Recent studies have shown that follow-up head CT is a strong predictor of functional outcomes in patients with middle cerebral artery stroke and mechanical thrombectomy. We sought to determine whether total and/or regional follow-up Alberta Stroke Program Early CT Score (ASPECTS
Abstract Historically, investigators have not differentiated between patients with and without hemorrhagic transformation ( HT ) in large core ischemic stroke at risk for life-threatening mass effect ( LTME ) from cerebral edema. Our objective was to determine whether LTME occurs faster in those with HT compared to those without. We conducted a two-center retrospective study of patients with ≥ 1/2 MCA territory infarct between 2006 and 2021. We tested the association of time-to-LTME and HT subtype (parenchymal, petechial) using Cox regression, controlling for age, mean arterial pressure, glucose, tissue plasminogen activator, mechanical thrombectomy, National Institute of Health Stroke Scale, antiplatelets, anticoagulation, temperature, and stroke side. Secondary and exploratory outcomes included mass effect-related death, all-cause death, disposition, and decompressive hemicraniectomy. Of 840 patients , 358 (42.6%) had no HT, 403 (48.0%) patients had petechial HT, and 79 (9.4%) patients had parenchymal HT. LTME occurred in 317 (37.7%) and 100 (11.9%) had mass effect-related deaths. Parenchymal (HR 8.24, 95% CI 5.46–12.42, p < 0.01) and petechial HT (HR 2.47, 95% CI 1.92–3.17, p < 0.01) were significantly associated with time-to-LTME and mass effect-related death. Understanding different risk factors and sequelae of mass effect with and without HT is critical for informed clinical decisions.
Asymmetric pupil reactivity or size can be early clinical indicators of midbrain compression due to supratentorial ischemic stroke or primary intraparenchymal hemorrhage (IPH). Radiographic midline shift is associated with worse functional outcomes and life-saving interventions. Better understanding of quantitative pupil characteristics would be a non-invasive, safe, and cost-effective way to improve identification of life-threatening mass effect and resource utilization of emergent radiographic imaging. We aimed to better characterize the association between midline shift at various anatomic levels and quantitative pupil characteristics.We conducted a multicenter retrospective study of brain CT images within 75 min of a quantitative pupil observation from patients admitted to Neuro-ICUs between 2016 and 2020 with large (>1/3 of the middle cerebral artery territory) acute supratentorial ischemic stroke or primary IPH > 30 mm3. For each image, we measured midline shift at the septum pellucidum (MLS-SP), pineal gland shift (PGS), the ratio of the ipsilateral to contralateral midbrain width (IMW/CMW), and other exploratory markers of radiographic shift/compression. Pupil reactivity was measured using an automated infrared pupillometer (NeurOptics®, Inc.), specifically the proprietary algorithm for Neurological Pupil Index® (NPi). We used rank-normalization and linear mixed-effects models, stratified by diagnosis and hemorrhagic conversion, to test associations of radiographic markers of shift and asymmetric pupil reactivity (Diff NPi), adjusting for age, lesion volume, Glasgow Coma Scale, and osmotic medications.Of 53 patients with 74 CT images, 26 (49.1%) were female, and median age was 67 years. MLS-SP and PGS were greater in patients with IPH, compared to patients with ischemic stroke (6.2 v. 4.0 mm, 5.6 v. 3.4 mm, respectively). We found no significant associations between pupil reactivity and the radiographic markers of shift when adjusting for confounders. However, we found potentially relevant relationships between MLS-SP and Diff NPi in our IPH cohort (β = 0.11, SE 0.04, P = 0.01), and PGS and Diff NPi in the ischemic stroke cohort (β = 0.16, SE 0.09, P = 0.07).We found the relationship between midline shift and asymmetric pupil reactivity may differ between IPH and ischemic stroke. Our study may serve as necessary preliminary data to guide further prospective investigation into how clinical manifestations of radiographic midline shift differ by diagnosis and proximity to the midbrain.
Space occupying cerebral edema is the most feared early complication after large ischemic stroke, occurring in up to 30% of patients with middle cerebral artery (MCA) occlusion, and is reported to peak 2-4 days after injury. Little is known about the factors and outcomes associated with peak edema timing, especially when it occurs after 96 hours. We aimed to characterize differences between patients who experienced maximum midline shift (MLS) or decompressive hemicraniectomy (DHC) in the acute (<48 hours), average (48-96 hours), and subacute (>96 hours) groups and determine whether patients with subacute peak edema timing have improved discharge dispositions.
In this study, we aim to describe quantitative pupil reactivity and size characteristics post-surgical decompression.
Background:
Poor pupil reactivity and asymmetry are potential hallmarks of worsening intracranial injury in patients with acute neurological conditions. However, their clinical significance after intracranial surgery, when mass effect is less likely to directly affect midbrain pupillary pathways, is unclear.
Design/Methods:
We performed a retrospective chart review of patients with quantitative pupillometry who received decompressive hemicraniectomy for ischemic stroke, traumatic brain injury (TBI), or intracranial hemorrhage (ICH). We identified clinical and radiological neuroworsening within 1 hour of pupil measurements. We report abnormal pupils, defined as abnormal reactivity (Neurologic Pupil Index (NPi) <3), or asymmetric pupil reactivity (NPi difference ≥ 0.7), or asymmetric size (>1 mm). We also tested abnormal pupil association with clinical and radiographic signs of neuroworsening before and after decompression.
Results:
Of 24 patients, the mean age was 45.29 ± 19.23 years and 16 were male (66.7%). Thirteen patients received hemicraniectomies for stroke (N=7) or ICH (N=6; spontaneous or related to another injury), 9 had hemicraniectomy for acute subdural hemorrhage, and 2 underwent suboccipital craniectomies for posterior circulation ICH. For all patients, pupil abnormalities occurred in 53.82% of post-surgical measurements, as compared to 45.5% of available pre-surgical measurements. Within the subgroup of patients with ≥3 measurements before and after surgery (n=13), the median minimum NPi post-surgery was lower than pre-surgery (3.8 [2.7–3.39] v. 3.9 [2.7–3.51], p < 0.001). Post-surgery, decreased NPi was associated with loss of cranial nerves, motor decline, and refractory intracranial pressure.
Conclusions:
Abnormalities in pupil reactivity and asymmetry occur frequently post-surgical decompression and are affiliated with neuroworsening events. Close quantitative monitoring of pupils may be indicated even after surgical decompression to identify episodes of neuroworsening, but further definitive studies are necessary. Disclosure: Ms. Hupp has nothing to disclose. The institution of Mr. Cronin has received research support from American Heart Association. Mrs. Kim has received personal compensation for serving as an employee of Boston Medical Center. Dr. Ong has nothing to disclose.
