Sonographic monitoring of midline shift in space-occupying stroke - An early outcome predictor

Background and Purpose-Transcranial color-coded duplex sonography (TCCS) al lows bedside imaging of intracranial hemodynamics and parenchymal structure s. It provides reliable information regarding midline shift (MLS) in space- occupying hemispheric stroke. We studied the value of MLS measurement to pr edict fatal outcome at different time points after stroke onset. Methods-Forty-two patients with acute, severe hemispheric stroke were enrol led. Cranial computed tomography (CCT) and extracranial duplex sonography w ere performed on admission. TCCS was carried out 8+/-3, 16+/-3, 34+/-3, 32/-3, and 40+/-3 hours after stroke onset. Lesion size was determined from f ollow-up CCT. Results-Twelve patients died as the result of cerebral herniation (group 1) ; 28 survived (group 2). Two patients received decompressive hemicraniectom y and were therefore excluded from further evaluation. MLS was significantl y higher in group 1 as early as 16 hours after onset of stroke. Specificity and positive predictive values for death caused by cerebral herniation of MLS greater than or equal to2.5, 3.5, 4.0, and 5.0 mm after 16, 24, 32, and 30 hours were 1.0. Conclusions-TCCS helps to estimate outcome as early as 16 hours after strok e onset and thus facilitates identification of patients who are unlikely to survive without decompressive craniectomy. Because of its noninvasive char acter and bedside suitability, sonographic monitoring of MLS might be a use ful tool in management of critically ill patients who cannot undergo repeat ed CCT scans.