Case 5-2004: A Man with Slurred Speech and Left Hemiparesis
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《新英格兰医药杂志》
To the Editor: Case 5-2004 (Feb. 12 issue)1 demonstrates the substantial progress that has been made in the treatment of cerebrovascular diseases. However, we have reservations regarding the management of this case. Early ischemic changes on computed tomography (CT) and a high score on the National Institutes of Health Stroke Scale (NIHSS) at presentation indicate a high risk of symptomatic hemorrhagic transformation and of a poor outcome after thrombolysis.2,3 Considering its high risk–benefit ratio and the marginal overall benefit it confers, the use of intravenous tissue plasminogen activator (t-PA) in this case was controversial; moreover, the use of intraarterial t-PA was not evidence-based.4 Magnetic resonance imaging (MRI) may identify a perfusion–diffusion mismatch, indicating a clinically significant ischemic penumbra but one that is viable and that may benefit from revascularization. We have used this approach successfully to select patients who have symptomatic carotid-artery dissections for emergency stenting.5
In the current case, diffusion-weighted MRI showed that irreversible infarction had already developed in most of the territory of the middle cerebral artery. Therefore, there was no sense in performing revascularization by stenting or thrombolysis. Indeed, the clinical course was typical for a malignant infarction involving the middle cerebral artery, irrespective of the heroic measures taken. The hemorrhagic transformation, which was due to thrombolysis in an already formed infarct, probably increased the intracerebral pressure and exacerbated the midline shift to the extent that hemicraniectomy was necessary.
Tamir Ben-Hur, M.D., Ph.D.
Jose E. Cohen, M.D.
Hadassah Hebrew University Hospital
Jerusalem 91120, Israel
tamir@hadassah.org.il
References
Case Records of the Massachusetts General Hospital (Case 5-2004). N Engl J Med 2004;350:707-716.
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581-1587.
The NINDS t-PA Stroke Study Group. Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke. Stroke 1997;28:2109-2118.
Adams HP Jr, Adams RJ, Brott T, et al. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke 2003;34:1056-1083.
Cohen JE, Leker RR, Gotkine M, Gomori M, Ben-Hur T. Emergent stenting to treat patients with carotid artery dissection: clinically and radiologically directed therapeutic decision making. Stroke 2003;34:e254-e257.
To the Editor: Carter provides an excellent discussion of the role of hemicraniectomy in the treatment of the malignant middle-cerebral-artery edema syndrome. However, I would like to offer a word of caution. It is worth noting not only that the best outcomes after hemicraniectomy have been observed in younger patients, as Carter mentions, but also that good outcomes are exceptional in older patients. A recent systematic review (of 12 studies plus the authors' experience, involving a total of 138 patients) concluded that an age greater than 50 years was a crucial predictor of poor functional outcome after hemicraniectomy in patients with a large middle-cerebral-artery infarction.1 The time to surgery or the presence of signs of herniation before surgery did not affect outcomes. I wholly agree with these conclusions. Among 20 patients my colleagues and I treated with hemicraniectomy for malignant ischemic brain edema, none of the 10 patients older than 52 years regained functional independence (unpublished data). Thus, hemicraniectomy is a valid option in younger patients, but its value in older patients is not well established.
Alejandro A. Rabinstein, M.D.
University of Miami School of Medicine
Miami, FL 33179
arabinstein@med.miami.edu
References
Gupta R, Connolly ES, Mayer S, Elkind MS. Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review. Stroke 2004;35:539-543.
Drs. Schwamm and Carter reply: Drs. Ben-Hur and Cohen point out that patients with a greater volume of tissue with perturbed perfusion, as compared with restricted diffusion, may benefit from early reperfusion strategies. In the patient described in Case 5-2004, there was incomplete infarction of the territory of the middle cerebral artery, with sparing of much of the inferior division, as mentioned in the article and as shown in the diffusion-weighted MRI scan. In addition, the clinical findings reflected electrical dysfunction in a large region of the brain supplied by the middle cerebral artery, a volume that was greater than the territory of involvement identified by imaging alone (i.e., a clinical-to-imaging mismatch). It is challenging to identify prospectively the patients in whom malignant brain edema will develop, especially in an older population. It is also important to emphasize that the subtle, early changes on CT and the elevated NIHSS score do not represent contraindications to the use of intravenous t-PA and that early changes on diffusion-weighted MRI do not always represent complete infarction in patients who undergo reperfusion.1 The Stroke Council of the American Stroke Association does not support emergency carotid-artery stenting in acute stroke outside of clinical research studies, but it does recommend that "intra-arterial thrombolysis is an option for treatment of selected patients with major stroke of <6 hours' duration due to large vessel occlusions of the middle cerebral artery (grade B)."2 Additional randomized trials of catheter-based mechanical and chemical thrombolysis need to be performed to help identify patients for whom this therapy is most appropriate.
Dr. Rabinstein highlights the importance of advanced age as a predictor of a poor outcome after a large infarction involving the middle cerebral artery. The anticipated benefit of hemicraniectomy should be considered in all potential cases, as should the many factors that influence outcome. The patient's and the family's expectations and previously expressed wishes for life-sustaining treatment must always be given considerable weight.
Lee H. Schwamm, M.D.
Bob. S. Carter, M.D.
Massachusetts General Hospital
Boston, MA 02114
Editor's note: Dr. Schwamm reports having served as a consultant to Boston Scientific/Target.
References
Kidwell CS, Saver JL, Starkman S, et al. Late secondary ischemic injury in patients receiving intraarterial thrombolysis. Ann Neurol 2002;52:698-703.
Adams HP Jr, Adams RJ, Brott T, et al. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke 2003;34:1056-1083.
In the current case, diffusion-weighted MRI showed that irreversible infarction had already developed in most of the territory of the middle cerebral artery. Therefore, there was no sense in performing revascularization by stenting or thrombolysis. Indeed, the clinical course was typical for a malignant infarction involving the middle cerebral artery, irrespective of the heroic measures taken. The hemorrhagic transformation, which was due to thrombolysis in an already formed infarct, probably increased the intracerebral pressure and exacerbated the midline shift to the extent that hemicraniectomy was necessary.
Tamir Ben-Hur, M.D., Ph.D.
Jose E. Cohen, M.D.
Hadassah Hebrew University Hospital
Jerusalem 91120, Israel
tamir@hadassah.org.il
References
Case Records of the Massachusetts General Hospital (Case 5-2004). N Engl J Med 2004;350:707-716.
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581-1587.
The NINDS t-PA Stroke Study Group. Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke. Stroke 1997;28:2109-2118.
Adams HP Jr, Adams RJ, Brott T, et al. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke 2003;34:1056-1083.
Cohen JE, Leker RR, Gotkine M, Gomori M, Ben-Hur T. Emergent stenting to treat patients with carotid artery dissection: clinically and radiologically directed therapeutic decision making. Stroke 2003;34:e254-e257.
To the Editor: Carter provides an excellent discussion of the role of hemicraniectomy in the treatment of the malignant middle-cerebral-artery edema syndrome. However, I would like to offer a word of caution. It is worth noting not only that the best outcomes after hemicraniectomy have been observed in younger patients, as Carter mentions, but also that good outcomes are exceptional in older patients. A recent systematic review (of 12 studies plus the authors' experience, involving a total of 138 patients) concluded that an age greater than 50 years was a crucial predictor of poor functional outcome after hemicraniectomy in patients with a large middle-cerebral-artery infarction.1 The time to surgery or the presence of signs of herniation before surgery did not affect outcomes. I wholly agree with these conclusions. Among 20 patients my colleagues and I treated with hemicraniectomy for malignant ischemic brain edema, none of the 10 patients older than 52 years regained functional independence (unpublished data). Thus, hemicraniectomy is a valid option in younger patients, but its value in older patients is not well established.
Alejandro A. Rabinstein, M.D.
University of Miami School of Medicine
Miami, FL 33179
arabinstein@med.miami.edu
References
Gupta R, Connolly ES, Mayer S, Elkind MS. Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review. Stroke 2004;35:539-543.
Drs. Schwamm and Carter reply: Drs. Ben-Hur and Cohen point out that patients with a greater volume of tissue with perturbed perfusion, as compared with restricted diffusion, may benefit from early reperfusion strategies. In the patient described in Case 5-2004, there was incomplete infarction of the territory of the middle cerebral artery, with sparing of much of the inferior division, as mentioned in the article and as shown in the diffusion-weighted MRI scan. In addition, the clinical findings reflected electrical dysfunction in a large region of the brain supplied by the middle cerebral artery, a volume that was greater than the territory of involvement identified by imaging alone (i.e., a clinical-to-imaging mismatch). It is challenging to identify prospectively the patients in whom malignant brain edema will develop, especially in an older population. It is also important to emphasize that the subtle, early changes on CT and the elevated NIHSS score do not represent contraindications to the use of intravenous t-PA and that early changes on diffusion-weighted MRI do not always represent complete infarction in patients who undergo reperfusion.1 The Stroke Council of the American Stroke Association does not support emergency carotid-artery stenting in acute stroke outside of clinical research studies, but it does recommend that "intra-arterial thrombolysis is an option for treatment of selected patients with major stroke of <6 hours' duration due to large vessel occlusions of the middle cerebral artery (grade B)."2 Additional randomized trials of catheter-based mechanical and chemical thrombolysis need to be performed to help identify patients for whom this therapy is most appropriate.
Dr. Rabinstein highlights the importance of advanced age as a predictor of a poor outcome after a large infarction involving the middle cerebral artery. The anticipated benefit of hemicraniectomy should be considered in all potential cases, as should the many factors that influence outcome. The patient's and the family's expectations and previously expressed wishes for life-sustaining treatment must always be given considerable weight.
Lee H. Schwamm, M.D.
Bob. S. Carter, M.D.
Massachusetts General Hospital
Boston, MA 02114
Editor's note: Dr. Schwamm reports having served as a consultant to Boston Scientific/Target.
References
Kidwell CS, Saver JL, Starkman S, et al. Late secondary ischemic injury in patients receiving intraarterial thrombolysis. Ann Neurol 2002;52:698-703.
Adams HP Jr, Adams RJ, Brott T, et al. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke 2003;34:1056-1083.