Prediction of malignant middle cerebral artery infarction by magnetic resonance imaging within 6 hours of symptom onset: A prospective multicenter observational study.
OBJECTIVE
Early identification of patients at risk of space-occupying "malignant" middle cerebral artery (MCA) infarction (MMI) is needed to enable timely decision for potentially life-saving treatment such as decompressive hemicraniectomy. We tested the hypothesis that acute stroke magnetic resonance imaging (MRI) predicts MMI within 6 hours of stroke onset.


METHODS
In a prospective, multicenter, observational cohort study patients with acute ischemic stroke and MCA main stem occlusion were studied by MRI including diffusion-weighted imaging (DWI), perfusion imaging (PI), and MR-angiography within 6 hours of symptom onset. Multivariate regression analysis was used to identify clinical and imaging predictors of MMI.


RESULTS
Of 140 patients included, 27 (19.3%) developed MMI. The following parameters were identified as independent predictors of MMI: larger acute DWI lesion volume (per 1 ml odds ratio [OR] 1.04, 95% confidence interval [CI] 1.02-1.06; p < 0.001), combined MCA + internal carotid artery occlusion (5.38, 1.55-18.68; p = 0.008), and severity of neurological deficit on admission assessed by the National Institutes of Health Stroke Scale score (per 1 point 1.16, 1.00-1.35; p = 0.053). The prespecified threshold of a DWI lesion volume >82 ml predicted MMI with high specificity (0.98, 95% CI 0.94-1.00), negative predictive value (0.90, 0.83-0.94), and positive predictive value (0.88, 0.62-0.98), but sensitivity was low (0.52, 0.32-0.71).


CONCLUSIONS
Stroke MRI on admission predicts malignant course in severe MCA stroke with high positive and negative predictive value and may help in guiding treatment decisions, such as decompressive surgery. In a subset of patients with small initial DWI lesion volumes, repeated diagnostic tests are required.
Thomalla
Götz
G
Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany. thomalla@uke.uni-hamburg.de
Hartmann
Frank
F
Juettler
Eric
E
Singer
Oliver C
OC
Lehnhardt
Fritz-Georg
FG
Köhrmann
Martin
M
Kersten
Jan F
JF
Krützelmann
Anna
A
Humpich
Marek C
MC
Sobesky
Jan
J
Gerloff
Christian
C
Villringer
Arno
A
Fiehler
Jens
J
Neumann-Haefelin
Tobias
T
Schellinger
Peter D
PD
Röther
Joachim
J
D000368:Aged; D019540:Area Under Curve; D002340:Carotid Artery Diseases / Q000175:diagnosis; D038524:Diffusion Magnetic Resonance Imaging / Q000379:methods; D005260:Female; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000175:diagnosis* / Q000188:drug therapy / Q000503:physiopathology*; D018810:Magnetic Resonance Angiography / Q000379:methods; D008297:Male; D008875:Middle Aged; D019370:Observation; D055420:Perfusion Imaging; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012044:Regression Analysis; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D015912:Thrombolytic Therapy