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Cerebral edema in acute ischemic stroke patients treated with intravenous thrombolysis

Authors

  • Daniel Strbian,

    Corresponding author
    • Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
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  • Atte Meretoja,

    1. Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
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    • AM Honoraria for educational symposia and payments for consultations from Boehringer-Ingelheim.
  • Jukka Putaala,

    1. Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
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    • JP None declared.
  • Markku Kaste,

    1. Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
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    • MK has received honoraria and his travel expenses have been covered for participating in the Steering Committee meetings of ECASS, ECASS-II, ECASS-III, DIAS, DIAS-2, and DIAS-4 trials, and as a consultant for: Boehringer-Ingelheim, PAION AG, Forest Research Laboratories, Inc., and H. Lundbeck A/S and as a speaker in educational meetings sponsored by Boehringer-Ingelheim (modest).
  • Turgut Tatlisumak,

    1. Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
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    • TT Research contract with Boehringer-Ingelheim, Sanofi Aventis, H. Lundbeck A/S, Mitsubishi Pharma, Schering Plough, Concentric Medical, PhotoThera, and BrainsGate (significant). Grant from Boehringer Ingelheim (modest). Advisory board/consultant: Boehringer Ingelheim, Mitsubishi Pharma, Bayer, BrainsGate (modest).
  • and for the Helsinki Stroke Thrombolysis Registry Group


  • Conflict of Interest: DS None declared.

Correspondence: Daniel Strbian, Department of Neurology, Helsinki University Central Hospital, Haartmaninkatu 4, 00290 Helsinki, Finland.

E-mail: daniel.strbian@hus.fi

Abstract

Background

Cerebral edema (CED) deteriorates outcome of ischemic stroke patients, and there is no effective medical treatment. Limited data exist on cerebral edema after stroke thrombolysis.

Aims

We aimed to analyze impact of cerebral edema on the outcome of thrombolysis-treated patients.

Methods

Our cohort included 943 thrombolysis-treated ischemic stroke patients at the Helsinki University Central Hospital (1995–2008). Cerebral edema represented focal brain swelling up to 1/3 (CED-1) or greater than 1/3 (CED-2) of the hemisphere, or midline shift (CED-3). We studied baseline parameters associated with development of cerebral edema and association of cerebral edema with three-month outcome (modified Rankin Scale, mRS).

Results

On control imaging, CED-1 was present in 167 (17·7%), CED-2 in 40 (4·2%), and CED-3 in 53 (5·6%) patients. Compared with patients without edema (n = 683), patients with cerebral edema had higher baseline National Institutes of Health Stroke Scale scores, more often hyperdense cerebral artery sign or early infarct signs on admission computerized tomography, and received thrombolysis later. Cerebral edema was independently associated with poor outcome (mRS 3–6) and mortality, whereas favorable outcome (mRS 0–2) was observed in 77 (46%), 5 (13%), and 3 (6%) patients with CED 1, 2, and 3, respectively. Anti-edema treatment was considered necessary and administered to 49/260 (19%) patients; only five had favorable outcome.

Conclusions

Cerebral edema is frequent (28%) among thrombolysis-treated ischemic stroke patients, occurring in severe forms in 10%. Higher baseline National Institutes of Health Stroke Scale, presence of hyperdense cerebral artery sign or early infarct signs, and longer treatment delays are associated with edema development. Edema is a strong independent predictor of three-month outcome. Effect of anti-edema treatment was modest.

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