional outcome (3 months modified Rankin scale scores ≤ 2) and major neurologic improvement (1 day NIHSS score improved to 0 or 1 point or > 8 points decrease from baseline) were more frequent for short clot segment group and good collateral group than poor collateral group. In logistic regression, after adjusting other variables, good collateral and short clot segment were independent predictors for good functional outcome compared poor collateral (good collateral: OR 12.117, p=0.013; short clot segment with good collateral: OR 44.418, p=0.003). Similarly, the major neurologic improvement was significantly related with good collateral and short segment group. (good collateral: OR 8.903, p=0.41; short clot segment with good collateral: OR 40.430, p=0.006) Conclusions: Short clot segment and good collateral flow assessed with MPCT were useful additional markers predicting clinical outcomes after recanalization therapy.

OBJECTIVES the purpose of this study is to suggest the landmarks for decompressive craniectomy so that surgery can be standardized to achieve adequate decompression in patients with malignant middle cerebral artery infarction. We also analyzed the efficacy and safety of this newly suggested surgical method. METHODS eleven patients (group A) underwent this newly suggested decompressive surgery. The bony landmarks for decompressive craniectomy are described. The area of the bone flap and the brain volume protruding out of the skull surface were measured. The outcomes were evaluated 3 months after the surgery. All the results were compared with that of 13 patients (group B) who were treated with conventional surgical methods. RESULTS the mean area of craniectomy was larger in group A (399.9 ± 50.9 cm) than that in group B (308.5 ± 50.5 cm, P=0.021). The brain volume protruding out of the skull surface was 161.8 ± 101.7 cm in group A and 106.3 ± 55.1 cm in group B, indicating that more decompression was performed in group A (P=0.034). Six (54.5%) of 11 patients in group A had favorable outcomes (modified Rankin Scale 0 to 3) without mortality, whereas 2 (15.4%) of 13 patients in group B had favorable outcomes and 3 (23.1%) patients in group B expired. CONCLUSION decompressive craniectomy using the newly suggested method is feasible and safe, and it may be more beneficial, compared with conventional craniectomy, for patients with malignant middle cerebral artery infarction. Furthermore, it may be easier to perform by training neurosurgeons.

In “Teaching NeuroImages: Multimodality imaging of carotid web,” Renard et al. presented representative images of a carotid web identified in a 52-year-old woman presenting with an ipsilateral acute middle cerebral artery infarction on 3 modalities: Doppler ultrasound, CT, and magnetic resonance angiography. In response, Dr. Sharma discusses the relative strengths and limitations of different modalities in identifying carotid webs. Dr. Sharma notes that in an ongoing study of high-resolution MRI in patients with significant symptomatic carotid stenosis, carotid webs were identified in about 22% of cases, but that the role of such webs in cryptogenic stroke remains unknown. In “Teaching NeuroImages: Multimodality imaging of carotid web,” Renard et al. presented representative images of a carotid web identified in a 52-year-old woman presenting with an ipsilateral acute middle cerebral artery infarction on 3 modalities: Doppler ultrasound, CT, and magnetic resonance angiography.

Purpose of review Space-occupying, malignant hemispheric infarction is one of the most devastating forms of ischemic stroke. Several case series had suggested decompressive hemicraniectomy as a life-saving therapy, but, until recently, there was no proof for this procedure from randomized controlled trials. Recent findings In 2007, results from a pooled analysis of three European trials as well as data from two of these trials were published and yield compelling evidence for the benefit of hemicraniectomy. Summary Data from the published trials leave no doubt about the benefit especially the life-saving character of hemicraniectomy for malignant hemispheric infarction. However, some open questions (i.e. timing of surgery, age limit for hemicraniectomy) remain to be answered in the future.

Four children developed homonymous hemianopia, exotropia with the deviating eye pointing in the direction of the field defect, and a face turn toward the side of the defect following complete third cranial nerve palsy after brain tumor resection, an in utero middle cerebral artery infarction, nonaccidental head trauma, and a hemispherectomy for an intractable seizure disorder. We present evidence that the exotropia and face turn are part of an adaptive mechanism to increase the useful visual field.

The size and severity of perfusion defects in acute cerebral ischaemia on single photon emission tomographic (SPET) images may provide useful information regarding long-term (> 3 month) stroke outcome. A decreased predictive value has been reported with delayed SPET more than 24 h after stroke onset. We examined 20 patients with acute middle cerebral artery (MCA) infarctions using serial 99Tcm-ECD or 99Tcm-HMPAO SPET (SPET 1 one day and SPET 2 three days after stroke onset). Neurological (NIH, SSS) and functional (Barthel, Rankin) scores were calculated simultaneously and 3 months poststroke. The two SPET scans correlated equally well with the severity of functional and neurological deficits evaluated 3 months after stroke onset. In comparison to clinical assessment, the prognostic value of SPET was relatively better on the first day than the third day. Crossed cerebellar diaschisis correlated with early SPET deficits, but did not predict functional outcome. Our results suggest that SPET, either with 99Tcm-ECD or 99Tcm-HMPAO, can be used to predict stroke outcome in acute MCA infarction up to 72 h poststroke without significant interference from luxury perfusion.

To the Editor: In their recent Stroke article, Haring and colleagues1 presented recent data from 31 patients with malignant middle cerebral artery infarction (mMCAI) and 31 control patients with non-mMCAI and concluded that presence of attenuated corticomedullary contrast over the entire MCA territory is the crucial CT criterion for predicting mMCAI with high sensitivity and specificity. I have major concerns about their methods and wish to make the following comments. I fully agree that patients with mMCAI have a high mortality rate2 3 and that decompressive craniectomy may be a life-saving procedure.4 Randomized clinical trials are awaited to confirm the benefit of decompressive craniectomy in reducing mortality and, hopefully, in improving the functional outcome in patients with mMCAI. One major obstacle in the design of the aforementioned clinical …

Reply from the Authors: We appreciate the interest of Drs. Demchuk and Krieger in our article and their comments concerning large MCA territory infarcts. Drs. Demchuk and Krieger address the importance of the involvement of additional arterial in large MCA infarcts for the development of mortal brain edema, as supported by their own findings and the available literature.5,6 Although we agree with their statement, we would nevertheless add some details concerning the difference between the death rate of 78% found by Hacke et al.5 and the death rate of 17% in our study.1 Selection criterion in the …

To the Editor: We read with interest Heinsius et al.'s report on large infarcts in the middle cerebral artery (MCA) territory.1 The focus of their article using the Lausanne Stroke Registry was a comparison of large infarcts with limited infarcts of the MCA territory. This publication identified internal carotid artery occlusion, internal carotid artery dissection, atrial fibrillation, cardiogenic embolism, and severe neurologic deficit as factors more commonly associated with large MCA infarcts than limited MCA infarcts. This study identified younger age, coma on day of admission, and carotid dissection as early clinical predictors of herniation applicable to …