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

Background and Purpose - Early identification of acute stroke patients at risk of fatal brain swelling is necessary to facilitate implementation of aggressive therapies. Initial clinical, laboratory, and CT characteristics that 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 design. Initial CT scans were analyzed for early ischemic abnormalities by 2 blinded investigators. Results - Twenty-three patients died from brain swelling, with minimum baseline National Institutes of Health Stroke Scale (NIHSS) scores of 20 (n = 12; mean, 23.2 +/- 1.8) with left and 15 (n = 11; mean, 17.6 +/- 2.2) with right hemispheric infarctions (P = 0.0001). A sample of 112 subjects with comparably severe strokes, but who did not die from brain swelling, was selected from the remaining population according to the same NIHSS scores. Among clinical and laboratory characteristics, nausea/vomiting within 24 hours after onset (odds ratio [OR], 5.1; 95% CI, 1.7 to 15.3; P = 0.003) and 12-hour 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 swelling. Among radiographic factors, only hypodensity of > 50% of the middle 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 20 with left or greater than or equal to 15 with right hemispheric infarctions within 6 hours of symptom onset who also have nausea/vomiting or > 50% middle cerebral artery territory hypodensity are at high risk for developing fatal brain swelling.