MASS EFFECT AND DEATH FROM SEVERE ACUTE STROKE

Background: In severe acute stroke, the degree of midline cerebral dis placement is related to level of consciousness but not to survival. Ea rly identification of patients at high risk of death from mass effect would assist patient management decisions. Methods: We measured lesion volume, horizontal pineal displacement (PD), and horizontal septum pe llucidum displacement (SD) on axial CT of consecutive patients with se vere (Canadian Neurological Scale score less than or equal to 5) acute hemispheric stroke. We correlated CT measurements with the probabilit y of 14-day survival. Results: Forty-six (39%) of 118 patients died wi thin 14 days and 72 (61%) died within 1 year following stroke. Crude r isk factors for Ii-day mortality were as follows: lesion volume greate r than or equal to 400 ml, SD greater than or equal to 9 mm, PD greate r than or equal to 4 mm, intraventricular hemorrhage, and coma on admi ssion. Only SD (p = 0.001) and coma on admission (p = 0.019) remained significant in multivariate analysis, but PD was highly correlated wit h SD (r = 0.82). PD of greater than or equal to 4 mm on a scan perform ed within 48 hours of stroke onset identified patients with a low prob ability of 14-day survival (0.16; CI 0 to 0.32) with a specificity of 89% and a sensitivity of 46%. Conclusions: The degree of horizontal mi dline cerebral displacement correlates with the likelihood of death fo llowing stroke. Patients with greater than or equal to 4 mm PD on CT p erformed within 48 hours of stroke onset are at high risk for early de ath.