Predictors of development and unfavorable outcome in patients with severe cerebral infarction_West China Medical Journal

Authors：

WANG Lu ¹ , CHANG Xueli ^1,2 , YUAN Ruozhen ¹ ,  LIU Ming ¹

1. Center of Cerebrovascular Disease, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;
2. Department of Neurology, the First Affiliated Hospital of Shanxi Medical University, Taiyuan, Shanxi 030000, P. R. China;

Corresponding author：

LIU Ming, Email: wyplmh@hotmail.com

Keywords：

Ischemic stroke; Severe cerebral infarction; Characteristic; Unfavorable outcome

DOI：

10.7507/1002-0179.201803088

Video：

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Objectives To investigate the risk factors, clinical features, and clinical outcomes of severe cerebral infarction (SCI), and explore the association between different risk factors and outcomes in SCI. Methods We prospectively registered consecutive cases of acute ischemic stroke at the neurological wards of West China Hospital, Sichuan University from January 1st, 2008 to May 27th, 2013. Patients with ischemic stroke within 30 days of symptom onset were included. SCI was defined as the score of National Institutes of Health Stroke Scale greater than 15. Data were collected on clinical and biological variables, risk factors for stroke and the presence of comorbidities. The data management and analysis were performed with the SPSS 16.0 package. Univariate and multivariate analysis were used to analyze the predictors of SCI and its outcomes. Results Of the 3 364 enrolled cases, 348 (10.3%) were SCI. Compared with non-SCI (NSCI), SCI patients were older, with a lower proportion of males, higher NIHSS scores, lower Glasgow Coma Scale (GCS) scores, and higher proportions of previous heart disease history and previous stroke history, and lower hemoglobin levels on admission. SCI group had a greater proportion of large-artery atherosclerosis (LAA) and cardioembolism (CE) and less proportion of small artery occlusive infarction. After adjustment for the confounders, age [odds ratio (OR)=1.020, 95% confidence interval (CI) (1.010, 1.031), P<0.001], LAA [OR=1.442, 95%CI (1.062, 1.958), P=0.019], and CE [OR=1.919, 95%CI (1.319, 2.793), P=0.001] were independently associated with SCI. The case fatality and case fatality or disability with SCI were 32.1% and 83.3% at the end of 3 months, and 41.8% and 79.3% at the end of 1 year. Among different types, patients with undetermined type had the highest mortality rate, with patients with LAA being the lowest (P≤0.001). There was no significant association between TOAST type and the rate of fatality or disability. Multiple factor analysis showed that the most important independent predictive factor of prognosis was age. Meanwhile, sex and previous stroke history were also the independent predictive factors for death at the 3rd month. Hyperlipidemia, valvular heart disease, and GCS score on admission were independent predictive factors for death/disability at the 3rd month. Conclusions Our study indicates that patients with SCI accounted for 10.3% of acute ischemic stroke. The case fatality or disability in SCI patients are higher than those in NSCI patients. The old age, LAA and CE are independent predictive factors of SCI. Age is the most important prognostic factor of patients with SCI.

Citation： WANG Lu, CHANG Xueli, YUAN Ruozhen, LIU Ming. Predictors of development and unfavorable outcome in patients with severe cerebral infarction. West China Medical Journal, 2018, 33(6): 665-672. doi: 10.7507/1002-0179.201803088 Copy

1.	Bill O, Zufferey P, Faouzi M, et al. Severe stroke: patient profile and predictors of favorable outcome. J Thromb Haemost, 2013, 11(1): 92-99.
2.	Wang W, Jiang B, Sun H, et al. Prevalence, incidence and mortality of stroke in China: results from a nationwide population-based survey of 480,687 adults. Circulation, 2017, 135(8): 759-771.
3.	Huttner HB, Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol, 2009, 8(10): 949-958.
4.	Albert AF, Kirkman MA. Clinical and radiological predictors of malignant middle cerebral artery infarction development and outcomes. J Stroke Cerebrovasc Dis, 2017, 26(11): 2671-2679.
5.	Golestanian E, Liou JI, Smith MA. Long-term survival in older critically ill patients with acute ischemic stroke. Crit Care Med, 2009, 37(12): 3107-3113.
6.	Güngen BD, Tunç A, Aras YG, et al. Predictors of intensive care unit admission and mortality in patients with ischemic stroke: investigating the effects of a pulmonary rehabilitation program. BMC Neurol, 2017, 17(1): 132.
7.	吴丽娥, 刘鸣, 张月辉, 等. 缺血性脑卒中 TOAST 病因分型和预后. 中华神经科杂志, 2004, 37(4): 9-12.
8.	de Jong G, van Raak L, Kessels F, et al. Stroke subtype and mortality: a follow-up study in 998 patients with a first cerebral infarct. J Clin Epidemiol, 2003, 56(3): 262-268.
9.	WHO Task Force on Stroke and other Cerebrovascular Disorders. Stroke--1989. recommendations on stroke prevention, diagnosis, and therapy. Report of the WHO task force on stroke and other cerebrovascular disorders. Stroke, 1989, 20(10): 1407-1431.
10.	Jüttler E, Schwab S, Schmiedek P, et al. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke, 2007, 38(9): 2518-2525.
11.	Vahedi K, Vicaut E, Mateo J, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial) Stroke, 2007, 38(9): 2506-2517.
12.	Di Carlo A, Lamassa M, Baldereschi M, et al. Risk factors and outcome of subtypes of ischemic stroke. Data from a multicenter multinational hospital-based registry. The European Community Stroke Project. J Neurol Sci, 2006, 244(1/2): 143-150.
13.	Koren-Morag N, Goldbourt U, Tanne D. Renal dysfunction and risk of ischemic stroke or TIA in patients with cardiovascular disease. Neurology, 2006, 67(2): 224-228.
14.	van Swieten JC, Koudstaal PJ, Visser MC, et al. Interobserver agreement for the assessment of handicap in stroke patients. Stroke, 1988, 19(5): 604-607.
15.	Serena J, Blanco M, Castellanos M, et al. The prediction of malignant cerebral infarction by molecular brain barrier disruption markers. Stroke, 2005, 36(9): 1921-1926.
16.	Petty GW, Brown RD, Whisnant JP, et al. Ischemic stroke subtypes: a population-based study of functional outcome, survival, and recurrence. Stroke, 2000, 31(5): 1062-1068.
17.	Flores A, Rubiera M, Ribo M, et al. Poor collateral circulation assessed by multiphase computed tomographic angiography predicts malignant middle cerebral artery evolution after reperfusion therapies. Stroke, 2015, 46(11): 3149-3153.
18.	Rastogi V, Lamb DG, Williamson JB, et al. Hemispheric differences in malignant middle cerebral artery stroke, J Neurol Sci, 2015, 353(1): 20-27.
19.	吴丽娥, 刘鸣. 缺血性脑卒中 TOAST 病因分型及研究进展. 中风与神经疾病杂志, 2005, 22(1): 87-89.
20.	李卫征, 刘鸣, 吴波, 等. 不同性别脑卒中危险因素类型及预后的比较研究. 中国实用内科杂志, 2009(5): 444-446.
21.	Shahar A, Sadeh M. Severe anemia associated with transient neurological deficits. Stroke, 1991, 22(9): 1201-1202.
22.	Hsiao KY, Hsiao CT, Lin LJ, et al. Severe anemia associated with transient ischemic attacks involving vertebrobasilar circulation. Am J Emerg Med, 2008, 26(3): 382.e3-382.e4.
23.	Jeng JS, Huang SJ, Tang SC, et al. Predictors of survival and functional outcome in acute stroke patients admitted to the stroke intensive care unit. J Neurol Sci, 2008, 270(1/2): 60-66.
24.	Navarrete-Navarro P, Rivera-Fernández R, López-Mutuberría MT, et al. Outcome prediction in terms of functional disability and mortality at 1 year among ICU-admitted severe stroke patients: a prospective epidemiological study in the south of the European Union (Evascan Project, Andalusia, Spain). Intensive Care Med, 2003, 29(8): 1237-1244.
25.	Jaramillo A, Gogora-Rivera F, Labreuche J, et al. Predictors for malignant middle cerebral artery infarctions: a postmortem analysis. Neurology, 2006, 66(6): 815-820.
26.	徐翠萍, 唐丹, 宁波, 等. 龙泉驿区脑卒中登记患者危险因素分析, 华西医学, 2014, 29(1): 87-88.

1. Bill O, Zufferey P, Faouzi M, et al. Severe stroke: patient profile and predictors of favorable outcome. J Thromb Haemost, 2013, 11(1): 92-99.
2. Wang W, Jiang B, Sun H, et al. Prevalence, incidence and mortality of stroke in China: results from a nationwide population-based survey of 480,687 adults. Circulation, 2017, 135(8): 759-771.
3. Huttner HB, Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol, 2009, 8(10): 949-958.
4. Albert AF, Kirkman MA. Clinical and radiological predictors of malignant middle cerebral artery infarction development and outcomes. J Stroke Cerebrovasc Dis, 2017, 26(11): 2671-2679.
5. Golestanian E, Liou JI, Smith MA. Long-term survival in older critically ill patients with acute ischemic stroke. Crit Care Med, 2009, 37(12): 3107-3113.
6. Güngen BD, Tunç A, Aras YG, et al. Predictors of intensive care unit admission and mortality in patients with ischemic stroke: investigating the effects of a pulmonary rehabilitation program. BMC Neurol, 2017, 17(1): 132.
7. 吴丽娥, 刘鸣, 张月辉, 等. 缺血性脑卒中 TOAST 病因分型和预后. 中华神经科杂志, 2004, 37(4): 9-12.
8. de Jong G, van Raak L, Kessels F, et al. Stroke subtype and mortality: a follow-up study in 998 patients with a first cerebral infarct. J Clin Epidemiol, 2003, 56(3): 262-268.
9. WHO Task Force on Stroke and other Cerebrovascular Disorders. Stroke--1989. recommendations on stroke prevention, diagnosis, and therapy. Report of the WHO task force on stroke and other cerebrovascular disorders. Stroke, 1989, 20(10): 1407-1431.
10. Jüttler E, Schwab S, Schmiedek P, et al. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke, 2007, 38(9): 2518-2525.
11. Vahedi K, Vicaut E, Mateo J, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial) Stroke, 2007, 38(9): 2506-2517.
12. Di Carlo A, Lamassa M, Baldereschi M, et al. Risk factors and outcome of subtypes of ischemic stroke. Data from a multicenter multinational hospital-based registry. The European Community Stroke Project. J Neurol Sci, 2006, 244(1/2): 143-150.
13. Koren-Morag N, Goldbourt U, Tanne D. Renal dysfunction and risk of ischemic stroke or TIA in patients with cardiovascular disease. Neurology, 2006, 67(2): 224-228.
14. van Swieten JC, Koudstaal PJ, Visser MC, et al. Interobserver agreement for the assessment of handicap in stroke patients. Stroke, 1988, 19(5): 604-607.
15. Serena J, Blanco M, Castellanos M, et al. The prediction of malignant cerebral infarction by molecular brain barrier disruption markers. Stroke, 2005, 36(9): 1921-1926.
16. Petty GW, Brown RD, Whisnant JP, et al. Ischemic stroke subtypes: a population-based study of functional outcome, survival, and recurrence. Stroke, 2000, 31(5): 1062-1068.
17. Flores A, Rubiera M, Ribo M, et al. Poor collateral circulation assessed by multiphase computed tomographic angiography predicts malignant middle cerebral artery evolution after reperfusion therapies. Stroke, 2015, 46(11): 3149-3153.
18. Rastogi V, Lamb DG, Williamson JB, et al. Hemispheric differences in malignant middle cerebral artery stroke, J Neurol Sci, 2015, 353(1): 20-27.
19. 吴丽娥, 刘鸣. 缺血性脑卒中 TOAST 病因分型及研究进展. 中风与神经疾病杂志, 2005, 22(1): 87-89.
20. 李卫征, 刘鸣, 吴波, 等. 不同性别脑卒中危险因素类型及预后的比较研究. 中国实用内科杂志, 2009(5): 444-446.
21. Shahar A, Sadeh M. Severe anemia associated with transient neurological deficits. Stroke, 1991, 22(9): 1201-1202.
22. Hsiao KY, Hsiao CT, Lin LJ, et al. Severe anemia associated with transient ischemic attacks involving vertebrobasilar circulation. Am J Emerg Med, 2008, 26(3): 382.e3-382.e4.
23. Jeng JS, Huang SJ, Tang SC, et al. Predictors of survival and functional outcome in acute stroke patients admitted to the stroke intensive care unit. J Neurol Sci, 2008, 270(1/2): 60-66.
24. Navarrete-Navarro P, Rivera-Fernández R, López-Mutuberría MT, et al. Outcome prediction in terms of functional disability and mortality at 1 year among ICU-admitted severe stroke patients: a prospective epidemiological study in the south of the European Union (Evascan Project, Andalusia, Spain). Intensive Care Med, 2003, 29(8): 1237-1244.
25. Jaramillo A, Gogora-Rivera F, Labreuche J, et al. Predictors for malignant middle cerebral artery infarctions: a postmortem analysis. Neurology, 2006, 66(6): 815-820.
26. 徐翠萍, 唐丹, 宁波, 等. 龙泉驿区脑卒中登记患者危险因素分析, 华西医学, 2014, 29(1): 87-88.

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