Early predictors of malignant course of middle cerebral artery infarction: clinical, laboratory and radiological study

ABSTRACT

Early predictors of deterioration may improve therapeutic decision in patients with acute cerebral ischemia. This study investigated whether measurement of serum protein S100B, beside other clinical and radiological determinants can predict a malignant course of infarction in acute middle cerebral artery [MCA] occlusion. The study included 24 stroke patients admitted within 24 hours after the symptoms onset. In all patients, the stroke was caused by middle cerebral artery infarction as proved by transcranial Doppler [TCD] or computed tomography [CT]. Patients of this study were divided into two groups group I included 17 patients with non malignant middle cerebral artery infarction [MCAI]. Group II included 7 patients with malignant MCAI [mMCAI]. All patients were subjected to complete history taking and thorough neuroglical examination using National Institutes of Health Stroke Scale [NIHSS], brain imaging by computed tomography, transcranial Doppler examination and routine laboratory studies. S100B serum levels were determined in all patients [on admission and 24 hours later] and in 15 age and sex matched control subjects. The functional state of patients was evaluated on discharge by Barthel index [BI] and after 2 months by modified Ranken Scale [MRS]. Patients with mMCAI had significantly higher S100 serum level after 24 hours, and higher NIHSS after 48 hours. These patients had higher incidence of poor outcome both early on discharge [lower BI] and after 2 months [MRS > 3]. On CT examination patients with mMCAI had significantly higher frequency of early hypodensity, large sized infarction, with more severe mass effect. Regarding S100B protein it could not be detected in any one of the control group. While no significant difference could be found between the two patients' groups on admission, its levels were significantly higher in patients with mMCAI after 24 hours. At that time, levels of S100 were significantly correlated to NIHSS at 48 hours, the infarct volume and the severity of mass effect. Again S100B protein could be correlated to functional outcome of the patients both on discharge and after 2 months. In this study predictors of stroke poor outcome were increased mean age of the patients, presence of diabetes, hypertensions, rapid deterioration in the first 48 hours, and significantly higher S100B after 24 hours from admission. Beside those clinical and laboratory data, neuroradiologic features such as the presence of early hypodenisty, large sized infarction [more than one lobe] and marked mass effect were good predictors of poor functional outcome. Serum S100B concentration 24 to 48 hours after the onset can predict a malignant course of infarction after MCA occlusion and may provide a valuable information for both neurological status and functional impairment on discharge and on long term outcome. Other predictors of the malignant course are early clinical deterioration of the patients, early hypodensity on CT with large sized infarction and severe mass effect. All of these factors beside old age and diabetes can also predict poor outcome after MCAI