Outcomes in severe middle cerebral artery ischemic stroke

Neurocrit Care. 2014 Aug;21(1):20-6. doi: 10.1007/s12028-013-9838-x.


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.

MeSH terms

  • Brain Edema / mortality*
  • Brain Edema / surgery
  • Female
  • Humans
  • Infarction, Anterior Cerebral Artery / mortality*
  • Infarction, Anterior Cerebral Artery / pathology
  • Infarction, Middle Cerebral Artery / mortality*
  • Infarction, Middle Cerebral Artery / pathology
  • Infarction, Middle Cerebral Artery / therapy
  • Male
  • Middle Aged
  • Patient Outcome Assessment*
  • Severity of Illness Index