Ipsilateral Sinus Hypoplasia and Poor Leptomeningeal Collaterals as Midline Shift Predictors.
BACKGROUND
We explore the role of dural sinus morphology, leptomeningeal collaterals, and clot localization in the development of malignant brain edema in acute ischemic stroke in anterior circulation.


METHODS
This is a single-center retrospective study of consecutive stroke patients with acute occlusion (middle cerebral artery M1 ± intracranial internal carotid artery) treated with intravenous thrombolysis (from November 2009 to November 2014). Admission computed tomography angiography data were evaluated for hypoplasia of dural sinuses, leptomeningeal collaterals, and clot location. Primary outcome was midline shift (<5 mm versus ≥5 mm) on follow-up computed tomography. Secondary outcomes were infarct volume and modified Rankin Scale score of 2 or lower at 90 days. Multivariate logistic regression was used.


RESULTS
Of 86 patients (49 females), 36 (42%) had poor collaterals, 26 (30%) had ipsilesional sinus hypoplasia, and 38 (44%) had proximal clots. A midline shift of 5 mm or higher was diagnosed in 14 patients (16%). Infarct volume was larger in the group with midline shift (median: 318 mL [interquartile range {IQR} = 260-350]) than in the group without midline shift (median: 44 mL [IQR = 28-60]) (P = .007). In multivariate analysis, poor leptomeningeal collaterals (odds ratio [OR] = .11, 95% confidence interval [CI] = .03-.44, P = .002 for good collaterals) and ipsilesional sinus hypoplasia (OR = 6.43, 95% CI = 1.5-46.1, P = .008) were independently associated with a midline shift of 5 mm or higher.


CONCLUSIONS
Patients with poor leptomeningeal collaterals and ipsilesional hypoplasia of dural sinuses are more likely to develop midline shift.
Stroke Research Program, International Clinical Research Centre, St. Anne's University Hospital, Brno, Czech Republic; Department of Neurology, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic. Electronic address: 214565@mail.muni.cz.
Ondrej
O
Volny
Stroke Research Program, International Clinical Research Centre, St. Anne's University Hospital, Brno, Czech Republic; Department of Medical Imaging, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
Petra
P
Cimflova
Stroke Research Program, International Clinical Research Centre, St. Anne's University Hospital, Brno, Czech Republic; Department of Neurology, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
Robert
R
Mikulik
D000368:Aged; D000369:Aged, 80 and over; D001929:Brain Edema / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology; D002545:Brain Ischemia / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000209:etiology* / Q000503:physiopathology; D020785:Central Nervous System Vascular Malformations / Q000150:complications* / Q000000981:diagnostic imaging / Q000503:physiopathology; D002533:Cerebral Angiography / Q000379:methods; D002560:Cerebrovascular Circulation; D003097:Collateral Circulation; D000072226:Computed Tomography Angiography; D003392:Cranial Sinuses / Q000002:abnormalities* / Q000000981:diagnostic imaging / Q000503:physiopathology; D018153:Czech Republic; D005260:Female; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000209:etiology* / Q000503:physiopathology; D020767:Intracranial Thrombosis / Q000150:complications* / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000503:physiopathology; D016015:Logistic Models; D008297:Male; D008578:Meninges / Q000098:blood supply*; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011379:Prognosis; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D015912:Thrombolytic Therapy
Stroke; anterior circulation; dural sinuses; edema; leptomeningeal collaterals; midline shift