Early clinical and radiological predictors of fatal brain swelling in ischemic stroke

Background and Purpose - Early identification of acute stroke patients at r isk of fatal brain swelling is necessary to facilitate implementation of ag gressive therapies. Initial clinical, laboratory, and CT characteristics th at may be used as selection criteria were analyzed to determine predictors of herniation and neurological death. Methods - Data from the placebo arm of the Lubeluzole-International-9 trial were reviewed to identify patients with fatal brain edema. Early clinical, laboratory, and radiographic parameters were evaluated in a case-control d esign. Initial CT scans were analyzed for early ischemic abnormalities by 2 blinded investigators. Results - Twenty-three patients died from brain swelling, with minimum base line National Institutes of Health Stroke Scale (NIHSS) scores of 20 (n = 1 2; mean, 23.2 +/- 1.8) with left and 15 (n = 11; mean, 17.6 +/- 2.2) with r ight hemispheric infarctions (P = 0.0001). A sample of 112 subjects with co mparably severe strokes, but who did not die from brain swelling, was selec ted from the remaining population according to the same NIHSS scores. Among clinical and laboratory characteristics, nausea/vomiting within 24 hours a fter onset (odds ratio [OR], 5.1; 95% CI, 1.7 to 15.3; P = 0.003) and 12-ho ur systolic blood pressure greater than or equal to 180 mmHg (OR, 4.2; 95% CI, 1.4 to 12.9; P = 0.01) were independently associated with fatal brain s welling. Among radiographic factors, only hypodensity of > 50% of the middl e cerebral artery territory on initial CT scan was an independent predictor (OR, 6.1; 95% CI, 2.3 to 16.6; p = 0.0004). Conclusions - Patients with baseline NIHSS score greater than or equal to 2 0 with left or greater than or equal to 15 with right hemispheric infarctio ns within 6 hours of symptom onset who also have nausea/vomiting or > 50% m iddle cerebral artery territory hypodensity are at high risk for developing fatal brain swelling.