The correlation of ct findings and in-hospital mortality after cerebral infarction

André, Charles; Pinheiro, Rubens S.A.

doi:10.1590/S0004-282X1995000300005

Abstracts

OBJECTIVE:To evaluate whether findings on computed tomography (CT) are useful to predict early mortality after acute cerebral infarction. METHODS: An admission CT was performed in 98 patients with disease-onset within 7 days; CT findings were analyzed using a checking list; their influence on hospital mortality was studied by logistic regression analysis. RESULTS: There were 29 hospital deaths. Uncal herniation and midline shift>4mm were strongly correlated with fatal outcome. Also associated with increased mortality: infarction of a whole hemisphere or in the distribution of internal carotid artery; massive (>90% expected area) infarction in the territory of the anterior or posterior cerebral arteries; massive or submassive (>50% expected area) middle cerebral artery infarction; large lesion volume (death in 9/13 patients with lesions >50cm³); any degree of mass effect. In 68 patients with single middle cerebral artery lesions, extension of the lesion to adjacent vascular territories was also associated with a worse outcome. The number of lesions and the presence of contrast enhancement, hemorrhagic changes or cerebral atrophy did not influence outcome. CONCLUSIONS: CT findings indicating significant mass effect and large infarcts are associated with mortality after ischemic stroke. The best combination of clinical and CT variables to estimate death risk in individual patients remains to be determined.

cerebral infarction; cerebrovascular disorders; cerebral hernia; mortality; prognosis; CT scan

OBJETIVO:Avaliar a importância dos achados à tomografia computadorizada (TC) na determinação do risco de vida precoce após o infarto cerebral. MÉTODOS: 98 pacientes com infarto cerebral com até 7 dias de evolução foram estudados por TC à admissão; os achados à TC foram avaliados de modo padronizado; a influência destes achados sobre a letalidade hospitalar foi estudada por análise de regressão logística. RESULTADOS: 29 pacientes faleceram durante a internação. Herniação de unco e desvio de estruturas de linha média superior a 4 mm associaram-se fortemente ao risco de vida elevado. Outros fatores positivamente relacionados: infarto hemisférico ou ocupando o território carotídeo (a. cerebral anterior e a. cerebral média); infarto maciço (>90% da área esperada) no território das artérias cerebrais anterior ou posterior; infarto maciço ou submaciço (>50% da área esperada) no território da artéria cerebral média; grande volume de lesão (morte em 9/13 pacientes com lesão >50cm³ ); qualquer grau de efeito de massa. Em 68 pacientes com lesões únicas no território da artéria cerebral média, a extensão da lesão a territórios vasculares adjacentes também associou-se a pior prognóstico. O número de lesões e a presença de captação de contraste, transformação hemorrágica ou de atrofia cerebral não influenciaram a evolução. CONCLUSÕES: os achados de importante efeito de massa e grandes lesões à TC associam-se fortemente a alta letalidade hospitalar após o infarto cerebral. Deve-se agora determinar a combinação de variáveis clínicas e tomográficas que melhor prevê o risco de vida em pacientes individuais.

desorderns cérebro-vasculares; hérnia cerebral; infarto cerebral; mortalidade; prognóstico; tomografia computadorizada

Charles André*; Rubens S.A. Pinheiro**

*From the Departments of Neurology and Radiology

**Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (UFRJ)

SUMMARY

OBJECTIVE:To evaluate whether findings on computed tomography (CT) are useful to predict early mortality after acute cerebral infarction.

METHODS: An admission CT was performed in 98 patients with disease-onset within 7 days; CT findings were analyzed using a checking list; their influence on hospital mortality was studied by logistic regression analysis.

RESULTS: There were 29 hospital deaths. Uncal herniation and midline shift>4mm were strongly correlated with fatal outcome. Also associated with increased mortality: infarction of a whole hemisphere or in the distribution of internal carotid artery; massive (>90% expected area) infarction in the territory of the anterior or posterior cerebral arteries; massive or submassive (>50% expected area) middle cerebral artery infarction; large lesion volume (death in 9/13 patients with lesions >50cm³); any degree of mass effect. In 68 patients with single middle cerebral artery lesions, extension of the lesion to adjacent vascular territories was also associated with a worse outcome. The number of lesions and the presence of contrast enhancement, hemorrhagic changes or cerebral atrophy did not influence outcome.

CONCLUSIONS: CT findings indicating significant mass effect and large infarcts are associated with mortality after ischemic stroke. The best combination of clinical and CT variables to estimate death risk in individual patients remains to be determined.

Keywords: cerebral infarction, cerebrovascular disorders, cerebral hernia, mortality, prognosis, CT scan.

RESUMO

OBJETIVO:Avaliar a importância dos achados à tomografia computadorizada (TC) na determinação do risco de vida precoce após o infarto cerebral.

MÉTODOS: 98 pacientes com infarto cerebral com até 7 dias de evolução foram estudados por TC à admissão; os achados à TC foram avaliados de modo padronizado; a influência destes achados sobre a letalidade hospitalar foi estudada por análise de regressão logística.

RESULTADOS: 29 pacientes faleceram durante a internação. Herniação de unco e desvio de estruturas de linha média superior a 4 mm associaram-se fortemente ao risco de vida elevado. Outros fatores positivamente relacionados: infarto hemisférico ou ocupando o território carotídeo (a. cerebral anterior e a. cerebral média); infarto maciço (>90% da área esperada) no território das artérias cerebrais anterior ou posterior; infarto maciço ou submaciço (>50% da área esperada) no território da artéria cerebral média; grande volume de lesão (morte em 9/13 pacientes com lesão >50cm³ ); qualquer grau de efeito de massa. Em 68 pacientes com lesões únicas no território da artéria cerebral média, a extensão da lesão a territórios vasculares adjacentes também associou-se a pior prognóstico. O número de lesões e a presença de captação de contraste, transformação hemorrágica ou de atrofia cerebral não influenciaram a evolução.

CONCLUSÕES: os achados de importante efeito de massa e grandes lesões à TC associam-se fortemente a alta letalidade hospitalar após o infarto cerebral. Deve-se agora determinar a combinação de variáveis clínicas e tomográficas que melhor prevê o risco de vida em pacientes individuais.

Palavras-chave: desorderns cérebro-vasculares, hérnia cerebral, infarto cerebral, mortalidade, prognóstico, tomografia computadorizada.

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Acknowledgments

We are indebted to Dr. Maurice B. Vincent and Dr. Romeu C. Domingues for critical review of the text, and to Mrs. Rosângela A. P. Noé for statistical analysis.

Aceite: 14-março-1995.

Dr. Charles André - Serviço de Neurologia, Hospital Universitário Clementino Fraga Filho, UFRJ - Av. Brigadeiro Trompowsky, s/nº, 10° andar - 21941-590 Rio de Janeiro RJ - Brasil. FAX: 55(21)290-7155

1. André C. A morte na fase aguda do infarto cerebral. Cronologia e causas de óbito e determinação dos fatores prognósticos adversos. Tese. Universidade Federal do Rio de Janeiro: Instituto de Neurologia Deolindo Couto. Rio de Janeiro 1991.
2. André C, Novis SAP. Determinantes prognósticos do risco de vida na fase aguda do infarto cerebral: análise de regressão múltipla em 109 casos (abstr). Arq Neuropsiquiatr 1990, 48(Supl): 25.
3. André C, Novis SAP. Distúrbios da consciência e mortalidade na fase aguda do infarto cerebral-importância central do exame neurológico sequencial (abstr). Arq Neuropsiquiatr 1990, 48(Supl): 104.
4. Berman SA, Hayman LA, Hinck VC. Correlation of CT cerebral vascular territories with function: 1. Anterior cerebral artery. Am J Roentgenol 1980, 135: 253-257.
5. Berman SA, Hayman LA, Hinck VC. Correlation of CT cerebral vascular territories with function: 3. Middle cerebral artery. Am J Roentgenol 1984, 142: 1035-1040.
6. BMDP Statistical Software Inc. BMDPLR- Stepwise logistic regression. Los Angeles: Regents of University of California, 1983.
7. Bonita R, Ford MA, Stewart AW. Predicting survival after stroke: a three-year follow-up. Stroke 1988, 19: 669-673.
8. Brott T, Marler JR, Olinger CP et al. Measurements of acute cerebral infarction: lesion size by computed tomography. Stroke 1989, 20: 871-875.
9. Cluzel R, Roberts JP. La géometrie et ses aplications. Paris: Delagrave, 1952, p 219-221.
10. De Weerd AW. The prognosis of intraventricular hemorrhage. J Neurol 1979, 222: 45-51.
11. Drake ME, Cheolsu S. Conversion of ischemic to hemorrhagic infarction by anticoagulant administration. Arch Neurol 1983, 40: 44-46.
12. Hakim AM, Hyder-Cooke A, Melanson D. Sequential computerized tomographic appearance of strokes. Stroke 1983, 14: 893-897.
13. Hayman LA, Berman SA, Hinck VC. Correlation of CT cerebral vascular territories with function: 2. Posterior cerebral artery. Am J Roentgenol 1981; 137: 13-19.
14. Hayman LA, Taber KH, Jhingran SG, Killian JM, Carroll RG. Cerebral infarction: diagnosis and assessment of prognosis by using ¹²³TMP-SPECT and CT. Am J Neuroradiol 1989, 10: 557-562.
15. Hornig CR, Dorndorf W, Agnoli AL. Hemorrhagic cerebral infarction: a prospective study. Stroke 1986, 17: 179-185.
16. Jayakumar PN, Taly AB, Bhavani UR, Arya BYT, Nagaraja D. Prognosis in solitary intraventricular haemorrhage: clinical and computed tomographic observations. Acta Neurol Scand 1989, 80: 1-5.
17. Kinkel WR, Jacobs L. Computerized axial transverse tomography in cerebrovascular disease. Neurology 1976, 26: 924-930.
18. Lodder J. CT-detected hemorrhagic infarction: relation with the size of infarct, and the presence of midline shift. Acta Neurol Scand. 1984, 70: 329-335.
19. Lodder J, Krijne-Kubat B, Broekman J. Cerebral hemorrhagic infarction at autopsy: cardiac embolic cause and the relationship to the cause of death. Stroke 1986, 17: 626-629.
20. Marquadsen J. The natural history of acute cerebrovascular disease: a prospective study of 769 patients. Acta Neurol Scand 1969, 45(Suppl.38): 1-192.
21. Ng LK, Nimmannitya J. Massive cerebral infarction with severe brain swelling: a clinicopathological study. Stroke 1970, 1: 158-163.
22. Okada Y, Sadoshima S, Nakane H, Utsunomiya H, Fujishima M. Early computed tomographic findings for thrombolytic therapy in patients with acute brain embolism. Stroke 1992, 23: 20-23.
23. Ott BR, Zamani A, Kleefield J, Funkenstein HH. The clinical spectrum of hemorrhagic infarction. Stroke 1986, 17: 630-637.
24. Pullicino P, Kendall BE. Contrast enhancement in ischaemic lesions: I. Relationship to prognosis. Neuroradiology 1980, 19: 235-239.
25. Rasmussen D, Kohler O, Worm-Petersen S et al. Computed tomography in prognostic stroke evaluation. Stroke 1992, 23: 506-510.
26. Ropper AH. Lateral displacement of the brain and the level of consciousness in patients with an acute hemispheral mass. N Engl J Med 1986, 314: 953-958.
27. Ruscadella J, Piero A. Prognostic factors in intraparenchymatous hematoma with ventricular hemorrhage. Neuroradiology 1986, 28: 34-37.
28. Saito I, Segawa H, Shiokawa Y, Taniguchi M, Tsutsumi K. Middle cerebral artery occlusion: correlation of computed tomography and angiography with clinical outcome. Stroke 1987, 18: 863-868.
29. Shaw C-M, Alvord EC Jr , Berry RG. Swelling of the brain following ischemic infarction with arterial occlusion. Arch Neurol 1959, 1: 161-177.
30. Steiner I, Gomor JM, Melamed E. The prognostic value of the CT scan in conservatively treated patients with intracerebral hematoma. Stroke 1984, 15: 279-282.
31. Von Arbin M, Britton M, de Faire U et al. Validation of admission criteria to a stroke unit. J Chron Dis 1980, 33: 215-220.
32. Weisberg LA. Computerized tomographic enhancement patterns in cerebral infarction. Arch Neurol 1980, 37: 21-24.
33. Young WB, Lee KP, Pessin MS et al. Prognostic significance of ventricular blood in supratentorial hemorrhage: a volumetric study. Neurology 1990, 40: 616-619.

The correlation of ct findings and in-hospital mortality after cerebral infarction

Correlação entre achados à TC e letalidade hospitalar após infarto cerebral

Publication Dates

Publication in this collection
09 Dec 2010
Date of issue
Sept 1995

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. André C. A morte na fase aguda do infarto cerebral. Cronologia e causas de óbito e determinação dos fatores prognósticos adversos. Tese. Universidade Federal do Rio de Janeiro: Instituto de Neurologia Deolindo Couto. Rio de Janeiro 1991.

[2] 2. André C, Novis SAP. Determinantes prognósticos do risco de vida na fase aguda do infarto cerebral: análise de regressão múltipla em 109 casos (abstr). Arq Neuropsiquiatr 1990, 48(Supl): 25.

[3] 3. André C, Novis SAP. Distúrbios da consciência e mortalidade na fase aguda do infarto cerebral-importância central do exame neurológico sequencial (abstr). Arq Neuropsiquiatr 1990, 48(Supl): 104.

[4] 4. Berman SA, Hayman LA, Hinck VC. Correlation of CT cerebral vascular territories with function: 1. Anterior cerebral artery. Am J Roentgenol 1980, 135: 253-257.

[5] 5. Berman SA, Hayman LA, Hinck VC. Correlation of CT cerebral vascular territories with function: 3. Middle cerebral artery. Am J Roentgenol 1984, 142: 1035-1040.

[6] 6. BMDP Statistical Software Inc. BMDPLR- Stepwise logistic regression. Los Angeles: Regents of University of California, 1983.

[7] 7. Bonita R, Ford MA, Stewart AW. Predicting survival after stroke: a three-year follow-up. Stroke 1988, 19: 669-673.

[8] 8. Brott T, Marler JR, Olinger CP et al. Measurements of acute cerebral infarction: lesion size by computed tomography. Stroke 1989, 20: 871-875.

[9] 9. Cluzel R, Roberts JP. La géometrie et ses aplications. Paris: Delagrave, 1952, p 219-221.

[10] 10. De Weerd AW. The prognosis of intraventricular hemorrhage. J Neurol 1979, 222: 45-51.

[11] 11. Drake ME, Cheolsu S. Conversion of ischemic to hemorrhagic infarction by anticoagulant administration. Arch Neurol 1983, 40: 44-46.

[12] 12. Hakim AM, Hyder-Cooke A, Melanson D. Sequential computerized tomographic appearance of strokes. Stroke 1983, 14: 893-897.

[13] 13. Hayman LA, Berman SA, Hinck VC. Correlation of CT cerebral vascular territories with function: 2. Posterior cerebral artery. Am J Roentgenol 1981; 137: 13-19.

[14] 14. Hayman LA, Taber KH, Jhingran SG, Killian JM, Carroll RG. Cerebral infarction: diagnosis and assessment of prognosis by using ¹²³TMP-SPECT and CT. Am J Neuroradiol 1989, 10: 557-562.

[15] 15. Hornig CR, Dorndorf W, Agnoli AL. Hemorrhagic cerebral infarction: a prospective study. Stroke 1986, 17: 179-185.

[16] 16. Jayakumar PN, Taly AB, Bhavani UR, Arya BYT, Nagaraja D. Prognosis in solitary intraventricular haemorrhage: clinical and computed tomographic observations. Acta Neurol Scand 1989, 80: 1-5.

[17] 17. Kinkel WR, Jacobs L. Computerized axial transverse tomography in cerebrovascular disease. Neurology 1976, 26: 924-930.

[18] 18. Lodder J. CT-detected hemorrhagic infarction: relation with the size of infarct, and the presence of midline shift. Acta Neurol Scand. 1984, 70: 329-335.

[19] 19. Lodder J, Krijne-Kubat B, Broekman J. Cerebral hemorrhagic infarction at autopsy: cardiac embolic cause and the relationship to the cause of death. Stroke 1986, 17: 626-629.

[20] 20. Marquadsen J. The natural history of acute cerebrovascular disease: a prospective study of 769 patients. Acta Neurol Scand 1969, 45(Suppl.38): 1-192.

[21] 21. Ng LK, Nimmannitya J. Massive cerebral infarction with severe brain swelling: a clinicopathological study. Stroke 1970, 1: 158-163.

[22] 22. Okada Y, Sadoshima S, Nakane H, Utsunomiya H, Fujishima M. Early computed tomographic findings for thrombolytic therapy in patients with acute brain embolism. Stroke 1992, 23: 20-23.

[23] 23. Ott BR, Zamani A, Kleefield J, Funkenstein HH. The clinical spectrum of hemorrhagic infarction. Stroke 1986, 17: 630-637.

[24] 24. Pullicino P, Kendall BE. Contrast enhancement in ischaemic lesions: I. Relationship to prognosis. Neuroradiology 1980, 19: 235-239.

[25] 25. Rasmussen D, Kohler O, Worm-Petersen S et al. Computed tomography in prognostic stroke evaluation. Stroke 1992, 23: 506-510.

[26] 26. Ropper AH. Lateral displacement of the brain and the level of consciousness in patients with an acute hemispheral mass. N Engl J Med 1986, 314: 953-958.

[27] 27. Ruscadella J, Piero A. Prognostic factors in intraparenchymatous hematoma with ventricular hemorrhage. Neuroradiology 1986, 28: 34-37.

[28] 28. Saito I, Segawa H, Shiokawa Y, Taniguchi M, Tsutsumi K. Middle cerebral artery occlusion: correlation of computed tomography and angiography with clinical outcome. Stroke 1987, 18: 863-868.

[29] 29. Shaw C-M, Alvord EC Jr , Berry RG. Swelling of the brain following ischemic infarction with arterial occlusion. Arch Neurol 1959, 1: 161-177.

[30] 30. Steiner I, Gomor JM, Melamed E. The prognostic value of the CT scan in conservatively treated patients with intracerebral hematoma. Stroke 1984, 15: 279-282.

[31] 31. Von Arbin M, Britton M, de Faire U et al. Validation of admission criteria to a stroke unit. J Chron Dis 1980, 33: 215-220.

[32] 32. Weisberg LA. Computerized tomographic enhancement patterns in cerebral infarction. Arch Neurol 1980, 37: 21-24.

[33] 33. Young WB, Lee KP, Pessin MS et al. Prognostic significance of ventricular blood in supratentorial hemorrhage: a volumetric study. Neurology 1990, 40: 616-619.