Outcome of acute supratentorial cerebral infarction in patients under 60

Summary

Thirty-five patients under the age of 60 were admitted to the Neurosurgical Department of the Inselspital with acute supratentorial ischaemic strokes between February 1985 and June 1990. The mean delay from the onset of the symptoms until emergency room admission was 10 hours. CT scan, Doppler sonography, and angiography were done routinely at the time of admission and CT was repeated 24 hours later. Initial treatment consisted of mannitol, low-molecular dextran and prednisolone. Intravenous nimodipine was added to the protocol in 1987. Intensive care including hyperventilation and intracranial pressure monitoring was instituted in cases of deteriorating level of consciousness and considerable oedema as visualized on the primary or repeat CT scan. Eight patients developing severe intracranial hypertension and/or unilateral mydriasis despite hyperventilation and osmotherapy underwent decompressive craniectomy. A total of 9 patients died in the acute stage, all but one due to a cerebral cause. At 6 months, only 6 patients were without significant neurological or neuropsychological deficits. Fourteen patients were moderately disabled and 6 were severely disabled. There were no vegetative survivors.

A number of demographic, clinical and radiological variables were investigated for a possible prognostic significance. A grading scale was developed for each variable. Of the initial neurological deficits, degree of motor paralysis, gaze deviation, and decreased level of consciousness correlated with an unfavourable result. While the prognostic significance of each of these individual variables was only moderate, the combined score of these 3 variables correlated better with outcome (r=0.62). More advanced age was found to correlate with a less favourable prognosis. The extension of the low-density area as visible on CT 24 hours after the event, was the single most significant prognostic factor (r=0.63). The site of vascular pathology, as visualized on angiography, was less predictive. Arterial recanalisation, as demonstrated by Doppler sonography, was weakly associated with a more favourable prognosis.

In conclusion, if the present preliminary data can be confirmed on a larger number of patients, the analysed variables allow assessment of the severity of hemispheric infarction for the purpose of therapeutic studies, however, the predictive value is not high enough to allow early therapeutic decisions for an individual patient.