title: Prediction of malignant middle cerebral artery infarction by magnetic resonance imaging within 6 hours of symptom onset: A prospective multicenter observational study.
abstract: 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.
authors.affiliation: Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany. thomalla@uke.uni-hamburg.de
authors.forename: Götz
authors.initials: G
authors.lastname: Thomalla
authors.forename: Frank
authors.initials: F
authors.lastname: Hartmann
authors.forename: Eric
authors.initials: E
authors.lastname: Juettler
authors.forename: Oliver C
authors.initials: OC
authors.lastname: Singer
authors.forename: Fritz-Georg
authors.initials: FG
authors.lastname: Lehnhardt
authors.forename: Martin
authors.initials: M
authors.lastname: Köhrmann
authors.forename: Jan F
authors.initials: JF
authors.lastname: Kersten
authors.forename: Anna
authors.initials: A
authors.lastname: Krützelmann
authors.forename: Marek C
authors.initials: MC
authors.lastname: Humpich
authors.forename: Jan
authors.initials: J
authors.lastname: Sobesky
authors.forename: Christian
authors.initials: C
authors.lastname: Gerloff
authors.forename: Arno
authors.initials: A
authors.lastname: Villringer
authors.forename: Jens
authors.initials: J
authors.lastname: Fiehler
authors.forename: Tobias
authors.initials: T
authors.lastname: Neumann-Haefelin
authors.forename: Peter D
authors.initials: PD
authors.lastname: Schellinger
authors.forename: Joachim
authors.initials: J
authors.lastname: Röther
mesh_terms: 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