title: Outcomes in severe middle cerebral artery ischemic stroke.
abstract: BACKGROUND
  Severe middle cerebral artery stroke (MCA) is associated with a high rate of morbidity and mortality. We assessed the hypothesis that patient-specific variables may be associated with outcomes. We also sought to describe under-recognized patient-centered outcomes.
  
  
  METHODS
  A consecutive, multi-institution, retrospective cohort of adult patients (≤70 years) was established from 2009 to 2011. We included patients with NIHSS score ≥15 and infarct volume ≥60 mL measured within 48 h of symptom onset. Malignant edema was defined as the development of midline brain shift of ≥5 mm in the first 5 days. Exclusion criterion was enrollment in any experimental trial. A univariate and multivariate logistic regression analysis was performed to model and predict the factors related to outcomes.
  
  
  RESULTS
  46 patients (29 female, 17 male; mean age 57.3 ± 1.5 years) met study criteria. The mortality rate was 28% (n = 13). In a multivariate analysis, only concurrent anterior cerebral artery (ACA) involvement was associated with mortality (OR 9.78, 95% CI 1.15, 82.8, p = 0.04). In the malignant edema subgroup (n = 23, 58%), 4 died (17%), 7 underwent decompressive craniectomy (30%), 7 underwent tracheostomy (30%), and 15 underwent gastrostomy (65%).
  
  
  CONCLUSIONS
  Adverse outcomes after severe stroke are common. Concurrent ACA involvement predicts mortality in severe MCA stroke. It is useful to understand the incidence of life-sustaining procedures, such as tracheostomy and gastrostomy, as well as factors that contribute to their necessity.
authors.affiliation: Harvard Medical School, Boston, MA, USA, walcott.brian@mgh.harvard.edu.
authors.forename: Brian P
authors.initials: BP
authors.lastname: Walcott
authors.forename: Jennifer C
authors.initials: JC
authors.lastname: Miller
authors.forename: Churl-Su
authors.initials: CS
authors.lastname: Kwon
authors.forename: Sameer A
authors.initials: SA
authors.lastname: Sheth
authors.forename: Marc
authors.initials: M
authors.lastname: Hiller
authors.forename: Carolyn A
authors.initials: CA
authors.lastname: Cronin
authors.forename: Lee H
authors.initials: LH
authors.lastname: Schwamm
authors.forename: J Marc
authors.initials: JM
authors.lastname: Simard
authors.forename: Kristopher T
authors.initials: KT
authors.lastname: Kahle
authors.forename: W Taylor
authors.initials: WT
authors.lastname: Kimberly
authors.forename: Kevin N
authors.initials: KN
authors.lastname: Sheth
mesh_terms: D001929:Brain Edema / Q000401:mortality* / Q000601:surgery; D005260:Female; D006801:Humans; D020243:Infarction, Anterior Cerebral Artery / Q000401:mortality* / Q000473:pathology; D020244:Infarction, Middle Cerebral Artery / Q000401:mortality* / Q000473:pathology / Q000628:therapy; D008297:Male; D008875:Middle Aged; D063868:Patient Outcome Assessment; D012720:Severity of Illness Index