Baroreflex sensitivity to predict malignant middle cerebral artery infarction.
OBJECTIVE
Hemicraniectomy has been shown to be an effective treatment of life-threatening edema (LTE) in malignant middle cerebral artery infarction when performed early. Identifying patients who will develop LTE is therefore imperative. We hypothesize that autonomic shift toward sympathetic dominance may relate to LTE formation. We aimed to investigate the predictive potential of baroreflex sensitivity (BRS) as a marker of autonomic balance for calculating the course of large middle cerebral artery infarction.


METHODS
Patients with middle cerebral artery infarction >2/3 of the territory and BRS measurement at admission were analyzed. BRS was estimated using the cross-correlational method. Demographic, clinical, and radiological data including stroke severity, infarct size, and basal ganglia involvement were recorded. Malignant course with LTE was defined as clinical deterioration and midline shift ≥5 mm in the first 48 hours.


RESULTS
Eighteen (62.8%) patients developed LTE. Patients with LTE had lower BRS (2.3 versus 4.4 mm Hg/ms, P=0.007), larger infarcts (214 versus 144 mL, P=0.03), more frequent involvement of the basal ganglia (14 versus 4, P=0.03), and more often underwent thrombolysis combined with endovascular intervention (6 versus 0, P=0.04). In a multivariate model, BRS (OR, 0.36; CI, 0.14-0.93; P=0.03) and basal ganglia involvement (OR, 11.53; CI, 1.15-115.9; P=0.04) were independent predictors for LTE. This model correctly classified 86.2% of the malignant cases.


CONCLUSIONS
Decreased BRS, mirroring sympathetic activation, and basal ganglia involvement were associated with development of malignant course with LTE in large middle cerebral artery infarction. The predictive relevance of our findings needs to be confirmed in further studies.
Department of Neurology, University Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany. marek.sykora@med.uni-heidelberg.de
Marek
M
Sykora
Thorsten
T
Steiner
Andrea
A
Rocco
Peter
P
Turcani
Werner
W
Hacke
Jennifer
J
Diedler
D000293:Adolescent; D000328:Adult; D000368:Aged; D001341:Autonomic Nervous System / Q000502:physiology; D017704:Baroreflex / Q000502:physiology*; D001479:Basal Ganglia / Q000473:pathology; D001794:Blood Pressure / Q000502:physiology; D001929:Brain Edema / Q000209:etiology / Q000503:physiopathology; D023381:Endpoint Determination; D005260:Female; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000503:physiopathology*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D011237:Predictive Value of Tests; D012372:ROC Curve; D020521:Stroke / Q000145:classification / Q000209:etiology / Q000503:physiopathology; D015912:Thrombolytic Therapy; D055815:Young Adult