The severity of ischemia determines and predicts malignant brain edema in patients with large middle cerebral artery infarction

Cerebrovasc Dis. 2012;33(1):1-7. doi: 10.1159/000330648. Epub 2011 Nov 30.


Background: In order to determine the impact of the severity of ischemia on malignant edema formation, we investigated various degrees of perfusional deficit by (11)C-flumazenil PET in patients with large middle cerebral artery (MCA) infarction.

Methods: 17 patients with large MCA stroke were included. Cerebral blood flow (CBF) was measured 15.9 ± 6.4 h after the ictus. Patients were divided into a malignant (n = 9) and a benign group (n = 8) as a function of their clinical courses and edema. Edema was measured as maximal midline shift on follow-up CTs. Total hypoperfusion volume was divided into different subvolumes according to the degree of CBF reduction.

Results: Subvolumes of severe ischemia relative to total ischemic area were significantly larger in the malignant group than in the benign group and were significantly correlated with edema formation. The highest correlation and best predictive values for edema formation with a sensitivity, specificity, and a positive and negative predictive value of 100% were found for subvolumes with severe ischemia. Correlation coefficients and prediction decreased for subvolumes with less severe perfusional deficit, pointing to the risk of misclassifying patients when relying on the volume of total perfusional deficit alone.

Conclusions: Malignant MCA infarction seems to be determined more by the volume of severe perfusional deficit than that of total perfusional deficit. Assessment of severely ischemic areas allows prediction of malignant edema formation and might help to select candidates for hemicraniectomy.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Brain Edema / diagnostic imaging
  • Brain Edema / etiology*
  • Brain Edema / physiopathology
  • Brain Edema / surgery
  • Cerebrovascular Circulation
  • Chi-Square Distribution
  • Decompressive Craniectomy
  • Female
  • Flumazenil
  • Germany
  • Humans
  • Infarction, Middle Cerebral Artery / complications*
  • Infarction, Middle Cerebral Artery / diagnostic imaging
  • Infarction, Middle Cerebral Artery / physiopathology
  • Infarction, Middle Cerebral Artery / surgery
  • Male
  • Middle Aged
  • Patient Selection
  • Perfusion Imaging / methods
  • Positron-Emission Tomography
  • Predictive Value of Tests
  • Prognosis
  • Radiopharmaceuticals
  • Risk Assessment
  • Risk Factors
  • Sensitivity and Specificity
  • Severity of Illness Index
  • Time Factors
  • Tomography, X-Ray Computed


  • Radiopharmaceuticals
  • Flumazenil